1
|
Kraft R, Mercuri M, Clayton N, Worster A, Mercier E, Emond M, Varner C, McLeod SL, Eagles D, Stiell I, Barbic D, Morris J, Jeanmonod R, Kagoma YK, Shoamanesh A, Engels PT, Sharma S, Papaioannou A, Parpia S, Buchanan I, Ali M, de Wit K. Emergency physician gender and head computed tomography orders for older adults who have fallen. Acad Emerg Med 2024; 31:1006-1013. [PMID: 38644592 DOI: 10.1111/acem.14928] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2024] [Revised: 03/25/2024] [Accepted: 04/06/2024] [Indexed: 04/23/2024]
Abstract
OBJECTIVE Physicians vary in their computed tomography (CT) scan usage. It remains unclear how physician gender relates to clinical practice or patient outcomes. The aim of this study was to assess the association between physician gender and decision to order head CT scans for older emergency patients who had fallen. METHODS This was a secondary analysis of a prospective observational cohort study conducted in 11 hospital emergency departments (EDs) in Canada and the United States. The primary study enrolled patients who were 65 years and older who presented to the ED after a fall. The analysis evaluated treating physician gender adjusted for multiple clinical variables. Primary analysis used a hierarchical logistic regression model to evaluate the association between treating physician gender and the patient receiving a head CT scan. Secondary analysis reported the adjusted odds ratio (OR) for diagnosing intracranial bleeding by physician gender. RESULTS There were 3663 patients and 256 physicians included in the primary analysis. In the adjusted analysis, women physicians were no more likely to order a head CT than men (OR 1.26, 95% confidence interval 0.98-1.61). In the secondary analysis of 2294 patients who received a head CT, physician gender was not associated with finding a clinically important intracranial bleed. CONCLUSIONS There was no significant association between physician gender and ordering head CT scans for older emergency patients who had fallen. For patients where CT scans were ordered, there was no significant relationship between physician gender and the diagnosis of clinically important intracranial bleeding.
Collapse
Affiliation(s)
- Rhys Kraft
- Department of Biomedical and Molecular Sciences, Queen's University, Kingston, Ontario, Canada
| | - Mathew Mercuri
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada
- Department of Philosophy, University of Johannesburg, Auckland Park, Gauteng, South Africa
- Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
| | - Natasha Clayton
- Department of Emergency Medicine, Queen's University, Kingston, Ontario, Canada
- Emergency Department, Hamilton Health Sciences, Hamilton, Ontario, Canada
| | - Andrew Worster
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
| | - Eric Mercier
- Centre de Recherche du CHU de Québec, Université Laval, Québec, Quebec, Canada
- VITAM-Centre de Recherche en Santé Durable, Université Laval, Québec, Quebec, Canada
| | - Marcel Emond
- Centre de Recherche du CHU de Québec, Université Laval, Québec, Quebec, Canada
- VITAM-Centre de Recherche en Santé Durable, Université Laval, Québec, Quebec, Canada
| | - Catherine Varner
- Schwartz/Reisman Emergency Medicine Institute, Sinai Health, Toronto, Ontario, Canada
- Division of Emergency Medicine, Department of Family and Community Medicine, Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Shelley L McLeod
- Schwartz/Reisman Emergency Medicine Institute, Sinai Health, Toronto, Ontario, Canada
- Division of Emergency Medicine, Department of Family and Community Medicine, Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Debra Eagles
- Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
- Department of Emergency Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Ian Stiell
- Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
- Department of Emergency Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - David Barbic
- Emergency Medicine, University of British Columbia, Vancouver, British Columbia, Canada
- Centre for Health Evaluation Outcome Sciences, St Paul's Hospital, Vancouver, British Columbia, Canada
| | - Judy Morris
- Department of Family Medicine and Emergency Medicine, Université de Montréal, Montreal, Québec, Canada
- Department of Family Medicine and Emergency Medicine, Université de Montréal, Québec, Québec, Canada
| | - Rebecca Jeanmonod
- Emergency Medicine, St. Luke's University Health Network, Bethlehem, Pennsylvania, USA
| | - Yoan K Kagoma
- Department of Radiology, McMaster University, Hamilton, Ontario, Canada
| | - Ashkan Shoamanesh
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Paul T Engels
- Department of Surgery, McMaster University, Hamilton, Ontario, Canada
| | - Sunjay Sharma
- Division of Neurosurgery, Department of Surgery, McMaster University, Hamilton, Ontario, Canada
| | | | - Sameer Parpia
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
- Ontario Clinical Oncology Group, McMaster University, Hamilton, Ontario, Canada
| | - Ian Buchanan
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Mariyam Ali
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Kerstin de Wit
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada
- Department of Emergency Medicine, Queen's University, Kingston, Ontario, Canada
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
| |
Collapse
|
2
|
Calluy E, Beaudart C, Alokail MS, Al-Daghri NM, Bruyère O, Reginster JY, Cavalier E, Ladang A. Confounding factors of the expression of mTBI biomarkers, S100B, GFAP and UCH-L1 in an aging population. Clin Chem Lab Med 2024; 62:2062-2069. [PMID: 38643415 DOI: 10.1515/cclm-2024-0194] [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: 09/15/2023] [Accepted: 04/02/2024] [Indexed: 04/22/2024]
Abstract
OBJECTIVES To evaluate some confounding factors that influence the concentrations of S100 calcium binding protein B (S100B), glial fibrillary acidic protein (GFAP), and ubiquitin carboxyl-terminal hydrolase L-1 (UCH-L1) in older individuals. Indeed, recent guidelines have proposed the combined use of S100B and the "GFAP-UCH-L1" mTBI test to rule out mild traumatic brain injuries (mTBI). As older adults are the most at risk of mTBI, it is particularly important to understand the confounding factors of those mTBI rule-out biomarkers in aging population. METHODS The protein S100B and the "GFAP and UCH-L1" mTBI test were measured using Liaison XL (Diasorin) and Alinity I (Abbott), respectively, in 330 and 341 individuals with non-suspected mTBI from the SarcoPhAge cohort. RESULTS S100B, GFAP and UCH-L1 were all significantly correlated with renal function whereas alcohol consumption, Geriatric Depression Score (GDS), smoking habits and anticoagulant intake were not associated with any of these three biomarkers. Body mass index (BMI) and age were associated with GFAP and UCH-L1 expression while sex and mini-mental state examination (MMSE) were only associated with GFAP. According to the manufacturer's cut-offs for mTBI rule-out, only 5.5 % of participants were positive for S100B whereas 66.9 % were positive for the "GFAP-UCH-L1" mTBI test. All positive "GFAP-UCH-L1" mTBI tests were GFAP+/UCH-L1-. Among individuals with cystatin C>1.55 mg/L, 25 % were positive for S100B while 90 % were positive for the mTBI test. CONCLUSIONS Our data show that confounding factors have different impacts on the positivity rate of the "GFAP-UCH-L1" mTBI test compared to S100B.
Collapse
Affiliation(s)
- Emma Calluy
- Clinical Chemistry Department, CHU de Liège, University of Liège, Liège, Belgium
| | - Charlotte Beaudart
- WHO Collaborating Center for Public Health Aspects of Musculoskeletal Health and Aging, Division of Public Health, Epidemiology and Health Economics, University of Liège, Liège, Belgium
- Clinical Pharmacology and Toxicology Research Unit (URPC), NARILIS, Department of Biomedical Sciences, Faculty of Medicine, University of Namur, Namur, Belgium
| | - Majed S Alokail
- Protein Research Chair, Biochemistry Department, 37850 College of Science, KSU , Riyadh, Kingdom of Saudi Arabia
| | - Nasser M Al-Daghri
- Chair for Biomarkers of Chronic Diseases, Biochemistry Department, 37850 College of Science, KSU , Riyadh, Kingdom of Saudi Arabia
| | - Olivier Bruyère
- WHO Collaborating Center for Public Health Aspects of Musculoskeletal Health and Aging, Division of Public Health, Epidemiology and Health Economics, University of Liège, Liège, Belgium
- Department of Sport and Rehabilitation Sciences, University of Liège, Liège, Belgium
| | - Jean-Yves Reginster
- WHO Collaborating Center for Public Health Aspects of Musculoskeletal Health and Aging, Division of Public Health, Epidemiology and Health Economics, University of Liège, Liège, Belgium
- Protein Research Chair, Biochemistry Department, 37850 College of Science, KSU , Riyadh, Kingdom of Saudi Arabia
| | - Etienne Cavalier
- Clinical Chemistry Department, CHU de Liège, University of Liège, Liège, Belgium
| | - Aurélie Ladang
- Clinical Chemistry Department, CHU de Liège, University of Liège, Liège, Belgium
| |
Collapse
|
3
|
Yang LJ, Lassarén P, Londi F, Palazzo L, Fletcher-Sandersjöö A, Ängeby K, Thelin EP, Rubenson Wahlin R. Risk factors for traumatic intracranial hemorrhage in mild traumatic brain injury patients at the emergency department: a systematic review and meta-analysis. Scand J Trauma Resusc Emerg Med 2024; 32:91. [PMID: 39289729 PMCID: PMC11406809 DOI: 10.1186/s13049-024-01262-6] [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: 04/22/2024] [Accepted: 09/08/2024] [Indexed: 09/19/2024] Open
Abstract
BACKGROUND Mild traumatic brain injury (mTBI), i.e. a TBI with an admission Glasgow Coma Scale (GCS) of 13-15, is a common cause of emergency department visits. Only a small fraction of these patients will develop a traumatic intracranial hemorrhage (tICH) with an even smaller subgroup suffering from severe outcomes. Limitations in existing management guidelines lead to overuse of computed tomography (CT) for emergency department (ED) diagnosis of tICH which may result in patient harm and higher healthcare costs. OBJECTIVE To perform a systematic review and meta-analysis to characterize known and potential novel risk factors that impact the risk of tICH in patients with mTBI to provide a foundation for improving existing ED guidelines. METHODS The literature was searched using MEDLINE, EMBASE and Web of Science databases. Reference lists of major literature was cross-checked. The outcome variable was tICH on CT. Odds ratios (OR) were pooled for independent risk factors. RESULTS After completion of screening, 17 papers were selected for inclusion, with a pooled patient population of 26,040 where 2,054 cases of tICH were verified through CT (7.9%). Signs of a skull base fracture (OR 11.71, 95% CI 5.51-24.86), GCS < 15 (OR 4.69, 95% CI 2.76-7.98), loss of consciousness (OR 2.57, 95% CI 1.83-3.61), post-traumatic amnesia (OR 2.13, 95% CI 1.27-3.57), post-traumatic vomiting (OR 2.04, 95% CI 1.11-3.76), antiplatelet therapy (OR 1.54, 95% CI 1.10-2.15) and male sex (OR 1.28, 95% CI 1.11-1.49) were determined in the data synthesis to be statistically significant predictors of tICH. CONCLUSION Our meta-analysis provides additional context to predictors associated with high and low risk for tICH in mTBI. In contrast to signs of a skull base fracture and reduction in GCS, some elements used in ED guidelines such as anticoagulant use, headache and intoxication were not predictive of tICH. Even though there were multiple sources of heterogeneity across studies, these findings suggest that there is potential for improvement over existing guidelines as well as a the need for better prospective trials with consideration for common data elements in this area. PROSPERO registration number CRD42023392495.
Collapse
Affiliation(s)
- Li Jin Yang
- Department of Emergency Medicine, Stockholm South General Hospital, Stockholm, Sweden.
- Department of Clinical Science and Education Södersjukhuset, Karolinska Institutet, Stockholm, Sweden.
| | - Philipp Lassarén
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
| | - Filippo Londi
- Department of Cardiac Surgery, Sant'Orsola-Malpighi Hospital, University of Bologna, Bologna, Italy
| | - Leonardo Palazzo
- Department of Neurology, San Raffaele Scientific Institute, Milan, Italy
| | - Alexander Fletcher-Sandersjöö
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
- Department of Neurosurgery, Karolinska University Hospital, Stockholm, Sweden
| | - Kristian Ängeby
- Department of Emergency Medicine, Stockholm South General Hospital, Stockholm, Sweden
- Department of Clinical Science and Education Södersjukhuset, Karolinska Institutet, Stockholm, Sweden
| | - Eric Peter Thelin
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
- Medical Unit Neurology, Karolinska University Hospital, Stockholm, Sweden
| | - Rebecka Rubenson Wahlin
- Department of Clinical Science and Education Södersjukhuset, Karolinska Institutet, Stockholm, Sweden
- Department of Perioperative Medicine and Intensive Care, Karolinska University Hospital, Stockholm, Sweden
| |
Collapse
|
4
|
Papa L, McKinley WI, Valadka AB, Newman ZC, Nordgren RK, Pramuka PE, Barbosa CE, Brito AMP, Loss LJ, Tinoco-Garcia L, Hinson HE, Schreiber MA, Rowell SE. Diagnostic Performance of GFAP, UCH-L1, and MAP-2 Within 30 and 60 Minutes of Traumatic Brain Injury. JAMA Netw Open 2024; 7:e2431115. [PMID: 39230905 PMCID: PMC11375473 DOI: 10.1001/jamanetworkopen.2024.31115] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/18/2024] [Accepted: 06/24/2024] [Indexed: 09/05/2024] Open
Abstract
Importance Data on the performance of traumatic brain injury (TBI) biomarkers within minutes of injury are lacking. Objectives To examine the performance of glial fibrillary acidic protein (GFAP), ubiquitin carboxy-terminal hydrolase L1 (UCH-L1), and microtubule-associated protein 2 (MAP-2) within 30 and 60 minutes of TBI in identifying intracranial lesions on computed tomography (CT) scan, need for neurosurgical intervention (NSI), and clinically important early outcomes (CIEO). Design, Setting, and Participants This cohort study is a biomarker analysis of a multicenter prehospital TBI cohort from the Prehospital Tranexamic Acid Use for TBI clinical trial conducted across 20 centers and 39 emergency medical systems in North America from May 2015 to March 2017. Prehospital hemodynamically stable adult patients with traumatic injury and suspected moderate to severe TBI were included. Blood samples were measured for GFAP, UCH-L1, and MAP-2. Data were analyzed from December 1, 2023, to March 15, 2024. Main Outcomes and Measures The presence of CT lesions, diffuse injury severity on CT, NSI within 24 hours of injury, and CIEO (composite outcome including early death, neurosurgery, or prolonged mechanical ventilation ≥7 days) within 7 days of injury. Results Of 966 patients enrolled, 804 patients (mean [SD] age, 41 [19] years; 418 [74.2%] male) had blood samples, including 563 within 60 minutes and 375 within 30 minutes of injury. Among patients with blood drawn within 30 minutes of injury, 212 patients (56.5%) had CT lesions, 61 patients (16.3%) had NSI, and 112 patients (30.0%) had CIEO. Among those with blood drawn within 60 minutes, 316 patients (56.1%) had CT lesions, 95 patients (16.9%) had NSI, and 172 patients (30.6%) had CIEO. All biomarkers showed significant elevations with worsening diffuse injury on CT within 30 and 60 minutes of injury. Among blood samples taken within 30 minutes, GFAP had the highest area under the receiver operating characteristic curve (AUC) to detect CT lesions, at 0.88 (95% CI, 0.85-0.92), followed by MAP-2 (AUC, 0.78; 95% CI, 0.73-0.83) and UCH-L1 (AUC, 0.75; 95% CI, 0.70-0.80). Among blood samples taken within 60 minutes, AUCs for CT lesions were 0.89 (95% CI, 0.86-0.92) for GFAP, 0.76 (95% CI, 0.72-0.80) for MAP-2, and 0.73 (95% CI, 0.69-0.77) for UCH-L1. Among blood samples taken within 30 minutes, AUCs for NSI were 0.78 (95% CI, 0.72-0.84) for GFAP, 0.75 (95% CI, 0.68-0.81) for MAP-2, and 0.69 (95% CI, 0.63-0.75) for UCH-L1; and for CIEO, AUCs were 0.89 (95% CI, 0.85-0.93) for GFAP, 0.83 (95% CI, 0.78-0.87) for MAP-2, and 0.77 (95% CI, 0.72-0.82) for UCH-L1. Combining the biomarkers was no better than GFAP alone for all outcomes. At GFAP of 30 pg/mL within 30 minutes, sensitivity for CT lesions was 98.1% (95% CI, 94.9%-99.4%) and specificity was 34.4% (95% CI, 27.2%-42.2%). GFAP levels greater than 6200 pg/mL were associated with high risk of NSI and CIEO. Conclusions and Relevance In this cohort study of prehospital patients with TBI, GFAP, UCH-L1, and MAP-2 measured within 30 and 60 minutes of injury were significantly associated with traumatic intracranial lesions and diffuse injury severity on CT scan, 24-hour NSI, and 7-day CIEO. GFAP was the strongest independent marker associated with all outcomes. This study sets a precedent for the early utility of GFAP in the first 30 minutes from injury in future clinical and research endeavors.
Collapse
Affiliation(s)
- Linda Papa
- Department of Emergency Medicine, Orlando Regional Medical Center, Orlando, Florida
| | - W. Ian McKinley
- Department of Surgery, The University of Chicago Medicine, Chicago, Illinois
| | - Alex B. Valadka
- Department of Neurological Surgery, University of Texas Southwestern Medical Center, Dallas
| | - Zachary C. Newman
- Pritzker School of Medicine, University of Chicago, Chicago, Illinois
| | - Rachel K. Nordgren
- Department of Public Health Sciences, University of Chicago, Chicago, Illinois
| | - Pierce E. Pramuka
- Department of Surgery, The University of Chicago Medicine, Chicago, Illinois
| | - Claire E. Barbosa
- Department of Social Sciences and Psychology, University of Chicago, Chicago, Illinois
| | | | - Lindsey J. Loss
- Department of Surgery, Oregon Health and Science University, Portland
| | | | - H. E. Hinson
- Department of Neurology, University of California, San Francisco
| | | | - Susan E. Rowell
- Department of Surgery, The University of Chicago Medicine, Chicago, Illinois
| |
Collapse
|
5
|
Akie TE, Gupta M, Rodriguez RM, Hendey GW, Wilson JL, Quinones AK, Mower WR. Characteristics of Intracranial Injuries in Pediatric Patients Following Blunt Head Trauma. Pediatr Emerg Care 2024; 40:e202-e208. [PMID: 38748466 DOI: 10.1097/pec.0000000000003214] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/30/2024]
Abstract
OBJECTIVES Pediatric head trauma is a frequent reason for presentation to the emergency department. Despite this, there are few reports on specific characteristics and injury patterns in head injured children. The goal of this study was to evaluate head injury patterns in children with blunt head injury and their prevalence by age group. METHODS This is a planned secondary analysis of the NEXUS II Head CT validation study. Consecutive patients with blunt head trauma were enrolled between 2006 and 2015. Demographics and criteria from 2 clinical decision instruments (NEXUS and Canadian Head CT rules) were gathered at the time of enrollment. We abstracted and cataloged injuries for pediatric patients based on radiologist report. Frequencies of injuries and severity were analyzed by developmental age group. RESULTS A total of 1018 pediatric patients were enrolled, 128 (12.6%) of whom had an injury on computed tomography scan. Median age was 11.9 (Interquartile range 4.5-15.5) for all patients and 12 (4.8-15.5) for injured patients. Of injured patients, 49 (38.3%) had a significant injury, and 27 (21.1%) received an intervention. Teenagers had the highest rate of significant injury (50%) and intervention (30%). Injuries were most frequently noted in the temporal (46.1%), frontal (45.3%), and parietal (45.3%) regions. Subarachnoid hemorrhage (29.7%) and subdural hematoma (28.9%) were the most common injuries observed.Intraparenchymal hemorrhage and cerebral edema were more prevalent in older age groups. The most common injury mechanism overall was fall from height (24.7%). Motor vehicle accidents and nonmotorized wheeled vehicle accidents were more common in older patients. CONCLUSIONS Serious injuries requiring intervention were rarely encountered in pediatric patients experiencing blunt head trauma. Mechanisms of injury, type of injury, and rates of intervention varied between developmental age groups.
Collapse
Affiliation(s)
| | | | - Robert M Rodriguez
- Department of Emergency Medicine, UCSF School of Medicine, San Francisco, CA
| | - Gregory W Hendey
- Department of Emergency Medicine, Ronald Reagan - UCLA Medical Center, Los Angeles
| | | | | | - William R Mower
- Department of Emergency Medicine, Ronald Reagan - UCLA Medical Center, Los Angeles
| |
Collapse
|
6
|
Shih RD, Alter SM, Wells M, Solano JJ, Engstrom G, Clayton LM, Hughes PG, Goldstein L, Lottenberg L, Ouslander JG. The Florida Geriatric Head Trauma CT Clinical Decision Rule. J Am Geriatr Soc 2024; 72:2738-2751. [PMID: 38959158 DOI: 10.1111/jgs.19057] [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: 01/26/2024] [Revised: 05/24/2024] [Accepted: 06/05/2024] [Indexed: 07/05/2024]
Abstract
BACKGROUND Several clinical decision rules have been devised to guide head computed tomography (CT) use in patients with minor head injuries, but none have been validated in patients 65 years or older. We aimed to derive and validate a head injury clinical decision rule for older adults. METHODS We conducted a secondary analysis of an existing dataset of consecutive emergency department (ED) patients >65 years old with blunt head trauma. The main predictive outcomes were significant intracranial injury and Need for Neurosurgical Intervention on CT. The secondary outcomes also considered in the model development and validation were All Injuries and All Intracranial Injuries. Predictor variables were identified using multiple variable logistic regression, and clinical decision rule models were developed in a split-sample derivation cohort and then tested in an independent validation cohort. RESULTS Of 5776 patients, 233 (4.0%) had significant intracranial injury and an additional 104 (1.8%) met CT criteria for Need for Neurosurgical Intervention. The best performing model, the Florida Geriatric Head Trauma CT Clinical Decision Rule, assigns points based on several clinical variables. If the points totaled 25 or more, a CT scan is indicated. The included predictors were arrival via Emergency Medical Services (+30 points), Glasgow Coma Scale (GCS) <15 (+20 points), GCS <14 (+50 points), antiplatelet medications (+17 points), loss of consciousness (+16 points), signs of basilar skull fracture (+50 points), and headache (+20 points). Utilizing this clinical decision rule in the validation cohort, a point total ≥25 had a sensitivity and specificity of 100.0% (95% CI: 96.0-100) and 12.3% (95% CI: 10.9-13.8), respectively, for significant intracranial injury and Need for Neurosurgical Intervention. CONCLUSIONS The Florida Geriatric Head Trauma CT Clinical Decision Rule has the potential to reduce unnecessary CT scans in older adults, without compromising safe emergency medicine practice.
Collapse
Affiliation(s)
- Richard D Shih
- Charles E. Schmidt College of Medicine, Florida Atlantic University, Boca Raton, Florida, USA
- Depatment of Emergency Medicine, Delray Medical Center, Delray Beach, Florida, USA
| | - Scott M Alter
- Charles E. Schmidt College of Medicine, Florida Atlantic University, Boca Raton, Florida, USA
- Depatment of Emergency Medicine, Delray Medical Center, Delray Beach, Florida, USA
- Depatment of Emergency Medicine, Bethesda Hospital East, Boynton Beach, Florida, USA
| | - Mike Wells
- Charles E. Schmidt College of Medicine, Florida Atlantic University, Boca Raton, Florida, USA
| | - Joshua J Solano
- Charles E. Schmidt College of Medicine, Florida Atlantic University, Boca Raton, Florida, USA
- Depatment of Emergency Medicine, Delray Medical Center, Delray Beach, Florida, USA
- Depatment of Emergency Medicine, Bethesda Hospital East, Boynton Beach, Florida, USA
| | - Gabriella Engstrom
- Charles E. Schmidt College of Medicine, Florida Atlantic University, Boca Raton, Florida, USA
| | - Lisa M Clayton
- Charles E. Schmidt College of Medicine, Florida Atlantic University, Boca Raton, Florida, USA
- Depatment of Emergency Medicine, Delray Medical Center, Delray Beach, Florida, USA
- Depatment of Emergency Medicine, Bethesda Hospital East, Boynton Beach, Florida, USA
| | - Patrick G Hughes
- Charles E. Schmidt College of Medicine, Florida Atlantic University, Boca Raton, Florida, USA
- Depatment of Emergency Medicine, Delray Medical Center, Delray Beach, Florida, USA
- Depatment of Emergency Medicine, Bethesda Hospital East, Boynton Beach, Florida, USA
| | - Lara Goldstein
- Department of Emergency Medicine, Memorial Healthcare System, Hollywood, Florida, USA
| | - Lawrence Lottenberg
- Charles E. Schmidt College of Medicine, Florida Atlantic University, Boca Raton, Florida, USA
- Department of Surgery, St. Mary's Medical Center, West Palm Beach, Florida, USA
| | - Joseph G Ouslander
- Charles E. Schmidt College of Medicine, Florida Atlantic University, Boca Raton, Florida, USA
| |
Collapse
|
7
|
Nielsen KK, Hviid CVB, Handberg A, Christensen PA. Comparison of sample materials for S100b analysis. Scand J Clin Lab Invest 2024; 84:345-349. [PMID: 39153180 DOI: 10.1080/00365513.2024.2392247] [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: 03/12/2024] [Revised: 07/08/2024] [Accepted: 08/11/2024] [Indexed: 08/19/2024]
Abstract
Head injury is a potentially lethal and frequently occurring condition in the emergency department (ED). Reliable and fast diagnosis is important both for patients and flow in the ED. Circulating S100B is used to rule out the need for head computer tomography in low-risk patients with mild head injury. The flow of these patients through the ED would benefit from shorter turn-around time. Standard serum clotting tubes require 30-60 min clotting time, followed by an analysis time of 45 min. Here, we evaluated the performance of two alternative blood collection tubes; a rapid serum tube (RST) with a recommend clotting time of 5 min and a hirudin tube (HIR) for instant anticoagulation. S100B measurement was performed on paired blood samples from 221 subjects using a Roche Cobas 602 analyser. The performances of the alternative tubes were evaluated by method comparison to the standard serum clotting tube, repeatability and agreement of results obtained from alternative tubes compared with the standard clotting tube. Both alternative tubes had a minor positive bias (RST = 0.011 µg/L, HIR = 0.008 µg/L). The repeatability was 2% for RST and 10% for HIR, while being 4% for the standard clotting tube. In the agreement analysis, the positive and negative predictive values for RST were 62% and 100% while being 73% and 99% for HIR respectively. Our study suggests that RST is a feasible alternative to reduce laboratory turn-around time in S100b analysis.
Collapse
Affiliation(s)
- Kasper Krogh Nielsen
- Department of Clinical Biochemistry, Aalborg University Hospital, Aalborg, Denmark
| | - Claus Vinter Bødker Hviid
- Department of Clinical Biochemistry, Aalborg University Hospital, Aalborg, Denmark
- Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - Aase Handberg
- Department of Clinical Biochemistry, Aalborg University Hospital, Aalborg, Denmark
- Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - Peter Astrup Christensen
- Department of Clinical Biochemistry, Aalborg University Hospital, Aalborg, Denmark
- Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| |
Collapse
|
8
|
Chen YH, Handly N, Chang DC, Chen YW. Racial difference in receiving computed tomography for head injury patients in emergency departments. Am J Emerg Med 2024; 83:54-58. [PMID: 38964277 DOI: 10.1016/j.ajem.2024.06.025] [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: 12/20/2023] [Revised: 04/19/2024] [Accepted: 06/17/2024] [Indexed: 07/06/2024] Open
Abstract
STUDY OBJECTIVE Prior studies have suggested potential racial differences in receiving imaging tests in emergency departments (EDs), but the results remain inconclusive. In addition, most prior studies may only have limited racial groups for minority patients. This study aimed to investigate racial differences in head computed tomography (CT) administration rates in EDs among patients with head injuries. METHODS Patients with head injuries who visited EDs were examined. The primary outcome was patients receiving head CT during ED visits, and the primary exposure was patient race/ethnicity, including Asian, Hispanic, Non-Hispanic Black (Black), and Non-Hispanic White (White). Multivariable logistic regression analyses were performed using the National Hospital Ambulatory Medical Care Survey database, adjusting for patients and hospital characteristics. RESULTS Among 6130 patients, 51.9% received a head CT scan. Asian head injury patients were more likely to receive head CT than White patients (59.1% versus 54.0%, difference 5.1%, p < 0.001). This difference persisted in adjusted results (odds ratio, 1.52; 95% CI, 1.06-2.16, p = 0.022). In contrast, Black and Hispanic patients have no significant difference in receiving head CT than White patients after the adjustment. CONCLUSIONS Asian head injury patients were more likely to receive head CT than White patients. This difference may be attributed to the limited English proficiency among Asian individuals and the fact that there is a wide variety of different languages spoken by Asian patients. Future studies should examine rates of receiving other diagnostic imaging modalities among different racial groups and possible interventions to address this difference.
Collapse
Affiliation(s)
- Yuan-Hsin Chen
- Department of Surgery, Massachusetts General Hospital/Harvard Medical School, Boston, MA, United States of America
| | - Neal Handly
- Department of Emergency Medicine, Contra Costa Regional Medical Center, Martinez, CA, United States of America; Department of Emergency Medicine, Drexel University College of Medicine, Philadelphia, PA, United States of America
| | - David C Chang
- Department of Surgery, Massachusetts General Hospital/Harvard Medical School, Boston, MA, United States of America
| | - Ya-Wen Chen
- Department of Surgery, Massachusetts General Hospital/Harvard Medical School, Boston, MA, United States of America.
| |
Collapse
|
9
|
Karamian A, Seifi A, Lucke-Wold B. Effects of preinjury oral anticoagulants on the outcomes of traumatic brain injury in elderly patients: a systematic review and meta-analysis. Brain Inj 2024:1-15. [PMID: 39140511 DOI: 10.1080/02699052.2024.2392163] [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: 03/18/2024] [Revised: 08/01/2024] [Accepted: 08/09/2024] [Indexed: 08/15/2024]
Abstract
BACKGROUND With the increasing cases of TBI cases in the elderly population taking anticoagulants for comorbidities, there is a need to better understand the safety of new anticoagulants and how to manage anticoagulated TBI patients. METHODS A meta-analysis using a random-effect model was conducted to compare the effect of preinjury use of DOACs and VKAs on the outcomes following TBI. RESULTS From 1951 studies, 49 studies with a total sample size of 15,180 met our inclusion criteria. Our meta-analysis showed no difference between preinjury use of DOACs or VKAs on ICH progression, in-hospital delayed ICH, delayed ICH at follow-up, and in-hospital mortality, but using DOACs was associated with a lower risk of immediate ICH (OR = 0.58; 95% CI = [0.42; 0.79]; p < 0.01) and neurosurgical interventions (OR = 0.59; 95% CI = [0.42; 0.82]; p < 0.01) compared to VKAs. Moreover, patients on DOACs experienced shorter length of stay in the hospital than those on VKAs (OR = -0.42; 95% CI = [-0.78; -0.07]; p = 0.02). CONCLUSION We found a lower risk of immediate ICH and surgical interventions as well as a shorter hospital stay in patients receiving DOACs compared to VKA users before the head injury.
Collapse
Affiliation(s)
- Armin Karamian
- School of Medicine, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Ali Seifi
- Department of Neurosurgery, University of Texas Health at San Antonio, San Antonio, Texas, USA
| | - Brandon Lucke-Wold
- Department of Neurosurgery, University of Florida, Gainesville, Florida, USA
| |
Collapse
|
10
|
Rowe BH, Yang E, Corrick S, Hussain MW. Reducing computed tomography (CT) imaging for adults with minor traumatic brain injuries in the emergency department. BMJ 2024; 386:e074867. [PMID: 39137946 DOI: 10.1136/bmj-2023-074867] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/15/2024]
Affiliation(s)
- Brian H Rowe
- Department of Emergency Medicine, Faculty of Medicine & Dentistry, College of Health Sciences, University of Alberta, Edmonton, Alberta, Canada
- School of Public Health, College of Health Science, University of Alberta
| | - Esther Yang
- Department of Emergency Medicine, Faculty of Medicine & Dentistry, College of Health Sciences, University of Alberta, Edmonton, Alberta, Canada
- SPOR SUPPORT Unit, Alberta Health Services (AHS), Edmonton
| | - Shaina Corrick
- Department of Emergency Medicine, Faculty of Medicine & Dentistry, College of Health Sciences, University of Alberta, Edmonton, Alberta, Canada
| | - M Wasif Hussain
- Department of Medicine, Division of Neurology, Faculty of Medicine & Dentistry, College of Health Sciences, University of Alberta
| |
Collapse
|
11
|
Wharton T, Bailey M, Peterson A, Sarmiento K, Bleser JA, Costello EH. Medical Coders' Use of the ICD-10-CM "Unspecified" Codes for Head and Brain Injury in Emergency Department Settings. JOURNAL OF PUBLIC HEALTH MANAGEMENT AND PRACTICE 2024:00124784-990000000-00281. [PMID: 39121394 DOI: 10.1097/phh.0000000000002003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/11/2024]
Abstract
CONTEXT In the emergency department (ED) setting, prioritizing triage and patient care may lead to challenges in capturing detailed documentation necessary for specific International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM) coding in medical records. Consequently, the prevalent use of the "unspecified head injury" code poses concerns about the precision of ED-based administrative billing claims data when analyzed for public health surveillance of nonfatal traumatic brain injuries (TBIs). Understanding the perspective of medical coders can illuminate coding processes and opportunities to enhance coding accuracy for TBI and other head injuries in the ED. OBJECTIVE This evaluation explores medical coders' perspectives and challenges when assigning ICD-10-CM codes to head injuries in the ED. DESIGN This qualitative evaluation utilized a phenomenological approach, which employed semi-structured interviews to understand medical coders' perspectives, processes, and coding determinations for head injuries in the ED. SETTING Interviews were conducted using a HIPAA-compliant video-based platform between July 2022 and January 2023. PARTICIPANTS Seventeen medical coders with ED coding experience were interviewed. Their backgrounds were diverse, though most had more than 15 years of experience. MAIN OUTCOMES Four qualitative themes emerged, which highlighted challenges with lack of detailed documentation, defaulting to unspecified codes, time, and productivity pressure, and additional insights into coders' assumptions and code determination processes. RESULTS Medical coders expressed challenges assigning ICD-10-CM codes to the highest level of specificity, citing issues including insufficient documentation by ED providers and terminology variations. Workplace time constraints and pressure for expedited claims also led to defaulting to unspecified codes. CONCLUSIONS This evaluation highlights the need for improved documentation consistency and detail in ED records to facilitate accurate ICD-10-CM coding. Alleviating time pressures, improving algorithms, and offering specialized training opportunities to medical coders could be helpful steps to improve coding specificity and data accuracy for head injuries in the ED.
Collapse
Affiliation(s)
- Tracy Wharton
- Author Affiliations: National Network of Public Health Institutes, Washington, District of Columbia (Dr Wharton, Ms Bailey, Ms Bleser, and Ms Costello); and Centers for Disease Control and Prevention, Division of Injury Prevention, Atlanta, Georgia (Dr Peterson and Ms Sarmiento)
| | | | | | | | | | | |
Collapse
|
12
|
Niklasson E, Svensson E, André L, Areskoug C, Forberg JL, Vedin T. Higher risk of traumatic intracranial hemorrhage with antiplatelet therapy compared to oral anticoagulation-a single-center experience. Eur J Trauma Emerg Surg 2024; 50:1237-1248. [PMID: 38512417 PMCID: PMC11458661 DOI: 10.1007/s00068-024-02493-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] [Received: 11/13/2023] [Accepted: 02/27/2024] [Indexed: 03/23/2024]
Abstract
PURPOSE Traumatic brain injury is the main reason for the emergency department visit of up to 3% of the patients and a major worldwide cause for morbidity and mortality. Current emergency management guidelines recommend close attention to patients taking oral anticoagulation but not patients on antiplatelet therapy. Recent studies have begun to challenge this. The aim of this study was to determine the impact of antiplatelet therapy and oral anticoagulation on traumatic intracranial hemorrhage. METHODS Medical records of adult patients triaged with "head injury" as the main reason for emergency care were retrospectively reviewed from January 1, 2017, to December 31, 2017, and January 1, 2020, to December 31, 2021. Patients ≥ 18 years with head trauma were included. Odds ratio was calculated, and multiple logistic regression was performed. RESULTS A total of 4850 patients with a median age of 70 years were included. Traumatic intracranial hemorrhage was found in 6.2% of the patients. The risk ratio for traumatic intracranial hemorrhage in patients on antiplatelet therapy was 2.25 (p < 0.001, 95% confidence interval 1.73-2.94) and 1.38 (p = 0.002, 95% confidence interval 1.05-1.84) in patients on oral anticoagulation compared to patients without mediations that affect coagulation. In binary multiple regression, antiplatelet therapy was associated with intracranial hemorrhage, but oral anticoagulation was not. CONCLUSION This study shows that antiplatelet therapy is associated with a higher risk of traumatic intracranial hemorrhage compared to oral anticoagulation. Antiplatelet therapy should be given equal or greater consideration in the guidelines compared to anticoagulation therapy. Further studies on antiplatelet subtypes within the context of head trauma are recommended to improve the guidelines' diagnostic accuracy.
Collapse
Affiliation(s)
- Emily Niklasson
- Clinical Sciences, Malmö, Clinical Research Centre, CRC, Lund University, Plan 11, Jan Waldenströms Gata 35, Malmö, Sweden
| | - Elin Svensson
- Clinical Sciences, Malmö, Clinical Research Centre, CRC, Lund University, Plan 11, Jan Waldenströms Gata 35, Malmö, Sweden
| | - Lars André
- Clinical Sciences, Helsingborg, Lund University, Svartbrödragränden 3-5, 251 87, Helsingborg, Sweden
| | - Christian Areskoug
- Clinical Sciences, Malmö, Clinical Research Centre, CRC, Lund University, Plan 11, Jan Waldenströms Gata 35, Malmö, Sweden
| | - Jakob Lundager Forberg
- Clinical Sciences, Helsingborg, Lund University, Svartbrödragränden 3-5, 251 87, Helsingborg, Sweden
| | - Tomas Vedin
- Clinical Sciences, Malmö, Clinical Research Centre, CRC, Lund University, Plan 11, Jan Waldenströms Gata 35, Malmö, Sweden.
| |
Collapse
|
13
|
Backus BE, Moustafa F, Skogen K, Sapin V, Rane N, Moya-Torrecilla F, Biberthaler P, Tenovuo O. Consensus paper on the assessment of adult patients with traumatic brain injury with Glasgow Coma Scale 13-15 at the emergency department: A multidisciplinary overview. Eur J Emerg Med 2024; 31:240-249. [PMID: 38744295 DOI: 10.1097/mej.0000000000001140] [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: 05/16/2024]
Abstract
Traumatic brain injury (TBI) is a common reason for presenting to emergency departments (EDs). The assessment of these patients is frequently hampered by various confounders, and diagnostics is still often based on nonspecific clinical signs. Throughout Europe, there is wide variation in clinical practices, including the follow-up of those discharged from the ED. The objective is to present a practical recommendation for the assessment of adult patients with an acute TBI, focusing on milder cases not requiring in-hospital care. The aim is to advise on and harmonize practices for European settings. A multiprofessional expert panel, giving consensus recommendations based on recent scientific literature and clinical practices, is employed. The focus is on patients with a preserved consciousness (Glasgow Coma Scale 13-15) not requiring in-hospital care after ED assessment. The main results of this paper contain practical, clinically usable recommendations for acute clinical assessment, decision-making on acute head computerized tomography (CT), use of biomarkers, discharge options, and needs for follow-up, as well as a discussion of the main features and risk factors for prolonged recovery. In conclusion, this consensus paper provides a practical stepwise approach for the clinical assessment of patients with an acute TBI at the ED. Recommendations are given for the performance of acute head CT, use of brain biomarkers and disposition after ED care including careful patient information and organization of follow-up for those discharged.
Collapse
Affiliation(s)
- Barbra E Backus
- Emergency Department, Franciscus Gasthuis and Vlietland, Rotterdam
- Emergency Department, Elisabeth-Tweesteden Hospital, Tilburg, The Netherlands
| | - Farès Moustafa
- Emergency Department, University Hospital Clermont Auvergne, Clermont-Ferrand, France
| | - Karoline Skogen
- Department of Radiology and Nuclear Medicine, Oslo University Hospitals, Oslo, Norway
| | - Vincent Sapin
- Biochemistry and Molecular Genetics Department, University Hospital Clermont Auvergne, Clermont-Ferrand, France
| | - Neil Rane
- Department of Neuroradiology, St Marys Hospital Major Trauma Centre, Imperial College London NHS Trust
| | - Francisco Moya-Torrecilla
- Physical Therapy Department, School of Health Sciences, University of Malaga, Spain
- International Medical Services, Vithas Xanit International Hospital, Malaga, Spain
| | - Peter Biberthaler
- Department of Trauma Surgery, Klinikum rechts der Isar Technische Universität, Munich, Germany
| | - Olli Tenovuo
- Department of Clinical Medicine, University of Turku, Turku, Finland
| |
Collapse
|
14
|
Mikolić A, Brasher PMA, Brubacher JR, Panenka W, Scheuermeyer FX, Archambault P, Khazei A, Silverberg ND. External Validation of the Post-Concussion Symptoms Rule for Predicting Mild Traumatic Brain Injury Outcome. J Neurotrauma 2024; 41:1929-1936. [PMID: 38226635 DOI: 10.1089/neu.2023.0484] [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] [Indexed: 01/17/2024] Open
Abstract
Persistent symptoms are common after a mild traumatic brain injury (mTBI). The Post-Concussion Symptoms (PoCS) Rule is a newly developed clinical decision rule for the prediction of persistent post-concussion symptoms (PPCS) 3 months after an mTBI. The PoCS Rule includes assessment of demographic and clinical characteristics and headache presence in the emergency department (ED), and follow-up assessment of symptoms at 7 days post-injury using two thresholds (lower/higher) for symptom scoring. We examined the PoCS Rule in an independent sample. We analyzed a clinical trial that recruited participants with mTBI from EDs in Greater Vancouver, Canada. The primary analysis used data from 236 participants, who were randomized to a usual care control group, and completed the Rivermead Postconcussion Symptoms Questionnaire at 3 months. The primary outcome was PPCS, as defined by the PoCS authors. We assessed the overall performance of the PoCS rule (area under the receiver operating characteristic curve [AUC]), sensitivity, and specificity. More than 40% of participants (median age 38 years, 59% female) reported PPCS at 3 months. Most participants (88%) were categorized as being at medium risk based on the ED assessment, and a majority were considered as being at high risk according to the final PoCS Rule (81% using a lower threshold and 72% using a higher threshold). The PoCS Rule showed a sensitivity of 93% (95% confidence interval [CI], 88-98; lower threshold) and 85% (95% CI, 78-92; higher threshold), and a specificity of 28% (95% CI, 21-36) and 37% (95% CI, 29-46), respectively. The overall performance was modest (AUC 0.61, 95% CI 0.59, 0.65). In conclusion, the PoCS Rule was sensitive for PPCS, but had a low specificity in our sample. Follow-up assessment of symptoms can improve risk stratification after mTBI.
Collapse
Affiliation(s)
- Ana Mikolić
- Department of Psychology, University of British Columbia, Vancouver, British Columbia, Canada
- Rehabilitation Research Program, Centre for Aging SMART at Vancouver Coastal Health, Vancouver, British Columbia, Canada
| | - Penelope M A Brasher
- Centre for Clinical Epidemiology & Evaluation, Vancouver Coastal Health Research Institute, Vancouver, British Columbia, Canada
| | - Jeffrey R Brubacher
- Department of Emergency Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | - William Panenka
- Department of Psychiatry, University of British Columbia, Vancouver, British Columbia, Canada
- British Columbia Provincial Neuropsychiatry Program, Vancouver, British Columbia, Canada
- Department of Djavad Mowafaghian Centre for Brain Health, University of British Columbia, Vancouver, British Columbia, Canada
| | - Frank X Scheuermeyer
- Department of Emergency Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | - Patrick Archambault
- Department of Djavad Mowafaghian Centre for Brain Health, University of British Columbia, Vancouver, British Columbia, Canada
| | - Afshin Khazei
- Department of Emergency Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | - Noah D Silverberg
- Department of Psychology, University of British Columbia, Vancouver, British Columbia, Canada
- Rehabilitation Research Program, Centre for Aging SMART at Vancouver Coastal Health, Vancouver, British Columbia, Canada
- Department of Family and Emergency Medicine, Université Laval, Québec, Québec, Canada
| |
Collapse
|
15
|
Arunachalam Jeykumar NS, Niban GM, Vadivel P, Masanam Kasi S. Mild Traumatic Brain Injury by the Glasgow Coma Scale Score and Early CT-Brain Findings in Acute Alcohol Intoxication Patients: A Prospective Observational Study. Cureus 2024; 16:e67669. [PMID: 39318935 PMCID: PMC11420600 DOI: 10.7759/cureus.67669] [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] [Accepted: 08/24/2024] [Indexed: 09/26/2024] Open
Abstract
Introduction Traumatic brain injuries (TBI) in recent years have proved to be a significant public health problem, with potentially life-changing consequences for the individual and their family. Alcohol consumption is a regular, well-documented problem among persons sustaining TBI due to road traffic accidents and accidental falls. The primary objective of this study was to find out the correlation between the Glasgow Coma Scale (GCS) score and CT brain findings among mild TBI patients under acute alcohol intoxication and determine if early CT-brain is indicated in this group. Methods A prospective observational study was conducted involving 111 alcohol-intoxicated patients with mild head injuries admitted to the surgical wards of Thanjavur Medical College Hospital over a period of three months. The Glasgow Coma Scale was used to assess the patient's neurological status and determine the severity of the brain injury. A semi-structured CT-brain findings chart and a severity of alcohol intoxication objective-based scoring system were developed and validated by experts. Descriptive statistics tools such as frequency, percentage, and mean were used, along with inferential statistics tools like the Chi-squared test, Fisher exact test, and Pearson's correlation coefficient test. Results The study findings showed that the comparison of GCS with early CT-brain was significant at a p-value of 0.012, and a negative correlation (r=-0.253) was found between GCS and CT-brain findings. A comparison of CT-brain findings with the severity of alcohol intoxication was non-significant at a p-value of 0.433. Conclusions Early CT-brain in intoxicated mild TBI patients may have a positive impact on early diagnosis and management, even in centers with limited resources catering to low-income population groups. The results of our short-term study show that early CT-Brain picks up lesions and helps initiate early management while it is up to the attending physician to keep in mind an adverse cost-benefit ratio in overuse of hospital resources and misdiagnosis leading to undertreatment causing long-term sequelae and morbidity before prescribing early CT-brain in this cohort of patients.
Collapse
Affiliation(s)
| | | | | | - Sumathy Masanam Kasi
- Medical Education, Jawaharlal Institute of Postgraduate Medical Education and Research, Pondicherry, IND
| |
Collapse
|
16
|
Forouzannia SM, Najafimehr H, Oskooi RK, Faridaalaee G, Dizaji SR, Toloui A, Forouzannia SA, Alavi SNR, Alizadeh M, Safari S, Baratloo A, Yousefifard M, Hosseini M. Clinical decision rules in predicting computed tomography scan findings and need for neurosurgical intervention in mild traumatic brain injury: a prospective observational study. Eur J Trauma Emerg Surg 2024; 50:1199-1207. [PMID: 37747501 DOI: 10.1007/s00068-023-02373-y] [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: 05/30/2023] [Accepted: 09/12/2023] [Indexed: 09/26/2023]
Abstract
PURPOSE In this study, we will compare the diagnostic values of head CT decision rules in predicting the findings of CT scans in a prospective multicenter study in university emergency departments in Iran. METHODS The primary outcome was any traumatic lesion findings in brain CT scans, and the secondary outcomes were death, the need for mechanical ventilation, and neurosurgical intervention. Decision rules including the Canadian CT Head Rule (CCHR), New Orleans Criteria (NOC), National Institute for Health and Clinical Excellence (NICE), National Emergency X-Radiography Utilization Study (NEXUS), and Neurotraumatology Committee of the World Federation of Neurosurgical Societies (NCWFNS) were compared for the main outcomes. RESULTS In total, 434 mild TBI patients were enrolled in the study. The NCWFNS had the highest sensitivity (91.14%) and the lowest specificity (39.42%) for predicting abnormal finding in CT scan compared to other models. While the NICE obtained the lowest sensitivity (79.75%), it was associated with the highest specificity (66.67%). All model performances were improved when administered to predict neurosurgical intervention among patients with GCS 13-15. NEXUS (AUC 0.862, 95% CI 0.799-0.924) and NCWFNS (AUC 0.813, 95% CI 0.723-0.903) had the best performance among all evaluated models. CONCLUSION The NCWFNS and the NEXUS decision rules performed better than the CCHR and NICE guidelines for predicting any lesion in the CT imaging and neurosurgical intervention among patients with mTBI with GCS 13-15. For a subset of mTBI patients with GCS 15, the NOC criteria have higher sensitivity for abnormal CT imaging, but lower specificity and more requested CTs.
Collapse
Affiliation(s)
| | - Hadis Najafimehr
- Department of Epidemiology and Biostatistics, School of Public Health, Tehran University of Medical Sciences, Tehran, Iran
| | | | - Gholamreza Faridaalaee
- Emergency Medicine and Trauma Research Center, Tabriz University of Medical Sciences, Tabriz, IR, Iran
- Department of Emergency Medicine, Maragheh University of Medical Sciences, Maragheh, IR, Iran
| | - Shayan Roshdi Dizaji
- Physiology Research Center, Iran University of Medical Sciences, Hemmat Highway, Tehran, Iran
| | - Amirmohammad Toloui
- Physiology Research Center, Iran University of Medical Sciences, Hemmat Highway, Tehran, Iran
| | - Seyed Ali Forouzannia
- Physiology Research Center, Iran University of Medical Sciences, Hemmat Highway, Tehran, Iran
| | | | - Mohammadreza Alizadeh
- Physiology Research Center, Iran University of Medical Sciences, Hemmat Highway, Tehran, Iran
| | - Saeed Safari
- Mens' Health and Reproductive Health Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran
- Emergency Department, Shohadaye Tajrish Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Alireza Baratloo
- Prehospital and Hospital Emergency Research Center, Tehran University of Medical Sciences, Tehran, Iran
| | - Mahmoud Yousefifard
- Physiology Research Center, Iran University of Medical Sciences, Hemmat Highway, Tehran, Iran.
| | - Mostafa Hosseini
- Department of Epidemiology and Biostatistics, School of Public Health, Tehran University of Medical Sciences, Poursina Ave. Enghelab Ave., Tehran, Iran.
| |
Collapse
|
17
|
Rezaee M, Nasehi MM, Effatpanah M, Jabbaripour S, Ghamkhar M, Karami H, Mehrizi R, Torabi P, Ghamkhar L. Overutilization of head computed tomography in cases of mild traumatic brain injury: a systematic review and meta-analysis. Emerg Radiol 2024; 31:551-565. [PMID: 38844658 DOI: 10.1007/s10140-024-02247-9] [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: 04/10/2024] [Accepted: 05/23/2024] [Indexed: 07/31/2024]
Abstract
Head computed tomography (CT) is the preferred imaging modality for mild traumatic brain injury (mTBI). The routine use of head CT in low-risk individuals with mild TBI offers no clinical benefit but also causes notable health and financial burden. Despite the availability of related guidelines, studies have reported considerable rate of non-indicated head CT requests. The objectives were to provide an overall estimate for the head CT overutilization rate and to identify the factors contributing to the overuse. A systematic review of PubMed, Scopus, Web of Science, and Embase databases was conducted up to November 2023, following PRISMA and MOOSE guidelines. Two reviewers independently selected eligible articles and extracted data. Quality assessment was performed using a bias risk tool, and a random-effects model was used for data synthesis. Fourteen studies, encompassing 28,612 patients, were included, with 27,809 undergoing head CT scans. Notably, 75% of the included studies exhibited a moderate to high risk of bias. The overutilization rate for pediatric and adult patients was 27% (95% CI: 5-50%) and 32% (95% CI: 21-44%), respectively. An alternative rate, focusing on low-risk pediatric patients, was 54% (95% CI: 20-89%). Overutilization rates showed no significant difference between teaching and non-teaching hospitals. Patients with mTBI from falls or assaults were less likely to receive non-indicated scans. There was no significant association between physician specialty or seniority and overuse, nor between patients' age or sex and the likelihood of receiving a non-indicated scan. Approximately one-third of head CT scans in mTBI cases are avoidable, underscoring the necessity for quality improvement programs to reduce unnecessary imaging and its associated burdens.
Collapse
Affiliation(s)
- Mehdi Rezaee
- Department of Orthopedics, School of Medicine, Tehran University of Medical Sciences, Tehran, Iran
| | - Mohammad Mehdi Nasehi
- Pediatric Neurology Research Center, Research Institute for Children's Health, Shahid Beheshti University of Medical Sciences, Tehran, Iran
- Pediatric Neurology Department, Mofid Children Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Mohammad Effatpanah
- Pediatric Department, School of Medicine, Imam Khomeini Hospital, Tehran University of Medical Sciences, National Center for Health Insurance Research, Tehran, Iran
| | - Sama Jabbaripour
- School of Medicine, Tehran University of Medical Sciences, Tehran, Iran
| | - Maryam Ghamkhar
- Islamic Azad University Challus Branch, Challus, Mazandaran, Iran
| | - Hossein Karami
- National Center for Health Insurance Research, Tehran, Iran
| | - Reza Mehrizi
- National Center for Health Insurance Research, Tehran, Iran
| | - Pegah Torabi
- Department of Radiology Arak, University of Medical Sciences, Arak, Iran
| | - Leila Ghamkhar
- Physical Therapy, National Center for Health Insurance Research, Tehran, Iran.
| |
Collapse
|
18
|
Karamian A, Seifi A, Karamian A, Lucke-Wold B. Incidence of intracranial bleeding in mild traumatic brain injury patients taking oral anticoagulants: a systematic review and meta-analysis. J Neurol 2024; 271:3849-3868. [PMID: 38755424 DOI: 10.1007/s00415-024-12424-y] [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: 02/26/2024] [Revised: 04/29/2024] [Accepted: 04/30/2024] [Indexed: 05/18/2024]
Abstract
BACKGROUND Traumatic brain injury (TBI) is one of the leading causes of disability and death worldwide. Most TBI cases occur in older people, because they are at a higher risk of accidental falling. As the population ages, the use of anticoagulants is increasing. Some serious complications of TBI, such as intracranial hemorrhage (ICH), may occur even in mild cases. According to the current guidelines regarding managing mild TBI patients, a CT head scan is recommended for all patients receiving anticoagulation. We aim to assess the incidence of ICH in patients with mild TBI taking oral anticoagulants. METHODS Our systematic review and meta-analysis were performed using the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) checklist. The protocol was registered in PROSPERO (CRD42024503086). Twenty-eight studies evaluating patients with a mild TBI from ten countries with a total sample size of 11,172, 5671 on DOACs, and 5501 on VKAs were included in our meta-analysis. RESULTS The random-effects overall incidence of ICH among oral anticoagulated patients with mild TBI was calculated to be 9.4% [95% CI 7.2-12.1%, I2 = 89%]. The rates of immediate ICH for patients taking DOACs and VKAs were 6.4% and 10.5%, respectively. The overall rate of immediate ICH in anticoagulated mild TBI patients was 8.5% [95% CI 6.6-10.9%], with a high heterogeneity between studies (I2 = 88%). Furthermore, the rates of delayed ICH in patients with mild TBI taking DOACs and VKAs were 1.6% and 1.9%, respectively. The overall incidence of delayed ICH among oral anticoagulated mild TBI patients was 1.7% [95% CI 1-2.8%, I2 = 79%]. The overall rate of ICH among mild TBI patients taking DOAC was calculated to be 7.3% [95% CI 5.2-10.3%], with significant heterogeneity between studies (I2 = 79%). However, the overall ICH rate is higher in patients who take only VKAs 11.3% [95% CI 8.6-14.7%, I2 = 83%]. Patients on DOACs were at lower risk of ICH after mild TBI compared to patients on VKAs (OR = 0.64, 95% CI 0.48-0.86, p < 0.01, I2 = 28%). CONCLUSION Our meta-analysis confirms the need for performing brain CT scan in patients with mild TBI patients who receive oral anticoagulants before injury. Due to limited data, further multi-center, prospective studies are warranted to confirm the true incidence of traumatic ICH in patients on anticoagulants.
Collapse
Affiliation(s)
- Armin Karamian
- School of Medicine, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Ali Seifi
- Department of Neurosurgery, University of Texas Health at San Antonio, San Antonio, TX, USA
| | - Amin Karamian
- Department of Biology and Anatomical Sciences, School of Medicine, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Brandon Lucke-Wold
- Department of Neurosurgery, University of Florida, Gainesville, FL, USA.
| |
Collapse
|
19
|
Chayoua W, Visser K, de Koning ME, Beishuizen A, IJmker R, van der Naalt J, Krabbe JG, van der Horn HJ. Evaluation of Glial Fibrillary Acidic Protein and Ubiquitin C-Terminal Hydrolase-L1 Using a Rapid Point of Care Test for Predicting Head Computed Tomography Lesions After Mild Traumatic Brain Injury in a Dutch Multi-Center Cohort. J Neurotrauma 2024; 41:e1630-e1640. [PMID: 38326742 DOI: 10.1089/neu.2023.0491] [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] [Indexed: 02/09/2024] Open
Abstract
Mild traumatic brain injury (mTBI) is a common condition seen in emergency departments worldwide. Blood-based biomarkers glial fibrillary acidic protein (GFAP) and ubiquitin C-terminal hydrolase-L1 (UCH-L1) are recently U.S. Food and Drug Administration-approved for the prediction of intracranial lesions on head computed tomography (CT) scans in mTBI. We evaluated the diagnostic performance of GFAP and UCH-L1 in a Dutch cohort using the i-STAT TBI assay. In a multi-center observational study, we enrolled 253 mTBI patients. Head CT scans were scored using the Marshall classification system. Logistic regression models were used to assess the contribution of biomarkers and clinical parameters to diagnostic performance. Detection of UCH-L1 and GFAP resulted in a sensitivity of 97% and specificity of 19% for CT positivity in mTBI patients, along with a negative predictive value of 95% (88-100%) and a positive predictive value of 27% (21-33%). Combining biomarker testing with loss of consciousness and time to sample increased specificity to 46%. Combined testing of UCH-L1 and GFAP testing resulted in possibly more unnecessary CT scans compared with GFAP testing alone, with only limited increase in sensitivity. This study confirmed high sensitivity of GFAP and UCH-L1 for CT abnormalities in mTBI patients using the i-STAT TBI test. The results support the potential use of GFAP and UCH-L1 as tools for determining the indication for CT scanning in mTBI patients, possibly offering a cost- and time-effective approach to management of patients with mTBI. Prospective studies in larger cohorts are warranted to validate our findings.
Collapse
Affiliation(s)
- Walid Chayoua
- Department of Clinical Chemistry and Laboratory Medicine, Medlon BV, Enschede, the Netherlands
- Department of Clinical Chemistry and Laboratory Medicine, Medisch Spectrum Twente, Enschede, the Netherlands
| | - Koen Visser
- Department of Neurology, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands
| | - Myrthe E de Koning
- Department of Neurology, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands
- Department of Neurology, Medisch Spectrum Twente, Enschede, the Netherlands
| | - Albertus Beishuizen
- Department of Intensive Care Medicine, Medisch Spectrum Twente, Enschede, the Netherlands
| | - Rein IJmker
- Department of Emergency Medicine, Medisch Spectrum Twente, Enschede, the Netherlands
| | - Joukje van der Naalt
- Department of Neurology, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands
| | - Johannes G Krabbe
- Department of Clinical Chemistry and Laboratory Medicine, Medlon BV, Enschede, the Netherlands
- Department of Clinical Chemistry and Laboratory Medicine, Medisch Spectrum Twente, Enschede, the Netherlands
| | - Harm Jan van der Horn
- Department of Neurology, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands
| |
Collapse
|
20
|
Elias J, Sutherland E, Kennedy E. Concussion Management in Older People: A Scoping Review. J Head Trauma Rehabil 2024; 39:293-303. [PMID: 38453625 DOI: 10.1097/htr.0000000000000933] [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: 03/09/2024]
Abstract
OBJECTIVE To map existing literature about concussion management in older people, identifying and analyzing gaps in our understanding. CONTEXT Concussion injuries affect older people, yet little guidance is available about how to approach concussion management with older people. Research does not always include older populations, and it is unclear to what extent standard concussion management is appropriate for older people. DESIGN Scoping review. METHOD A structured literature search was conducted using 4 databases to identify existing literature relating to concussion management in older people. Studies that assessed outcomes relating to the management of concussion/mild traumatic brain injury in those 65 years or older were included and mapped according to the main themes addressed. RESULTS The search yielded a total of 18 articles. Three themes related to early management (use of anticoagulants n = 6, intracranial lesions n = 3, and service delivery for older people n = 5), and 1 theme related to general management (cognitive issues n = 4). A lack of articles exploring general management in older people was observed. CONCLUSION Existing literature indicates that specific management strategies are needed for older people with concussion, especially in early management. This review highlights that good evidence is available about early management and this is reflected in some guidelines, yet little evidence about general management is available and this gap is not acknowledged in guidelines. Distinct approaches to early management in older people are clearly recommended to mitigate the risk of poor outcomes. In contrast, general concussion management for older people is poorly understood, with older people poorly represented in research. A better understanding is needed because-as observed in early management-older people have distinct characteristics that may render standard management approaches unsuitable.
Collapse
Affiliation(s)
- Josh Elias
- Author Affiliations: Centre for Health, Activity, and Rehabilitation Research, School of Physiotherapy, University of Otago, Dunedin, New Zealand (Mr Elias and Dr Kennedy); and Department of Physiology, University of Otago, Dunedin, New Zealand (Ms Sutherland)
| | | | | |
Collapse
|
21
|
Eryilmaz A, Sahin T. Comparison of scoring systems for patients with head injury presenting to the emergency department. Eur J Trauma Emerg Surg 2024:10.1007/s00068-024-02589-6. [PMID: 38940949 DOI: 10.1007/s00068-024-02589-6] [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: 11/16/2023] [Accepted: 06/14/2024] [Indexed: 06/29/2024]
Abstract
PURPOSE The present study aimed to compare the National Emergency X-Radiography Utilization Study II (NEXUS-II), New Orleans Criteria (NOC), Canadian Computed Tomography (CT) Head Rule (CCTHR) scoring systems, and Advanced Trauma Life Support (ATLS®) 10th edition algorithm in patients with head injury presenting to the emergency department and to investigate the effectiveness of these scoring systems in determining injury severity and the need for cranial CT scanning. METHODS This prospective and observational study was conducted in a tertiary care emergency medicine clinic. The study included 794 adult patients who had a Glasgow Coma Scale (GCS) score ≥ 13, and were considered as having minor head injury. Patients included in the study were categorized as having low or high risk according to the CCTHR, NOC, NEXUS-II scores, and ATLS algorithm. RESULTS The mean age of the patients was 40.7 ± 18.7 years, and 592 (74.6%) were male. The proportion of patients considered as having high risk was 27.7%, 84.8%, and 34.5% according to CCTHR, NOC, and NEXUS-II, respectively. According to the ATLS, 14.7% and 14.1% of the patients were considered at medium risk and high risk, respectively. CT scanning was performed in 757 (95.3%) patients, and pathologic findings were detected in 18 patients (2.3%). NOC in contrary showed a sensitivity of 100% but a specificity of 15.6%. CONCLUSION In our region, there was no significant difference among the CCTHR, NEXUS-II systems, and ATLS algorithm regarding the accuracy of pathological findings in patients with head injury; any of these systems can be used in clinical practice and determining CT scan necessity. Although the sensitivity of the NOC system is very high, it has been observed that its low specificity may lead to a large number of unnecessary CT scans, which may increase the patient-based cost and waiting time in the emergency department.
Collapse
Affiliation(s)
- Alihan Eryilmaz
- Emergency Medicine Clinic, Inegol State Hospital, Bursa, Türkiye, Turkey
| | - Taner Sahin
- Department of Emergency Medicine, University of Health Science Kayseri Medicine Faculty, Kayseri, Türkiye, Turkey.
| |
Collapse
|
22
|
Menditto VG, Rossetti G, Sampaolesi M, Buzzo M, Pomponio G. Traumatic Brain Injury in Patients under Anticoagulant Therapy: Review of Management in Emergency Department. J Clin Med 2024; 13:3669. [PMID: 38999235 PMCID: PMC11242576 DOI: 10.3390/jcm13133669] [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: 04/26/2024] [Revised: 06/15/2024] [Accepted: 06/17/2024] [Indexed: 07/14/2024] Open
Abstract
The best management of patients who suffer from traumatic brain injury (TBI) while on oral anticoagulants is one of the most disputed problems of emergency services. Indeed, guidelines, clinical decision rules, and observational studies addressing this topic are scarce and conflicting. Moreover, relevant issues such as the specific treatment (and even definition) of mild TBI, rate of delayed intracranial injury, indications for neurosurgery, and anticoagulant modulation are largely empiric. We reviewed the most recent evidence on these topics and explored other clinically relevant aspects, such as the promising role of dosing brain biomarkers, the strategies to assess the extent of anticoagulation, and the indications of reversals and tranexamic acid administration, in cases of mild TBI or as a bridge to neurosurgery. The appropriate timing of anticoagulant resumption was also discussed. Finally, we obtained an insight into the economic burden of TBI in patients on oral anticoagulants, and future directions on the management of this subpopulation of TBI patients were proposed. In this article, at the end of each section, a "take home message" is stated.
Collapse
Affiliation(s)
- Vincenzo G Menditto
- Emergency and Internal Medicine Department, Azienda Ospedaliero Universitaria delle Marche, 60126 Ancona, Italy
| | - Giulia Rossetti
- Internal Medicine, Santa Croce Hospital AST1 Pesaro Urbino, 61032 Fano, Italy
| | - Mattia Sampaolesi
- Emergency and Internal Medicine Department, Azienda Ospedaliero Universitaria delle Marche, 60126 Ancona, Italy
| | - Marta Buzzo
- Emergency and Internal Medicine Department, Azienda Ospedaliero Universitaria delle Marche, 60126 Ancona, Italy
| | - Giovanni Pomponio
- Clinica Medica, Azienda Ospedaliero Universitaria delle Marche, 60126 Ancona, Italy
| |
Collapse
|
23
|
Zibetti M, Di Resta C, Banfi G, Tomaiuolo R. Value-Based Health Care Implementation: The Case Study of mTBI Biomarkers. J Pers Med 2024; 14:634. [PMID: 38929855 PMCID: PMC11204511 DOI: 10.3390/jpm14060634] [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: 05/15/2024] [Revised: 06/09/2024] [Accepted: 06/11/2024] [Indexed: 06/28/2024] Open
Abstract
Traumatic brain injury is a significant global health issue, affecting approximately 69 million people annually. Early diagnosis is crucial for effective management, and biomarkers provide a promising approach to identifying traumatic brain injury in various settings. This study investigates the perceived usefulness of biomarker testing in two distinct contexts: emergency departments and sports settings. Comprehensive interviews were conducted among healthcare professionals in emergency departments and sports-related medical staff. The interviews assessed their perceptions of the diagnostic accuracy, practicality, and overall value of traumatic brain injury biomarker testing. The findings indicate that the perceived usefulness of biomarker testing is high among professionals in both settings. However, significant differences emerged in the perceived barriers to implementation, with emergency department staff citing logistical issues and sports professionals expressing cost concerns. Addressing identified barriers could enhance the adoption and effectiveness of these tests, ultimately improving patient outcomes. Future research should focus on optimizing testing protocols and reducing implementation challenges. This study aims to evaluate the implementation of mild traumatic brain injury biomarkers within the framework of value-based health care, focusing on diagnostic accuracy and patient outcomes.
Collapse
Affiliation(s)
- Martina Zibetti
- Faculty of Medicine, Università Vita-Salute San Raffaele, 20132 Milan, Italy
| | - Chiara Di Resta
- Faculty of Medicine, Università Vita-Salute San Raffaele, 20132 Milan, Italy
| | - Giuseppe Banfi
- Faculty of Medicine, Università Vita-Salute San Raffaele, 20132 Milan, Italy
- IRCCS Galeazzi-Sant’Ambrogio, 20157 Milan, Italy
| | - Rossella Tomaiuolo
- Faculty of Medicine, Università Vita-Salute San Raffaele, 20132 Milan, Italy
- IRCCS Galeazzi-Sant’Ambrogio, 20157 Milan, Italy
| |
Collapse
|
24
|
Cooper RJ, Akie TE, Gujral T, Rana S, Bui K, Factora R, Quinones A, Gupta M, Hendey GW, Rodriguez RM, Mower WR. Traumatic injury to the posterior fossa: a secondary analysis and description of case series from the NEXUS head injury dataset. LANCET REGIONAL HEALTH. AMERICAS 2024; 34:100760. [PMID: 38764982 PMCID: PMC11101874 DOI: 10.1016/j.lana.2024.100760] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 09/14/2023] [Revised: 04/18/2024] [Accepted: 04/22/2024] [Indexed: 05/21/2024]
Abstract
Background Traumatic brain injuries involving the posterior fossa are rare and case reports indicate they often result in severe outcomes. We seek to describe characteristics and outcomes of traumatic posterior fossa injuries. Methods We performed a planned secondary analysis of all patients with posterior fossa injuries enrolled in the NEXUS head computed tomography (CT) validation study dataset. The dataset includes prospectively collected data on all patients undergoing non-contrast cranial CT following blunt traumatic head injury from April 2006 to December 2015, at four emergency departments comprising community and university sites, as well as urban, suburban and rural settings in California (Antelope Valley Hospital, San Francisco General Hospital, UCLA Ronald Reagan Medical Center, UCSF Fresno Community Regional Medical Center). We classified each patient into one of three injury patterns: Type I-notable traumatic injuries primarily above the tentorium, with minimal posterior fossa involvement; Type II-notable traumatic injuries both above and within the posterior fossa; and Type III-notable traumatic injuries primarily within the posterior fossa. We extracted demographic data for each patient as well as physician assessments of the NEXUS head CT and Canadian Head CT rule clinical criteria, mechanisms of injury, patient outcomes, and the location and types of intracranial injuries sustained. Findings Of 11,770 patients in the database, 184 (1.6%) had posterior fossa injuries on CT imaging. Mean age was 55.4 years (standard deviation 22.5 years, range 2-96 years); 131 (71.2%) were males. We identified 63 patients with Type I injuries, 87 with Type II injuries, and 34 Type III injuries. The most common mechanisms of injury were falls (41%), pedestrian vs automobile (15%), and motor vehicle collisions (13%). On presentation most patients had altered mental status (72%), abnormal behavior (53%), or a neurologic deficit (55%). The majority of individuals, 151 (82%), had clinically important injuries and 111 (60%) required neurosurgical intervention. The dispositions for the subjects included 52 deaths (28%), 49 (27%) patients discharged home, and 48 (26%) discharged to rehabilitation facilities. When compared to individuals with Type I and Type II injuries, patients with Type III injuries had lower mortality (6% vs 30% and 35%) and higher percentage of patients discharged home (60% vs 19% and 21%). Interpretation Patients with Type I and II injury patterns (those that involve both the posterior fossa and supratentorium) experienced high mortality and disability. Patients with Type III injuries (isolated posterior fossa) had a better prognosis. Funding None.
Collapse
Affiliation(s)
- Richelle J. Cooper
- Department of Emergency Medicine, Ronald Reagan – University of California, Los Angeles Medical Center, Los Angeles, CA, USA
- David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
| | - Thomas E. Akie
- Department of Emergency Medicine, UMass Chan Medical School, Worcester, MA, USA
| | - Tarika Gujral
- Department of Emergency Medicine, Ronald Reagan – University of California, Los Angeles Medical Center, Los Angeles, CA, USA
- David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
| | - Shivam Rana
- Department of Emergency Medicine, Ronald Reagan – University of California, Los Angeles Medical Center, Los Angeles, CA, USA
- David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
| | - Kyle Bui
- Department of Emergency Medicine, Ronald Reagan – University of California, Los Angeles Medical Center, Los Angeles, CA, USA
- David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
| | - Ryan Factora
- Department of Emergency Medicine, Ronald Reagan – University of California, Los Angeles Medical Center, Los Angeles, CA, USA
- David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
| | - Alexandra Quinones
- Department of Emergency Medicine, University of California at San Francisco School of Medicine, San Francisco, CA, USA
| | - Malkeet Gupta
- Department of Emergency Medicine, Ronald Reagan – University of California, Los Angeles Medical Center, Los Angeles, CA, USA
- Antelope Valley Hospital, Lancaster, CA, USA
- David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
| | - Gregory W. Hendey
- Department of Emergency Medicine, Ronald Reagan – University of California, Los Angeles Medical Center, Los Angeles, CA, USA
- UCSF-Fresno, Medical Education Program, Fresno, CA, USA
- David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
| | - Robert M. Rodriguez
- Department of Emergency Medicine, University of California at San Francisco School of Medicine, San Francisco, CA, USA
| | - William R. Mower
- Department of Emergency Medicine, Ronald Reagan – University of California, Los Angeles Medical Center, Los Angeles, CA, USA
- David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
| |
Collapse
|
25
|
Uchiyama M, Mori K, Abe T, Imaki S. Risk factors for clinically important traumatic brain injury in minor head injury in older people. Am J Emerg Med 2024; 80:156-161. [PMID: 38608468 DOI: 10.1016/j.ajem.2024.04.003] [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: 12/27/2023] [Revised: 02/26/2024] [Accepted: 04/01/2024] [Indexed: 04/14/2024] Open
Abstract
BACKGROUND AND OBJECTIVES The incidence of traumatic brain injury (TBI) in older individuals is increasing with an increase in the older population. For older people, the required medical interventions and hospitalization following minor head injury have negative impacts, which have not been reported in literature up till now. We aimed to investigate the risk factors for clinically important traumatic brain injury (ciTBI) in older patients with minor head injury. METHODS This is a retrospective single-center cohort study. Older patients aged ≥65 years presenting with head injury and a Glasgow Coma Scale (GCS) score of ≥13 upon arrival at the hospital between January 1, 2018, and October 31, 2021, were included. Patients with an injury duration of ≥24 h were excluded. The primary outcome was defined as ciTBI (including death, surgery, intubation, medical interventions, and hospital stays of ≥2 nights). Multiple logistic regression analysis was conducted to identify the risk factors. RESULTS A total of 296 patients were included initially, and 6 of them were excluded subsequently. ciTBI was identified in 62 cases. According to the results of the multiple logistic regression analysis, GCS scores of ≤14 (OR 3.72, 95% CI 1.89-7.30), high-risk mechanisms of injury (OR 2.80, 95% CI 1.39-5.64), vomiting (OR 5.01, 95% CI 1.19-21.1), and retrograde amnesia (OR 6.90, 95% CI 3.37-14.1) were identified as risk factors. CONCLUSION In older patients with minor head injury, GCS ≤14, high-risk mechanisms of injury, vomiting, and retrograde amnesia are risk factors for ciTBI.
Collapse
Affiliation(s)
- Makoto Uchiyama
- Department of Emergency Medicine, Yokohama Municipal Citizen's Hospital, 1-1 Mitsuzawanishimachi, Kanagawa-ku, Yokohama-shi, Kanagawa 221-0855, Japan; Department of Surgery, Shin-Kuki General Hospital, 418-1 Kamihayami, Kuki-shi, Saitama 346-8530, Japan.
| | - Kosuke Mori
- Department of Emergency Medicine, Yokohama Municipal Citizen's Hospital, 1-1 Mitsuzawanishimachi, Kanagawa-ku, Yokohama-shi, Kanagawa 221-0855, Japan
| | - Takeru Abe
- Center for Integrated Science and Humanities, Fukushima Medical University, 1 Hikariga-oka, Fukushima-shi, Fukushima 960-1295, Japan.
| | - Shohei Imaki
- Department of Emergency Medicine, Yokohama Municipal Citizen's Hospital, 1-1 Mitsuzawanishimachi, Kanagawa-ku, Yokohama-shi, Kanagawa 221-0855, Japan.
| |
Collapse
|
26
|
Kisembo HN, Malumba R, Sematimba H, Ankunda R, Nalweyiso ID, Malwadde EK, Rutebemberwa E, Kasasa S, Salama DH, Kawooya MG. Understanding the factors that influence CT utilization for mild traumatic brain injury in a low resource setting - a qualitative study using the Theoretical Domains Framework. Afr J Emerg Med 2024; 14:103-108. [PMID: 38756826 PMCID: PMC11096711 DOI: 10.1016/j.afjem.2024.04.004] [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] [Received: 08/17/2023] [Revised: 04/15/2024] [Accepted: 04/18/2024] [Indexed: 05/18/2024] Open
Abstract
Introduction In low resource settings (LRS), utilization of Computed Tomography scan (CTS) for mild traumatic brain injuries (mTBIs) presents unique challenges and considerations given the limited infrastructure, financial resources, and trained personnel. The Theoretical Domains Framework (TDF) offers a comprehensive theoretical lens to explore factors influencing the decision-making to order CTS for mTBI by imaging referrers (IRs). Objectives The primary objective was to explore IRs' beliefs about factors influencing CT utilization in mTBIs using TDF in Uganda.Differences in the factors influencing CTS ordering behavior across specialties, levels of experience, and hospital category were also explored. Materials and Methods In-depth semi-structured interviews guided by TDF were conducted among purposively selected IRs from 6 tertiary public and private hospitals with functional CTS services. A thematic analysis was performed with codes and emerging themes developed based on the TDF. Results Eleven IRs including medical officers, non-neurosurgeon specialists and neurosurgeons aged on average 42 years (SD+/-12.3 years) participated.Identified factors within skills domain involved IRs' clinical assessment and decision-making abilities, while beliefs about capabilities and consequences encompassed their confidence in diagnostic abilities and perceptions of CTS risks and benefits. The environmental context and resources domain addressed the availability of CT scanners and financial constraints. The knowledge domain elicited IRs' understanding of clinical guidelines and evidence-based practices while social influences considered peer influence and institutional culture. For memory, attention & decision processes domain, IRs adherence to guidelines and intentions to order CT scans were cited. Conclusion Using TDF, IRs identified several factors believed to influence decision making to order CTS in mTBI in a LRS. The findings can inform stakeholders to develop targeted strategies and evidence-based interventions to optimize CT utilization in mTBI such as; educational programs, workflow modifications, decision support tools, and infrastructure improvements, among others.
Collapse
Affiliation(s)
- Harriet Nalubega Kisembo
- Makerere University, College of Health Sciences, School of Medicine
- Department of Radiology, Mulago National Referral and Teaching Hospital, Kampala, Uganda
| | - Richard Malumba
- Ernest cook Ultrasound Research and Education Institute, Mengo Hospital, Kampala, Uganda
| | - Henry Sematimba
- Ernest cook Ultrasound Research and Education Institute, Mengo Hospital, Kampala, Uganda
| | - Racheal Ankunda
- Ernest cook Ultrasound Research and Education Institute, Mengo Hospital, Kampala, Uganda
| | | | - Elsie-Kiguli Malwadde
- African Centre for Global Health and Social Transformation (ACHEST), Kampala, Uganda
| | - Elizeus Rutebemberwa
- School of Public Health, Department of Health Policy & Management, Makerere University, Kampala, Uganda
| | - Simon Kasasa
- Department of Epidemiology & Biostatistics, School of Public Health, Makerere University, Kampala, Uganda
| | | | - Michael Grace Kawooya
- Ernest cook Ultrasound Research and Education Institute, Mengo Hospital, Kampala, Uganda
| |
Collapse
|
27
|
Stępniewska E, Kałas M, Świderska J, Siemiński M. mTBI Biological Biomarkers as Predictors of Postconcussion Syndrome-Review. Brain Sci 2024; 14:513. [PMID: 38790491 PMCID: PMC11119822 DOI: 10.3390/brainsci14050513] [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: 04/10/2024] [Revised: 05/16/2024] [Accepted: 05/17/2024] [Indexed: 05/26/2024] Open
Abstract
Postconcussion syndrome (PCS) is one of the leading complications that may appear in patients after mild head trauma. Every day, thousands of people, regardless of age, gender, and race, are diagnosed in emergency departments due to head injuries. Traumatic Brain Injury (TBI) is a significant public health problem, impacting an estimated 1.5 million people in the United States and up to 69 million people worldwide each year, with 80% of these cases being mild. An analysis of the available research and a systematic review were conducted to search for a solution to predicting the occurrence of postconcussion syndrome. Particular biomarkers that can be examined upon admission to the emergency department after head injury were found as possible predictive factors of PCS development. Setting one unequivocal definition of PCS is still a challenge that causes inconsistent results. Neuron Specific Enolase (NSE), Glial Fibrillary Acidic Protein (GFAP), Ubiquitin C-terminal Hydrolase-L1 (UCH-L1), Serum Protein 100 B (s100B), and tau protein are found to be the best predictors of PCS development. The presence of all mentioned biomarkers is confirmed in severe TBI. All mentioned biomarkers are used as predictors of PCS. A combined examination of NSE, GFAP, UCH-1, S100B, and tau protein should be performed to detect mTBI and predict the development of PCS.
Collapse
Affiliation(s)
| | | | | | - Mariusz Siemiński
- Department of Emergency Medicine, Medical University of Gdansk, 80-435 Gdansk, Poland; (E.S.); (M.K.); (J.Ś.)
| |
Collapse
|
28
|
André L, Björkelund A, Ekelund U, Vedin T, Björk J, Forberg JL. The prevalence of clinically relevant delayed intracranial hemorrhage in head trauma patients treated with oral anticoagulants is very low: a retrospective cohort register study. Scand J Trauma Resusc Emerg Med 2024; 32:42. [PMID: 38730480 PMCID: PMC11084042 DOI: 10.1186/s13049-024-01214-0] [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: 02/27/2024] [Accepted: 04/27/2024] [Indexed: 05/12/2024] Open
Abstract
BACKGROUND Current guidelines from Scandinavian Neuro Committee mandate a 24-hour observation for head trauma patients on anticoagulants, even with normal initial head CT scans, as a means not to miss delayed intracranial hemorrhages. This study aimed to assess the prevalence, and time to diagnosis, of clinically relevant delayed intracranial hemorrhage in head trauma patients treated with oral anticoagulants. METHOD Utilizing comprehensive two-year data from Region Skåne's emergency departments, which serve a population of 1.3 million inhabitants, this study focused on adult head trauma patients prescribed oral anticoagulants. We identified those with intracranial hemorrhage within 30 days, defining delayed intracranial hemorrhage as a bleeding not apparent on their initial CT head scan. These cases were further defined as clinically relevant if associated with mortality, any intensive care unit admission, or neurosurgery. RESULTS Out of the included 2,362 head injury cases (median age 84, 56% on a direct acting oral anticoagulant), five developed delayed intracranial hemorrhages. None of these five cases underwent neurosurgery nor were admitted to an intensive care unit. Only two cases (0.08%, 95% confidence interval [0.01-0.3%]) were classified as clinically relevant, involving subdural hematomas in patients aged 82 and 87 years, who both subsequently died. The diagnosis of these delayed intracranial hemorrhages was made at 4 and 7 days following initial presentation to the emergency department. CONCLUSION In patients with head trauma, on oral anticoagulation, the incidence of clinically relevant delayed intracranial hemorrhage was found to be less than one in a thousand, with detection occurring four days or later after initial presentation. This challenges the effectiveness of the 24-hour observation period recommended by the Scandinavian Neurotrauma Committee guidelines, suggesting a need to reassess these guidelines to optimise care and resource allocation. TRIAL REGISTRATION This is a retrospective cohort study, does not include any intervention, and has therefore not been registered.
Collapse
Affiliation(s)
- Lars André
- Department of Clinical Sciences, Lund University, Lund, Sweden.
- Department of Emergency Medicine, Helsingborg Hospital, Helsingborg, Sweden.
| | - Anders Björkelund
- Centre for Environmental and Climate Science, Lund University, Lund, Sweden
| | - Ulf Ekelund
- Department of Clinical Sciences, Lund University, Lund, Sweden
- Department of Internal medicine and Emergency care, Skåne University Hospital, Lund, Sweden
| | - Tomas Vedin
- Department of Clinical Sciences, Lund University, Malmö, Sweden
- Department of Surgery, Skåne University Hospital, Malmö, Sweden
| | - Jonas Björk
- Department of Laboratory Medicine, Lund University, Lund, Sweden
- Skåne University Hospital, Forum South, Clinical Studies Sweden, Lund, Sweden
| | - Jakob Lundager Forberg
- Department of Clinical Sciences, Lund University, Lund, Sweden
- Department of Emergency Medicine, Helsingborg Hospital, Helsingborg, Sweden
| |
Collapse
|
29
|
Piwowarczyk S, Obłój P, Janicki Ł, Kowalik K, Łukaszuk A, Siemiński M. Seizure-Related Head Injuries: A Narrative Review. Brain Sci 2024; 14:473. [PMID: 38790452 PMCID: PMC11118010 DOI: 10.3390/brainsci14050473] [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: 04/10/2024] [Revised: 04/29/2024] [Accepted: 05/04/2024] [Indexed: 05/26/2024] Open
Abstract
Epilepsy is one of the most common neurological diseases. Epileptic seizures very often result in head injuries that may lead to many adverse consequences, both acute and chronic. They contribute to the need for hospitalization, modification of treatment, and a general decline in social productivity. The objective of our review is to characterize and assess management aspects of seizure-related head injuries (SRHIs) as an important and frequent clinical problem present in emergency department settings. PubMed and other relevant databases and websites were systematically searched for articles on traumatic brain injuries connected with the occurrence of seizures published from inception to 9 April 2024; then, we reviewed the available literature. Our review showed that SRHIs can lead to various acute complications, in some cases requiring hospitalization and neurosurgical intervention. Long-term complications and cognitive decline after injury might be present, eventually implying a negative impact on a patient's quality of life. Despite being frequent and clinically important, there are still no widely accepted, uniform recommendations for the management of patients with SRHIs. As such, a concise and standardized protocol for the management of seizure-related head injuries in emergency departments is worth consideration.
Collapse
Affiliation(s)
- Sebastian Piwowarczyk
- Department of Emergency Medicine, Medical University of Gdansk, Mariana Smoluchowskiego 17, 80-952 Gdansk, Poland; (S.P.); (P.O.); (Ł.J.); (K.K.)
| | - Paweł Obłój
- Department of Emergency Medicine, Medical University of Gdansk, Mariana Smoluchowskiego 17, 80-952 Gdansk, Poland; (S.P.); (P.O.); (Ł.J.); (K.K.)
| | - Łukasz Janicki
- Department of Emergency Medicine, Medical University of Gdansk, Mariana Smoluchowskiego 17, 80-952 Gdansk, Poland; (S.P.); (P.O.); (Ł.J.); (K.K.)
| | - Kornelia Kowalik
- Department of Emergency Medicine, Medical University of Gdansk, Mariana Smoluchowskiego 17, 80-952 Gdansk, Poland; (S.P.); (P.O.); (Ł.J.); (K.K.)
| | - Adam Łukaszuk
- Edinburgh Medical School, College of Medicine And Veterinary Medicine, The University of Edinburgh, Edinburgh EH8 9YL, UK;
| | - Mariusz Siemiński
- Department of Emergency Medicine, Medical University of Gdansk, Mariana Smoluchowskiego 17, 80-952 Gdansk, Poland; (S.P.); (P.O.); (Ł.J.); (K.K.)
| |
Collapse
|
30
|
Mower WR, Akie TE, Morizadeh N, Gupta M, Hendey GW, Wilson JL, Leonid Duvergne LP, Ma P, Krishna P, Rodriguez RM. Blunt Head Injury in the Elderly: Analysis of the NEXUS II Injury Cohort. Ann Emerg Med 2024; 83:457-466. [PMID: 38340132 DOI: 10.1016/j.annemergmed.2024.01.003] [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: 09/28/2023] [Revised: 12/06/2023] [Accepted: 01/02/2024] [Indexed: 02/12/2024]
Abstract
BACKGROUND Changes with aging make older patients vulnerable to blunt head trauma and alter the potential for injury and the injury patterns seen among this expanding cohort. High-quality care requires a clear understanding of the factors associated with blunt head injuries in the elderly. Our objective was to develop a detailed assessment of the injury mechanisms, presentations, injury patterns, and outcomes among older blunt head trauma patients. METHODS We conducted a planned secondary analysis of patients aged 65 or greater who were enrolled in the National Emergency X-Radiography Utilization Study (NEXUS) Head Computed Tomography validation study. We performed a detailed assessment of the demographics, mechanisms, presentations, injuries, interventions, and outcomes among older patients. RESULTS We identified 3,659 patients aged 65 years or greater, among the 11,770 patients enrolled in the NEXUS validation study. Of these older patients, 325 (8.9%) sustained significant injuries, as compared with significant injuries in 442 (5.4%) of the 8,111 younger patients. Older females (1,900; 51.9%) outnumbered older males (1,753; 47.9%), and occult presentations (exhibiting no high-risk clinical criteria beyond age) occurred in 48 (14.8%; 95% confidence interval (CI) 11.1 to 19.1) patients with significant injuries. Subdural hematomas (377 discreet lesions in 299 patients) and subarachnoid hemorrhages (333 discreet instances in 256 patients) were the most frequent types of injuries occurring in our elderly population. A ground-level fall was the most frequent mechanism of injury among all patients (2,211; 69.6%), those sustaining significant injuries (180; 55.7%), and those who died of their injuries (37; 46.3%), but mortality rates were highest among patients experiencing a fall from a ladder (11.8%; 4 deaths among 34 cases [95% CI 3.3% to 27.5%]) and automobile versus pedestrian events (10.7%; 16 deaths among 149 cases [95% CI 6.3% to 16.9%]). Among older patients who required neurosurgical intervention for their injuries, only 16.4% (95% CI 11.1% to 22.9%) were able to return home, 32.1% (95% CI 25.1% to 39.8%) required extended facility care, and 41.8% (95% CI 34.2% to 49.7%) died from their injuries. CONCLUSIONS Older blunt head injury patients are at high risk of sustaining serious intracranial injuries even with low-risk mechanisms of injury, such as ground-level falls. Clinical evaluation is unreliable and frequently fails to identify patients with significant injuries. Outcomes, particularly after intervention, can be poor, with high rates of long-term disability and mortality.
Collapse
Affiliation(s)
- William R Mower
- Department of Emergency Medicine, David Geffen School of Medicine at UCLA, Los Angeles, CA.
| | - Thomas E Akie
- Department of Emergency Medicine, UMass Chan Medical School, Worcester, MA
| | | | - Malkeet Gupta
- Department of Emergency Medicine, David Geffen School of Medicine at UCLA, Los Angeles, CA; Department of Emergency Medicine, Antelope Valley Medical Center, Lancaster, CA
| | - Gregory W Hendey
- Department of Emergency Medicine, David Geffen School of Medicine at UCLA, Los Angeles, CA
| | - Jake L Wilson
- Department of Emergency Medicine, David Geffen School of Medicine at UCLA, Los Angeles, CA
| | | | - Phillip Ma
- Department of Emergency Medicine, David Geffen School of Medicine at UCLA, Los Angeles, CA
| | - Pravin Krishna
- Department of Emergency Medicine, Antelope Valley Medical Center, Lancaster, CA
| | - Robert M Rodriguez
- Department of Emergency Medicine, UCSF School of Medicine, San Francisco, CA
| |
Collapse
|
31
|
Hamel C, Abdeen N, Avard B, Campbell S, Corser N, Ditkofsky N, Berger F, Murray N. Canadian Association of Radiologists Trauma Diagnostic Imaging Referral Guideline. Can Assoc Radiol J 2024; 75:279-286. [PMID: 37679336 DOI: 10.1177/08465371231182972] [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: 09/09/2023] Open
Abstract
The Canadian Association of Radiologists (CAR) Trauma Expert Panel consists of adult and pediatric emergency and trauma radiologists, emergency physicians, a family physician, a patient advisor, and an epidemiologist/guideline methodologist. After developing a list of 21 clinical/diagnostic scenarios, a systematic rapid scoping review was undertaken to identify systematically produced referral guidelines that provide recommendations for 1 or more of these clinical/diagnostic scenarios. Recommendations from 49 guidelines and contextualization criteria in the Grading of Recommendations, Assessment, Development and Evaluations (GRADE) for guidelines framework were used to develop 50 recommendation statements across the 21 scenarios related to the evaluation of traumatic injuries. This guideline presents the methods of development and the recommendations for head, face, neck, spine, hip/pelvis, arms, legs, superficial soft tissue injury foreign body, chest, abdomen, and non-accidental trauma.
Collapse
Affiliation(s)
- Candyce Hamel
- Canadian Association of Radiologists, Ottawa, ON, Canada
| | - Nishard Abdeen
- Children's Hospital of Eastern Ontario, Ottawa, ON, Canada
| | - Barb Avard
- North York General Hospital, Toronto, ON, Canada
| | - Samuel Campbell
- Queen Elizabeth II Health Sciences Centre, Halifax, NS, Canada
| | | | - Noah Ditkofsky
- St Michael's Hospital, Toronto, ON, Canada
- Michael Garon Hospital , Toronto, ON, Canada
| | - Ferco Berger
- Sunnybrook Health Sciences Centre, Toronto, ON, Canada
- University of Toronto, Toronto, ON, Canada
| | | |
Collapse
|
32
|
Ukachukwu AEK, Nischal SA, Trillo-Ordonez Y, Nwaribe EE, Abu-Bonsrah N, Malomo TA, Oyemolade TA, Badejo OA, Deng DD, Still MEH, Oboh EC, Okere OE, Asemota I, Oboh EN, Ogundeji OD, Ugorji C, Rahman R, Reddy P, Seas A, Waguia-Kouam R, von Isenburg M, Fuller AT, Haglund MM, Adeleye AO. Epidemiological Burden of Neurotrauma in Nigeria: A Systematic Review and Pooled Analysis of 45,763 Patients. World Neurosurg 2024; 185:e99-e142. [PMID: 38741332 DOI: 10.1016/j.wneu.2023.11.070] [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: 06/13/2023] [Revised: 11/14/2023] [Accepted: 11/15/2023] [Indexed: 05/16/2024]
Abstract
OBJECTIVE Neurotrauma is a significant cause of morbidity and mortality in Nigeria. We conducted this systematic review to generate nationally generalizable reference data for the country. METHODS Four research databases and gray literature sources were electronically searched. Risk of bias was assessed using the Risk of Bias in Non-Randomized Studies of Interventions and Cochrane's risk of bias tools. Descriptive analysis, narrative synthesis, and statistical analysis (via paired t-tests and χ2 independence tests) were performed on relevant article metrics (α = 0.05). RESULTS We identified a cohort of 45,763 patients from 254 articles. The overall risk of bias was moderate to high. Most articles employed retrospective cohort study designs (37.4%) and were published during the last 2 decades (81.89%). The cohort's average age was 32.5 years (standard deviation, 20.2) with a gender split of ∼3 males per female. Almost 90% of subjects were diagnosed with traumatic brain injury, with road traffic accidents (68.6%) being the greatest cause. Altered consciousness (48.4%) was the most commonly reported clinical feature. Computed tomography (53.5%) was the most commonly used imaging modality, with skull (25.7%) and vertebral fracture (14.1%) being the most common radiological findings for traumatic brain injury and traumatic spinal injury, respectively. Two-thirds of patients were treated nonoperatively. Outcomes were favorable in 63.7% of traumatic brain injury patients, but in only 20.9% of traumatic spinal injury patients. Pressure sores, infection, and motor deficits were the most commonly reported complications in the latter. CONCLUSIONS This systematic review and pooled analysis demonstrate the significant burden of neurotrauma across Nigeria.
Collapse
Affiliation(s)
- Alvan-Emeka K Ukachukwu
- Division of Global Neurosurgery and Neurology, Duke University, Durham, North Carolina, USA; Department of Neurosurgery, Duke University Health System, Durham, North Carolina, USA.
| | - Shiva A Nischal
- Division of Global Neurosurgery and Neurology, Duke University, Durham, North Carolina, USA; University of Cambridge School of Clinical Medicine, Cambridge, UK
| | - Yesel Trillo-Ordonez
- Division of Global Neurosurgery and Neurology, Duke University, Durham, North Carolina, USA
| | | | - Nancy Abu-Bonsrah
- Department of Neurosurgery, Johns Hopkins University, Baltimore, Maryland, USA
| | - Toluyemi A Malomo
- Department of Neuroscience, University of British Columbia, Vancouver, British Columbia, Canada
| | | | - Oluwakemi A Badejo
- Department of Neurosurgery, University College Hospital, Ibadan, Nigeria
| | - Di D Deng
- Division of Global Neurosurgery and Neurology, Duke University, Durham, North Carolina, USA
| | - Megan E H Still
- Department of Neurosurgery, University of Florida, Gainesville, Florida, USA
| | - Ena C Oboh
- Division of Global Neurosurgery and Neurology, Duke University, Durham, North Carolina, USA
| | | | - Isaac Asemota
- Division of Global Neurosurgery and Neurology, Duke University, Durham, North Carolina, USA
| | - Ehita N Oboh
- Michigan State University College of Human Medicine, Grand Rapids, Michigan, USA
| | - Olaniyi D Ogundeji
- Division of Global Neurosurgery and Neurology, Duke University, Durham, North Carolina, USA
| | - Chiazam Ugorji
- Division of Global Neurosurgery and Neurology, Duke University, Durham, North Carolina, USA
| | - Raphia Rahman
- Division of Global Neurosurgery and Neurology, Duke University, Durham, North Carolina, USA
| | - Padmavathi Reddy
- University of Florida College of Medicine, Gainesville, Florida, USA
| | - Andreas Seas
- Division of Global Neurosurgery and Neurology, Duke University, Durham, North Carolina, USA; Duke University Pratt School of Engineering, Durham, North Carolina, USA; Duke University School of Medicine, Durham, North Carolina, USA
| | | | - Megan von Isenburg
- Duke University Medical Center Library and Archives, Durham, North Carolina, USA
| | - Anthony T Fuller
- Division of Global Neurosurgery and Neurology, Duke University, Durham, North Carolina, USA; Department of Neurosurgery, Duke University Health System, Durham, North Carolina, USA; Duke University Global Health Institute, Durham, North Carolina, USA
| | - Michael M Haglund
- Division of Global Neurosurgery and Neurology, Duke University, Durham, North Carolina, USA; Department of Neurosurgery, Duke University Health System, Durham, North Carolina, USA; Duke University Global Health Institute, Durham, North Carolina, USA
| | - Amos O Adeleye
- Department of Neurosurgery, University College Hospital, Ibadan, Nigeria
| |
Collapse
|
33
|
Uccella L, Riboni C, Polinelli F, Biondi C, Uccheddu G, Petrino R, Majno-Hurst P. Use of the Canadian CT head rule for patients on anticoagulant/anti-platelet therapy presenting with mild traumatic brain injury: prospective observational study. Front Neurol 2024; 15:1327871. [PMID: 38699056 PMCID: PMC11063395 DOI: 10.3389/fneur.2024.1327871] [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] [Received: 10/26/2023] [Accepted: 04/02/2024] [Indexed: 05/05/2024] Open
Abstract
Background and importanceMild traumatic brain injury (mTBI) is a frequent presentation in Emergency Department (ED). There are standardised guidelines, the Canadian CT Head Rule (CCHR), for CT scan in mTBI that rule out patients on either anticoagulant or anti-platelet therapy. All patients with these therapies undergo a CT scan irrespectively of other consideration.ObjectiveTo determine whether standard guidelines could be applied to patients on anticoagulants or anti-platelet drugs.Design, settings, and participants1,015 patients with mTBI and Glasgow Coma Score (GCS) of 15 were prospectively recruited, 509 either on anticoagulant or anti-platelet therapy and 506 on neither. All patients on neither therapy underwent CT scan following guidelines. All patients with mTBI on either therapy underwent CT scan irrespective of the guidelines.Outcome measure and analysisPrimary endpoint was the incidence of post-traumatic intracranial bleeding in patients either on anticoagulants or anti-platelet drugs and in patients who were not on these therapies. Bayesian statistical analysis with calculation of Confidence Intervals (CI) was then performed.Main resultsSixty scans were positive for bleeding: 59 patients fulfilled the criteria and 1 did not. Amongst patients with haemorrhage, 24 were on either therapy and only one did not meet the guidelines but in this patient the CT scan was performed before 2 h from the mTBI. Patients on either therapy did not have higher bleeding rates than patients on neither. There were higher bleeding rates in patients on anti-platelet therapy who met the guidelines vs. patients who did not. These rates overlapped with patients on neither therapy, meeting CCHR.ConclusionThe CCHR might be used for mTBI patients on either therapy. Anticoagulants and anti-platelet drugs should not be considered a risk factor for patients with mTBI and a GCS of 15. Multicentric studies are needed to confirm this result.
Collapse
Affiliation(s)
- Laura Uccella
- Emergency Department—EOC—Ospedale Regionale di Lugano, Lugano, Switzerland
| | - Cristiana Riboni
- Emergency Department—EOC—Ospedale Regionale di Lugano, Lugano, Switzerland
| | | | - Carola Biondi
- Emergency Department—EOC—Ospedale Regionale di Lugano, Lugano, Switzerland
| | - Graziano Uccheddu
- Emergency Department—EOC—Ospedale Regionale di Lugano, Lugano, Switzerland
| | - Roberta Petrino
- Emergency Department—EOC—Ospedale Regionale di Lugano, Lugano, Switzerland
| | - Pietro Majno-Hurst
- Surgery Department—EOC—Ospedale Regionale di Lugano, Lugano, Switzerland
| |
Collapse
|
34
|
Schwedt TJ. Posttraumatic Headache. Continuum (Minneap Minn) 2024; 30:411-424. [PMID: 38568491 DOI: 10.1212/con.0000000000001410] [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: 04/05/2024]
Abstract
OBJECTIVE This article provides an overview of the epidemiology, diagnosis, clinical presentation, pathophysiology, prognosis, and treatment of posttraumatic headache attributed to mild traumatic brain injury (mTBI). LATEST DEVELOPMENTS The International Classification of Headache Disorders, Third Edition requires that posttraumatic headache begin within 7 days of the inciting trauma. Although posttraumatic headache characteristics and associated symptoms vary, most commonly there is substantial overlap with symptoms of migraine or tension-type headache. New insights into posttraumatic headache pathophysiology suggest roles for neuroinflammation, altered pain processing and modulation, and changes in brain structure and function. Although the majority of posttraumatic headache resolves during the acute phase, about one-third of individuals have posttraumatic headache that persists for at least several months. Additional work is needed to identify predictors and early markers of posttraumatic headache persistence, but several potential predictors have been identified such as having migraine prior to the mTBI, the total number of TBIs ever experienced, and the severity of initial symptoms following the mTBI. Few data are available regarding posttraumatic headache treatment; studies investigating different treatments and the optimal timing for initiating posttraumatic headache treatment are needed. ESSENTIAL POINTS Posttraumatic headache begins within 7 days of the causative injury. The characteristics of posttraumatic headache most commonly resemble those of migraine or tension-type headache. Posttraumatic headache persists for 3 months or longer in about one-third of individuals. Additional studies investigating posttraumatic headache treatment are needed.
Collapse
|
35
|
Stein D, Broderick M. Management of Head Trauma. Surg Clin North Am 2024; 104:325-341. [PMID: 38453305 DOI: 10.1016/j.suc.2023.09.006] [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] [Indexed: 03/09/2024]
Abstract
Traumatic brain injury (TBI) represents a heterogenous spectrum of disease. It is essential to rapidly assess a patient's neurologic status and implement measures to prevent secondary brain injury. Intracranial hypertension, a common sequela of TBI, is managed in a tiered and systematic fashion, starting with the least invasive and moving toward the most invasive. TBI has long-lasting effects on patients and their families and represents a substantial financial and social influence on society. Research regarding the prognosis and treatment of TBI is essential to limit the influence of this widespread disease.
Collapse
Affiliation(s)
- Deborah Stein
- Department of Surgery, R Adams Cowley Shock Trauma Center, 22 South Greene Street, Baltimore, MD 21201, USA.
| | - Meaghan Broderick
- Department of Surgery, R Adams Cowley Shock Trauma Center, 22 South Greene Street, Baltimore, MD 21201, USA
| |
Collapse
|
36
|
Buonora MJ, Axson SA, Cohen SM, Becker WC. Paths Forward for Clinicians Amidst the Rise of Unregulated Clinical Decision Support Software: Our Perspective on NarxCare. J Gen Intern Med 2024; 39:858-862. [PMID: 37962733 PMCID: PMC11043299 DOI: 10.1007/s11606-023-08528-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/26/2023] [Accepted: 11/02/2023] [Indexed: 11/15/2023]
Abstract
Amidst the US overdose epidemic, policymakers, law enforcement agencies, and healthcare institutions have contributed to a decrease in opioid prescribing, assuming reduced mortality would result-an assumption we now understand was oversimplified. At this intersection between public health and public safety domains as they relate to opioid prescribing, unregulated and proprietary clinical decision support tools have emerged without rigorous external validation or public data sharing. In the following piece, we discuss challenges facing clinicians practicing medicine amidst unregulated clinical decision support tools, using the case of Bamboo Health's NarxCare-a prescription drug monitoring program-based analytics platform marketed as a clinical decision support tool-that is already positioned to impact over 1 billion patient encounters annually. We argue that sufficient evidence does not yet exist to support NarxCare's wide implementation, and that clinical decision support tools like NarxCare have flourished in recent years due to a lack of federal regulatory oversight and shielding by their proprietary formulas, which have facilitated their unchecked and outsized influence on patient care. Finally, we suggest specific actions by federal regulatory agencies, healthcare institutions, individual clinicians, and researchers, as well as academic journals, to mitigate potential harms associated with unregulated clinical decision support tools.
Collapse
Affiliation(s)
- Michele J Buonora
- National Clinician Scholars Program, Yale School of Medicine, New Haven, CT, USA.
- Department of Internal Medicine & Program in Addiction Medicine, Yale School of Medicine, New Haven, CT, USA.
- General Internal Medicine, Veterans Affairs Connecticut Healthcare System, West Haven, CT, USA.
- Division of General Internal Medicine, Montefiore Medical Center, Bronx, NY, USA.
| | - Sydney A Axson
- National Clinician Scholars Program, Yale School of Medicine, New Haven, CT, USA
- General Internal Medicine, Veterans Affairs Connecticut Healthcare System, West Haven, CT, USA
- Ross and Carol Nese College of Nursing and the Rock Ethics Institute, The Pennsylvania State University, University Park, PA, USA
| | - Shawn M Cohen
- Department of Internal Medicine & Program in Addiction Medicine, Yale School of Medicine, New Haven, CT, USA
| | - William C Becker
- National Clinician Scholars Program, Yale School of Medicine, New Haven, CT, USA
- Department of Internal Medicine & Program in Addiction Medicine, Yale School of Medicine, New Haven, CT, USA
- Pain Research, Informatics, Multimorbidities & Education Center of Innovation, Veterans Affairs Connecticut Healthcare System, West Haven, CT, USA
| |
Collapse
|
37
|
Hibi A, Cusimano MD, Bilbily A, Krishnan RG, Tyrrell PN. Impact of Automated Prognostication on Traumatic Brain Injury Care: A Focus Group Study. Can J Neurol Sci 2024:1-9. [PMID: 38438281 DOI: 10.1017/cjn.2024.24] [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: 03/06/2024]
Abstract
BACKGROUND Prognosticating outcomes for traumatic brain injury (TBI) patients is challenging due to the required specialized skills and variability among clinicians. Recent attempts to standardize TBI prognosis have leveraged machine learning (ML) methodologies. This study evaluates the necessity and influence of ML-assisted TBI prognostication through healthcare professionals' perspectives via focus group discussions. METHODS Two virtual focus groups included ten key TBI care stakeholders (one neurosurgeon, two emergency clinicians, one internist, two radiologists, one registered nurse, two researchers in ML and healthcare and one patient representative). They answered six open-ended questions about their perceptions and potential ML use in TBI prognostication. Transcribed focus group discussions were thematically analyzed using qualitative data analysis software. RESULTS The study captured diverse perceptions and interests in TBI prognostication across clinical specialties. Notably, certain clinicians who currently do not prognosticate expressed an interest in doing so independently provided they had access to ML support. Concerns included ML's accuracy and the need for proficient ML researchers in clinical settings. The consensus suggested using ML as a secondary consultation tool and promoting collaboration with internal or external research resources. Participants believed ML prognostication could enhance disposition planning and standardize care regardless of clinician expertise or injury severity. There was no evidence of perceived bias or interference during the discussions. CONCLUSION Our findings revealed an overall positive attitude toward ML-based prognostication. Despite raising multiple concerns, the focus group discussions were particularly valuable in underscoring the potential of ML in democratizing and standardizing TBI prognosis practices.
Collapse
Affiliation(s)
- Atsuhiro Hibi
- Institute of Medical Science, University of Toronto, Toronto, ON, Canada
- Department of Medical Imaging, University of Toronto, Toronto, ON, Canada
- Division of Neurosurgery, St Michael's Hospital, Unity Health Toronto, Toronto, Canada
| | - Michael D Cusimano
- Institute of Medical Science, University of Toronto, Toronto, ON, Canada
- Division of Neurosurgery, St Michael's Hospital, Unity Health Toronto, Toronto, Canada
| | - Alexander Bilbily
- Department of Medical Imaging, University of Toronto, Toronto, ON, Canada
- Sunnybrook Health Sciences Centre, Toronto, Canada
| | - Rahul G Krishnan
- Department of Computer Science, University of Toronto, Toronto, ON, Canada
- Department of Laboratory Medicine & Pathobiology, University of Toronto, Toronto, ON, Canada
| | - Pascal N Tyrrell
- Institute of Medical Science, University of Toronto, Toronto, ON, Canada
- Department of Medical Imaging, University of Toronto, Toronto, ON, Canada
- Department of Statistical Sciences, University of Toronto, Toronto, ON, Canada
| |
Collapse
|
38
|
Santing JAL, Hopman JH, Verheul RJ, van der Naalt J, van den Brand CL, Jellema K. Clinical value of S100B in detecting intracranial injury in elderly patients with mild traumatic brain injury. Injury 2024; 55:111313. [PMID: 38219558 DOI: 10.1016/j.injury.2024.111313] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/18/2023] [Revised: 12/21/2023] [Accepted: 01/02/2024] [Indexed: 01/16/2024]
Abstract
OBJECTIVE The biomarker S100B is a sensitive biomarker to detect traumatic intracranial injury in patients mild traumatic brain injury (mTBI). Higher blood values of S100B, resulting in lower specificity and decreased head computed tomography (CT) reduction has been regarded as one of shortcomings in patients over 65 years of age. The purpose of this study was to assess the accuracy of plasma S100B to detect intracranial injury in elderly patients with mTBI. METHODS A posthoc analysis was performed of a larger prospective cohort study. Previous recorded patient variables and plasma values of S100B from patients with mTBI who presented to the Emergency Department (ED) within 6 h of injury, underwent a head CT and had a blood sample drawn as part of their routine clinical care, were partitioned at 65 years of age. Sensitivity, specificity, negative predictive value, and positive predictive value of plasma S100B for predicting traumatic intracranial lesions on head CT, with a cut-off set at 0.105 μg/L, were calculated. Results were compared with data from an additional systematic review on the accuracy of S100B to detect intracranial injury in elderly patients with mTBI. RESULTS Data of 240 patients (48.4 %) of 65 years or older were analyzed. Sensitivity and NPV of S100B were 89 % and 86 % respectively, which is lower than among younger patients (both 97 %). The specificity decreased stepwise with older age: 22 %, 18 %, and 5 % for the age groups 65-74, 75-84, and ≥ 85 years old, respectively. The meta-analysis comprised 4 studies and the current study with data from 2166 patients. Pooled data estimated the sensitivity of s100B as 97.4 % (95 % CI 83.3-100 %) and specificity as 17.3 % (95 % CI 9.5-29.3 %) to detect intracranial injury in elderly patients with mTBI. CONCLUSION The biomarker S100B at the routine threshold has a limited clinical value in the management of elderly mTBI patients mainly due to a poor specificity leading to only a small decrease in head CTs. Alternate cut-off values and combining several plasma biomarkers with clinical variables may be useful strategies to increase the accuracy of S100B in (subgroups of) elderly mTBI patients.
Collapse
Affiliation(s)
| | - Joella H Hopman
- Department of Emergency Medicine, Haaglanden Medical Center, The Hague, The Netherlands
| | - Rolf J Verheul
- Department of Clinical Chemistry and Laboratory Medicine, Haaglanden Medical Center, The Hague, The Netherlands
| | - Joukje van der Naalt
- Department of Neurology, University Medical Center Groningen, Groningen, The Netherlands
| | - Crispijn L van den Brand
- Department of Emergency Medicine, Haaglanden Medical Center, The Hague, The Netherlands; Department of Emergency Medicine, Erasmus Medical Center, The Netherlands
| | - Korné Jellema
- Department of Neurology, Haaglanden Medical Center, The Hague, The Netherlands
| |
Collapse
|
39
|
Chien SC, Kang SC, Tu PH, Chen CC, Tee YS, Liao CH, Chuang CC, Fu CY. Nuance and profound impact: Evaluating the effects of the unmet full coma scale in patients with mild subdural hemorrhage. Am J Emerg Med 2024; 77:60-65. [PMID: 38103392 DOI: 10.1016/j.ajem.2023.11.038] [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: 10/17/2023] [Revised: 11/17/2023] [Accepted: 11/18/2023] [Indexed: 12/19/2023] Open
Abstract
INTRODUCTION Patients with subdural hemorrhage (SDH) and a Glasgow Coma Scale (GCS) score of 13-15 are typically categorized as having mild traumatic brain injury. We hypothesize that patients without a maximum GCS score - specifically, patients with GCS scores of 13 and 14 - may exhibit poorer neurological outcomes. METHOD Between January 1, 2019, and December 31, 2020, SDH patients with GCS scores ranging from 13 to 15 were retrospectively studied. We compared outcomes between patients with a maximum GCS score of 15 and those with scores of either 13 or 14. Independent factors associated with neurological deterioration among patients with a GCS score of 15 were evaluated using multivariate logistic regression (MLR) analysis. RESULTS During the study period, 470 patients with SDH and GCS scores between 13 and 15 were examined. Compared to patients with a maximum GCS score (N = 375), those in the GCS 13-14 group (N = 95) showed significantly higher rates of neurological deterioration (33.7% vs. 10.4%, p value <0.001) and neurosurgical interventions (26.3% vs. 16.3%, p value <0.024). Moreover, the GCS 13-14 group had a significantly poorer prognosis than patients with a GCS score of 15 [mortality rate: 7.4% vs. 2.4%, p value <0.017; rate of impaired consciousness at discharge: 21.1% vs. 4.0%, p value <0.001; and rate of neurological disability at discharge: 29.5% vs. 6.9%, p value <0.001]. The MLR analysis revealed that SDH thickness (odds ratio = 1.127, p value = 0.006) was an independent risk factor for neurological disability at discharge in patients with a GCS score of 15. CONCLUSION Among SDH patients with mild TBI, those with GCS scores of 13-14 exhibited poorer neurological outcomes than those with a maximum GCS score. The thickness of the SDH is positively associated with neurological disability in SDH patients with a maximum GCS score.
Collapse
Affiliation(s)
- Shuo-Chi Chien
- Department of Neurosurgery, Chang Gung Memorial Hospital, Linkou Medical Center, Chang Gung Medical College &University, Taoyuan City, Taiwan
| | - Shih-Ching Kang
- Department of Trauma and Emergency Surgery, Chang Gung Memorial Hospital, Linkou Medical Center, Chang Gung Medical College & University, Taoyuan City, Taiwan
| | - Po-Hsun Tu
- Department of Neurosurgery, Chang Gung Memorial Hospital, Linkou Medical Center, Chang Gung Medical College &University, Taoyuan City, Taiwan
| | - Ching-Chang Chen
- Department of Neurosurgery, Chang Gung Memorial Hospital, Linkou Medical Center, Chang Gung Medical College &University, Taoyuan City, Taiwan
| | - Yu-San Tee
- Department of Trauma and Emergency Surgery, Chang Gung Memorial Hospital, Linkou Medical Center, Chang Gung Medical College & University, Taoyuan City, Taiwan
| | - Chien-Hung Liao
- Department of Trauma and Emergency Surgery, Chang Gung Memorial Hospital, Linkou Medical Center, Chang Gung Medical College & University, Taoyuan City, Taiwan
| | - Chi-Cheng Chuang
- Department of Neurosurgery, Chang Gung Memorial Hospital, Linkou Medical Center, Chang Gung Medical College &University, Taoyuan City, Taiwan.
| | - Chih-Yuan Fu
- Department of Trauma and Emergency Surgery, Chang Gung Memorial Hospital, Linkou Medical Center, Chang Gung Medical College & University, Taoyuan City, Taiwan.
| |
Collapse
|
40
|
Simon GE, Johnson E, Shortreed SM, Ziebell RA, Rossom RC, Ahmedani BK, Coleman KJ, Beck A, Lynch FL, Daida YG. Predicting suicide death after emergency department visits with mental health or self-harm diagnoses. Gen Hosp Psychiatry 2024; 87:13-19. [PMID: 38277798 PMCID: PMC10939795 DOI: 10.1016/j.genhosppsych.2024.01.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/26/2023] [Revised: 01/21/2024] [Accepted: 01/21/2024] [Indexed: 01/28/2024]
Abstract
OBJECTIVE Use health records data to predict suicide death following emergency department visits. METHODS Electronic health records and insurance claims from seven health systems were used to: identify emergency department visits with mental health or self-harm diagnoses by members aged 11 or older; extract approximately 2500 potential predictors including demographic, historical, and baseline clinical characteristics; and ascertain subsequent deaths by self-harm. Logistic regression with lasso and random forest models predicted self-harm death over 90 days after each visit. RESULTS Records identified 2,069,170 eligible visits, 899 followed by suicide death within 90 days. The best-fitting logistic regression with lasso model yielded an area under the receiver operating curve of 0.823 (95% CI 0.810-0.836). Visits above the 95th percentile of predicted risk included 34.8% (95% CI 31.1-38.7) of subsequent suicide deaths and had a 0.303% (95% CI 0.261-0.346) suicide death rate over the following 90 days. Model performance was similar across subgroups defined by age, sex, race, and ethnicity. CONCLUSIONS Machine learning models using coded data from health records have moderate performance in predicting suicide death following emergency department visits for mental health or self-harm diagnosis and could be used to identify patients needing more systematic follow-up.
Collapse
Affiliation(s)
- Gregory E Simon
- Kaiser Permanente Washington Health Research Institute, Seattle, WA, United States of America.
| | - Eric Johnson
- Kaiser Permanente Washington Health Research Institute, Seattle, WA, United States of America
| | - Susan M Shortreed
- Kaiser Permanente Washington Health Research Institute, Seattle, WA, United States of America
| | - Rebecca A Ziebell
- Kaiser Permanente Washington Health Research Institute, Seattle, WA, United States of America
| | - Rebecca C Rossom
- HealthPartners Institute, Minneapolis, MN, United States of America
| | - Brian K Ahmedani
- Henry Ford Health Center for Health Services Research, Detroit, MI, United States of America
| | - Karen J Coleman
- Kaiser Permanente Southern California Department of Research and Evaluation, Pasadena, CA, United States of America
| | - Arne Beck
- Kaiser Permanente Colorado Institute for Health Research, Denver, CO, United States of America
| | - Frances L Lynch
- Kaiser Permanente Northwest Center for Health Research, Portland, OR, United States of America
| | - Yihe G Daida
- Kaiser Permanente Hawaii Center for Integrated Health Care Research, Honolulu, HI, United States of America
| |
Collapse
|
41
|
Orso D, Furlanis G, Romanelli A, Gheller F, Tecchiolli M, Cominotto F. Risk Factors Analysis for 90-Day Mortality of Adult Patients with Mild Traumatic Brain Injury in an Italian Emergency Department. Geriatrics (Basel) 2024; 9:23. [PMID: 38525740 PMCID: PMC10961819 DOI: 10.3390/geriatrics9020023] [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: 12/11/2023] [Revised: 02/16/2024] [Accepted: 02/21/2024] [Indexed: 03/26/2024] Open
Abstract
Purpose: The most prominent risk factors for mortality after mild traumatic brain injury (TBI) have not been established. This study aimed to establish risk factors related to 90-day mortality after a traumatic event. Methods: A retrospective cohort study on adult patients entering the Emergency Department of the University Hospital of Trieste for mild TBI from 1 January 2020 to 31 December 2020 was conducted. Results: The final population was 1221 patients (median age of 78 years). The 90-day mortality rate was 7% (90 patients). In the Cox regression model (likelihood ratio 110.9; p < 2 × 10-16), the variables that significantly correlated to 90-day mortality were age (less than 75 years old is a protective factor, HR 0.29 [95%CI 0.16-0.54]; p < 0.001); chronic liver disease (HR 4.59 [95%CI 2.56-8.24], p < 0.001); cognitive impairment (HR 2.76 [95%CI 1.78-4.27], p < 0.001); intracerebral haemorrhage (HR 15.38 [95%CI 6.13-38.63], p < 0.001); and hospitalization (HR 2.56 [95%CI 1.67-3.92], p < 0.001). Cardiovascular disease (47% vs. 11%; p < 0.001) and cognitive impairment (36% vs. 10%; p < 0.001) were more prevalent in patients over 75 years of age than the rest of the population. Conclusions: In our cohort of patients with mild TBI, 90-day mortality was low but not negligible. The risk factors associated with 90-day mortality included age, history of chronic liver disease, and cognitive impairment, as well as evidence of intracerebral hemorrhage and hospitalization. The mortality of the sub-population of older patients was likely to be linked to cardiovascular comorbidities and neurodegenerative diseases.
Collapse
Affiliation(s)
- Daniele Orso
- Department of Anesthesia and Intensive Care, ASUFC University Hospital of Udine, Via Pozzuolo 330, 33100 Udine, Italy
| | - Giulia Furlanis
- Department of Emergency Medicine, ASUGI University Hospital of Trieste, 34100 Trieste, Italy; (G.F.); (F.C.)
| | - Alice Romanelli
- Department of Emergency Medicine, ASUGI University Hospital of Trieste, 34100 Trieste, Italy; (G.F.); (F.C.)
| | - Federica Gheller
- Department of Emergency Medicine, ASUGI University Hospital of Trieste, 34100 Trieste, Italy; (G.F.); (F.C.)
| | - Marzia Tecchiolli
- Department of Emergency Medicine, ASUGI University Hospital of Trieste, 34100 Trieste, Italy; (G.F.); (F.C.)
| | - Franco Cominotto
- Department of Emergency Medicine, ASUGI University Hospital of Trieste, 34100 Trieste, Italy; (G.F.); (F.C.)
| |
Collapse
|
42
|
Reddy A, Poonthottathil F, Jonnakuti R, Thomas R. Efficacy of the Canadian CT Head Rule in Patients Presenting to the Emergency Department with Minor Head Injury. Indian J Crit Care Med 2024; 28:148-151. [PMID: 38323261 PMCID: PMC10839931 DOI: 10.5005/jp-journals-10071-24620] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2023] [Accepted: 11/20/2023] [Indexed: 02/08/2024] Open
Abstract
Introduction Approximately, one in three computed tomography (CT) scans performed for head injury may be avoidable. We evaluate the efficacy of the Canadian CT head rule (CCHR) on head CT imaging in minor head injury (MHI) and its association of Glasgow Coma Scale (GCS) and structural abnormality. Materials and methods We conducted a prospective cross-sectional study from May 2018 to October 2019 in the Department of Emergency Medicine, Pushpagiri Institute of Medical Sciences and Research Centre, Thiruvalla, Kerala. The CCHR is applied to patients with MHIs (GCS 13-15) after initial stabilization and it is ascertained, if they require a non-contrast CT head and imaging is done. For those who do not require CT head as per the CCHR are excluded from this study. After imaging the patients who have a positive finding on CT head are admitted and followed up if they underwent any neurosurgical intervention, those with no findings in CT head are discharged from the hospital. A total of 203 patients were included during study period. Results A total of 203 patients were included in study with mean age of 49.5 years. Approximately, 70% (142) were male. Sensitivity of CCHR for predicting positive CT finding in the present study sample was 68% and specificity was 42.5%. Conclusion Canadian CT head rule is a useful tool in the Emergency Department for predicting the requirement of CT in patients with MHI. Canadian CT head rule can reduce the number of CT scans ordered following MHI in ED, thus improving the healthcare costs. How to cite this article Reddy A, Poonthottathil F, Jonnakuti R, Thomas R. Efficacy of the Canadian CT Head Rule in Patients Presenting to the Emergency Department with Minor Head Injury. Indian J Crit Care Med 2024;28(2):148-151.
Collapse
Affiliation(s)
- Ashok Reddy
- Department of Emergency Medicine, NRI Medical College, Mangalagiri, Andhra Pradesh, India
| | | | - Rani Jonnakuti
- Department of Emergency Medicine, Siddartha Medical College, Vijayawada, Andhra Pradesh, India
| | - Roney Thomas
- Department of Emergency Medicine, Pushpagiri Medical College, Kerala, India
| |
Collapse
|
43
|
Wania R, Lampart A, Niedermeier S, Stahl R, Trumm C, Reidler P, Kammerlander C, Böcker W, Klein M, Pedersen V. Diagnostic value of protein S100b as predictor of traumatic intracranial haemorrhage in elderly adults with low-energy falls: results from a retrospective observational study. Eur J Trauma Emerg Surg 2024; 50:205-213. [PMID: 37442831 PMCID: PMC10924004 DOI: 10.1007/s00068-023-02324-7] [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: 01/08/2023] [Accepted: 07/01/2023] [Indexed: 07/15/2023]
Abstract
PURPOSE The objectives of this study were to analyse the clinical value of protein S100b (S100b) in association with clinical findings and anticoagulation therapy in predicting traumatic intracranial haemorrhage (tICH) and unfavourable outcomes in elderly individuals with low-energy falls (LEF). METHODS We conducted a retrospective study in the emergency department (ED) of the LMU University Hospital, Munich by consecutively including all patients aged ≥ 65 years presenting to the ED following a LEF between September 2014 and December 2016 and receiving an emergency cranial computed tomography (cCT) examination. Primary endpoint was the prevalence of tICH. Multivariate logistic regression models and receiver operating characteristics were used to measure the association between clinical findings, anticoagulation therapy and S100b and tICH. RESULTS We included 2687 patients, median age was 81 years (60.4% women). Prevalence of tICH was 6.7% (180/2687) and in-hospital mortality was 6.1% (11/180). Skull fractures were highly associated with tICH (odds ratio OR 46.3; 95% confidence interval CI 19.3-123.8, p < 0.001). Neither anticoagulation therapy nor S100b values were significantly associated with tICH (OR 1.14; 95% CI 0.71-1.86; OR 1.08; 95% CI 0.90-1.25, respectively). Sensitivity of S100b (cut-off: 0.1 ng/ml) was 91.6% (CI 95% 85.1-95.9), specificity was 17.8% (CI 95% 16-19.6), and the area under the curve value was 0.59 (95% CI 0.54 - 0.64) for predicting tICH. CONCLUSION In conclusion, under real ED conditions, neither clinical findings nor protein S100b concentrations or presence of anticoagulation therapy was sufficient to decide with certainty whether a cCT scan can be bypassed in elderly patients with LEF. Further prospective validation is required.
Collapse
Affiliation(s)
- Rebecca Wania
- Department of Orthopedics and Trauma Surgery, Musculoskeletal University Center Munich (MUM), University Hospital, LMU Munich, Marchioninistr 15., 81377, Munich, Germany
| | - Alina Lampart
- Department of Medicine, Kantonsspital Lucerne, Spitalstrasse, 6000, Lucerne, Switzerland
| | - Sandra Niedermeier
- Department of Anaesthesiology and Intensive Care Medicine, ISAR Klinikum, Sonnenstr. 24-26, 80331, Munich, Germany
| | - Robert Stahl
- Institute of Diagnostic and Interventional Neuroradiology, University Hospital, LMU Munich, Marchioninistr. 15, 81377, Munich, Germany
| | - Christoph Trumm
- Institute of Diagnostic and Interventional Neuroradiology, University Hospital, LMU Munich, Marchioninistr. 15, 81377, Munich, Germany
| | - Paul Reidler
- Department of Radiology, University Hospital, LMU Munich, Marchioninistr. 15, 81377, Munich, Germany
| | - Christian Kammerlander
- Department of Orthopedics and Trauma Surgery, Musculoskeletal University Center Munich (MUM), University Hospital, LMU Munich, Marchioninistr 15., 81377, Munich, Germany
- Trauma Hospital Styria, Goestinger Straße 24, 8020, Graz, Austria
| | - Wolfgang Böcker
- Department of Orthopedics and Trauma Surgery, Musculoskeletal University Center Munich (MUM), University Hospital, LMU Munich, Marchioninistr 15., 81377, Munich, Germany
| | - Matthias Klein
- Department of Neurology, University Hospital, LMU Munich, Marchioninistr. 15, 81377, Munich, Germany
- Emergency Department, University Hospital, LMU Munich, Marchioninistr. 15, 81377, Munich, Germany
| | - Vera Pedersen
- Department of Orthopedics and Trauma Surgery, Musculoskeletal University Center Munich (MUM), University Hospital, LMU Munich, Marchioninistr 15., 81377, Munich, Germany.
- Emergency Department, University Hospital, LMU Munich, Marchioninistr. 15, 81377, Munich, Germany.
| |
Collapse
|
44
|
Menditto VG, Moretti M, Babini L, Sampaolesi M, Buzzo M, Montillo L, Raponi A, Riccomi F, Marcosignori M, Rocchi M, Pomponio G. Minor head injury in anticoagulated patients: Outcomes and analysis of clinical predictors. A prospective study. Am J Emerg Med 2024; 76:105-110. [PMID: 38056055 DOI: 10.1016/j.ajem.2023.11.023] [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: 07/04/2023] [Revised: 11/01/2023] [Accepted: 11/13/2023] [Indexed: 12/08/2023] Open
Abstract
BACKGROUND The optimal management of patients taking oral anticoagulants who experience minor head injury (MHI) is unclear. The availability of validated protocols and reliable predictors of prognosis would be of great benefit. We investigated clinical factors as predictors of clinical outcomes and intracranial injury (ICI). METHODS We conducted a single-cohort, prospective, observational study in an ED. Our structured clinical pathway included a first head CT scan, 24 h observation and a second CT scan. The primary outcome was the occurrence of MHI-related death or re-admission to ED at day +30. The secondary outcome was the rate of delayed ICI (dICI), defined as second positive CT scan after a first negative CT scan. We assessed some clinical predictors derived from guidelines and clinical prediction rules as potential risk factors for the outcomes. RESULTS 450 patients with a negative first CT scan who underwent a second CT scan composed our 'study population'. The rate of the primary outcome was 4%. The rate of the secondary outcome was 4.7%. Upon univariate and multivariate analysis no statistically significant predictors for the outcomes were found. CONCLUSIONS Previous retrospective studies showed a lot of negative predictive factors for anticoagulated patients suffering a minor head injury. In our prospective study no clinical factors emerged as predictors of poor clinical outcomes and dICI. So, even if we confirmed a low rate of adverse outcomes, the best management of these patients in ED remains not so clear and future trials are needed.
Collapse
Affiliation(s)
- V G Menditto
- Emergency and Internal Medicine Department, Azienda Ospedaliero Universitaria delle Marche, Ancona, Ancona, Italy.
| | - M Moretti
- Medicina di Laboratorio, Azienda Ospedaliero Universitaria delle Marche, Ancona, Italy
| | - L Babini
- Medicina di Laboratorio, Azienda Ospedaliero Universitaria delle Marche, Ancona, Italy
| | - M Sampaolesi
- Emergency and Internal Medicine Department, Azienda Ospedaliero Universitaria delle Marche, Ancona, Ancona, Italy
| | - M Buzzo
- Emergency and Internal Medicine Department, Azienda Ospedaliero Universitaria delle Marche, Ancona, Ancona, Italy
| | - L Montillo
- Emergency and Internal Medicine Department, Azienda Ospedaliero Universitaria delle Marche, Ancona, Ancona, Italy
| | - A Raponi
- Emergency and Internal Medicine Department, Azienda Ospedaliero Universitaria delle Marche, Ancona, Ancona, Italy
| | - F Riccomi
- Emergency and Internal Medicine Department, Azienda Ospedaliero Universitaria delle Marche, Ancona, Ancona, Italy
| | - M Marcosignori
- Emergency and Internal Medicine Department, Azienda Ospedaliero Universitaria delle Marche, Ancona, Ancona, Italy
| | - M Rocchi
- Statistica Medica, Dipartimento di Scienze Biomolecolari, Università di Urbino, Urbino, Italy
| | - G Pomponio
- Clinica Medica, Azienda Ospedaliero Universitaria delle Marche, Ancona, Italy
| |
Collapse
|
45
|
Ibáñez Pérez de la Blanca MA. Antithrombotic and risk of hemorrhagic complications in over-60-year-olds after mild-minimal traumatic brain injury. Brain Inj 2023; 37:1355-1361. [PMID: 38152883 DOI: 10.1080/02699052.2023.2284907] [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: 11/08/2022] [Accepted: 08/22/2023] [Indexed: 12/29/2023]
Abstract
PRIMARY OBJECTIVE to identify if antithombotics are risk factors for intracereral lesion in older adults with minimal-mild traumatic brain injury (m-mTBI). RESEARCH DESING prospective cohort study. METHODS AND PROCEDURES We included 2,303 patients over 60 years arriving at our Emergency Department within 24 hours of an mTBI with a Glasgow Coma Scale (GSC) of 14-15. Data were gathered on clinical history, cranial CT scans, blood analyses. OUTCOMES AND RESULTS 91.1% had an admission GSC score of 15, and 23.6% developed intracranial complications. In bivariate analyses, statins were associated with a 1.28-fold lower risk of IC. Hemorrhagic progression was 29.76-fold higher in patients receiving anticoagulants, with no difference among anticoagulant types. Male sex, GSC of 14, alcohol consumption, and the presence of tumor were risk factors for IC. In multivariate analysis, GSC of 14, alcohol consumption, and malignancy emerged as risk factors for these complications, neurological disease and diabetes as protective factors. After exclusion of neurological disease and diabetes from the multivariate model, a GSC of 14 showed the highest predictive capacity. CONCLUSIONS Antithrombotics intake are not risks factor for intracranial injury in minimal-mild brain injury trauma. Further research is needed taking account of their fragility and comorbidities.
Collapse
|
46
|
Martínez-Rivas JJ, Rodríguez-Lucas F, Planells G, Corrales D, Cocho D. Risk of cerebral hemorrhage in mild traumatic brain injury and antithrombotic treatment. Rev Clin Esp 2023; 223:604-609. [PMID: 37898355 DOI: 10.1016/j.rceng.2023.10.005] [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: 06/04/2023] [Accepted: 09/21/2023] [Indexed: 10/30/2023]
Abstract
INTRODUCTION The observation time in mild traumatic brain injury (mTBI) is controversial. Our aim was to assess the risk of neurological complications in mTBI with and without antithrombotic treatment. METHOD We retrospectively evaluated patients with mTBI seen in the emergency room for 3 years. We considered MTBI those with Glasgow ≥13 at admission. A cranial CT was performed in all cases with ≥1 risk factor at admission and at 24 h in those with neurological impairment or initial pathological cranial CT. Complications in the following 3 months were retrospectively reviewed. RESULTS We evaluated 907 patients with a mean age of 73 ± 19 years. Ninety-one percent presented risk factors, with 60% on antithrombotic treatment. We detected 11% of initial brain hemorrhage, 0.4% at 24 h, and no cases at 3 months. Antithrombotic treatment was not associated with an increased risk of brain hemorrhage (9.9% with vs 11.9% without treatment, p = 0.3). 39% of the hemorrhages presented neurological symptoms (18% post-traumatic amnesia, 12% headache, 8% vomiting, 1% seizures), with 78.4% having mild symptoms. Of the 4 hemorrhages detected at 24 h, 3 were asymptomatic and one case that worsened the initial headache. No asymptomatic patient without lesion on initial clinical cranial CT presented at 24 h. CONCLUSIONS Our study suggests that patients with asymptomatic mTBI, without a lesion on the initial cranial CT, would not require the observation period or CT control regardless of antithrombotic treatment or INR level.
Collapse
Affiliation(s)
- J J Martínez-Rivas
- Servicio de urgencias, Hospital General de Granollers, Barcelona, Spain.
| | - F Rodríguez-Lucas
- Servicio de urgencias, Hospital General de Granollers, Barcelona, Spain
| | - G Planells
- Servicio de urgencias, Hospital General de Granollers, Barcelona, Spain
| | - D Corrales
- Servicio de urgencias, Hospital General de Granollers, Barcelona, Spain
| | - D Cocho
- Servicio de Neurología, Hospital General de Granollers, Barcelona, Spain; Universitat Internacional de Catalunya, Barcelona, Spain
| |
Collapse
|
47
|
Turchiaro ML, Solano JJ, Clayton LM, Hughes PG, Shih RD, Alter SM. Computed Tomography Imaging of Geriatric Patients with Uncertain Head Trauma. J Emerg Med 2023; 65:e511-e516. [PMID: 37838489 DOI: 10.1016/j.jemermed.2023.07.009] [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: 04/01/2023] [Accepted: 07/15/2023] [Indexed: 10/16/2023]
Abstract
BACKGROUND Although clinical decision rules exist for patients with head injuries, no tool assesses patients with unknown trauma events. Patients with uncertain trauma may have unnecessary brain imaging. OBJECTIVE This study evaluated risk factors and outcomes of geriatric patients with uncertain head injury. METHODS This prospective cohort study included geriatric patients with definite or uncertain head injury presenting to two emergency departments (EDs). Patients were grouped as definite or uncertain head trauma based on history and physical examination. Outcomes were intracranial hemorrhage (ICH) on head computed tomography (CT), need for neurosurgical intervention, and mortality. Risk factors assessed included gender, alcohol use, tobacco use, history of dementia, anticoagulant use, antiplatelet use, and Glasgow Coma Scale (GCS) score < 15. RESULTS We enrolled 2905 patients with definite head trauma and 950 with uncertain head trauma. Rates of acute ICH (10.7% vs. 1.5%; odds ratio [OR] 8.02; 95% confidence interval [CI] 4.67-13.76), delayed ICH (0.7% vs. 0.1%; OR 6.58; 95% CI 4.67-13.76), and neurosurgical intervention (1.2% vs. 0.3%; OR 3.74; 95% CI 1.15-12.20) were all higher in definite vs. uncertain head injuries. There were no differences in mortality. Patients with definite trauma had higher rates of ICH with male gender (OR 1.58; 95% CI 1.24-1.99), alcohol use (OR 1.62; 95% CI 1.25-2.09), antiplatelet use (OR 1.84; 95% CI 1.46-2.31), and GCS score < 15 (OR 3.24; 95% CI 2.54-4.13). Patients with uncertain trauma had no characteristics associated with increased ICH. CONCLUSIONS Although ICH rates among patients with uncertain head trauma was eight times lower than those with definite head trauma, the risk of ICH is high enough to warrant CT imaging of all geriatric patients with uncertain head injury.
Collapse
Affiliation(s)
- Michael L Turchiaro
- Department of Emergency Medicine, Florida Atlantic University Charles E. Schmidt College of Medicine, Boca Raton, Florida; Department of Emergency Medicine, Delray Medical Center, Delray Beach, Florida
| | - Joshua J Solano
- Department of Emergency Medicine, Florida Atlantic University Charles E. Schmidt College of Medicine, Boca Raton, Florida; Department of Emergency Medicine, Delray Medical Center, Delray Beach, Florida
| | - Lisa M Clayton
- Department of Emergency Medicine, Florida Atlantic University Charles E. Schmidt College of Medicine, Boca Raton, Florida; Department of Emergency Medicine, Delray Medical Center, Delray Beach, Florida
| | - Patrick G Hughes
- Department of Emergency Medicine, Florida Atlantic University Charles E. Schmidt College of Medicine, Boca Raton, Florida; Department of Emergency Medicine, Delray Medical Center, Delray Beach, Florida
| | - Richard D Shih
- Department of Emergency Medicine, Florida Atlantic University Charles E. Schmidt College of Medicine, Boca Raton, Florida; Department of Emergency Medicine, Delray Medical Center, Delray Beach, Florida
| | - Scott M Alter
- Department of Emergency Medicine, Florida Atlantic University Charles E. Schmidt College of Medicine, Boca Raton, Florida; Department of Emergency Medicine, Delray Medical Center, Delray Beach, Florida
| |
Collapse
|
48
|
Hayden EM, Borczuk P, Dutta S, Liu SW, White BA, Lavin-Parsons K, Zheng H, Filbin MR, Zachrison KS. Can video-based telehealth examinations of the abdomen safely determine the need for imaging? J Telemed Telecare 2023; 29:761-774. [PMID: 34142893 DOI: 10.1177/1357633x211023346] [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: 11/17/2022]
Abstract
There is little evidence on the reliability of the video-based telehealth physical examinations. Our objective was to evaluate the feasibility of a physician-directed abdominal examination using telehealth. This was a prospective, blinded observational study of patients >19 years of age presenting with abdominal pain to a large, academic emergency department. In addition to their usual care, patients had a video-based telehealth examination by an emergency physician early in the visit. We compared the in-person and telehealth providers' decisions on imaging. Thirty patients were enrolled and providers' recommendations for imaging were YES (telehealth: 18 (60%); in-person: 22 (73%)), UNSURE (telehealth: 9 (30%); in-person: 2 (7%)) and NO (telehealth: 6 (20%); in-person: 3 (10%)). There were 20 patients for whom both telehealth and in-person providers were not unsure; of these, 16 (80%, 95% confidence interval 56.3-94.3%) patients had a provider agreement on the need for imaging. While the use of video-based telehealth may be feasible for patients seeking emergency department care for abdominal pain, further study is needed to determine how it may be safely deployed. Currently, caution should be exercised when evaluating the need for abdominal imaging remotely.
Collapse
Affiliation(s)
- Emily M Hayden
- Department of Emergency Medicine, Massachusetts General Hospital, USA
| | - Pierre Borczuk
- Department of Emergency Medicine, Massachusetts General Hospital, USA
| | - Sayon Dutta
- Department of Emergency Medicine, Massachusetts General Hospital, USA
| | - Shan W Liu
- Department of Emergency Medicine, Massachusetts General Hospital, USA
| | - Benjamin A White
- Department of Emergency Medicine, Massachusetts General Hospital, USA
| | | | - Hui Zheng
- Department of Biostatistics, Massachusetts General Hospital, USA
| | - Michael R Filbin
- Department of Emergency Medicine, Massachusetts General Hospital, USA
| | - Kori S Zachrison
- Department of Emergency Medicine, Massachusetts General Hospital, USA
| |
Collapse
|
49
|
Barrett JW, Williams J, Skene SS, Griggs JE, Bootland D, Leung J, Da Costa A, Ballantyne K, Davies R, Lyon RM. Head injury in older adults presenting to the ambulance service: who do we convey to the emergency department, and what clinical variables are associated with an intracranial bleed? A retrospective case-control study. Scand J Trauma Resusc Emerg Med 2023; 31:65. [PMID: 37908011 PMCID: PMC10619243 DOI: 10.1186/s13049-023-01138-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2023] [Accepted: 10/18/2023] [Indexed: 11/02/2023] Open
Abstract
OBJECTIVE Most older adults with traumatic brain injuries (TBI) reach the emergency department via the ambulance service. Older adults, often with mild TBI symptoms, risk being under-triaged and facing poor outcomes. This study aimed to identify whether sufficient information is available on the scene to an ambulance clinician to identify an older adult at risk of an intracranial haemorrhage following a head injury. METHODS This was a retrospective case-control observational study involving one regional ambulance service in the UK and eight emergency departments. 3545 patients aged 60 years and over presented to one regional ambulance service with a head injury between the 1st of January 2020 and the 31st of December 2020. The primary outcome was an acute intracranial haemorrhage on head computed tomography (CT) scan in patients conveyed to the emergency department (ED). A secondary outcome was factors associated with conveyance to the ED by the ambulance clinician. RESULTS In 2020, 2111 patients were conveyed to the ED and 162 patients were found to have an intracranial haemorrhage on their head CT scan. Falls from more than 2 m (adjusted odds ratio (aOR) 3.45, 95% CI 1.78-6.40), chronic kidney disease (CKD) (aOR 2.80, 95% CI 1.25-5.75) and Clopidogrel (aOR 1.98, 95% CI 1.04-3.59) were associated with an intracranial haemorrhage. Conveyance to the ED was associated with patients taking anticoagulant and antiplatelet medication or a visible head injury or head injury symptoms. CONCLUSION This study highlights that while most older adults with a head injury are conveyed to the ED, only a minority will have an intracranial haemorrhage following their head injury. While mechanisms of injury such as falls from more than 2 m remain a predictor, this work highlights that Clopidogrel and CKD are also associated with an increased odds of tICH in older adults following a head injury. These findings may warrant a review of current ambulance head injury guidelines.
Collapse
Affiliation(s)
- J W Barrett
- South East Coast Ambulance Service NHS FT, Crawley, UK.
- University of Surrey, Guildford, UK.
| | - J Williams
- South East Coast Ambulance Service NHS FT, Crawley, UK
- Paramedic Clinical Research Unit, University of Hatfield, Hatfield, UK
| | | | - J E Griggs
- University of Surrey, Guildford, UK
- Air Ambulance Charity Kent, Surrey and Sussex, Redhill, UK
| | - D Bootland
- Air Ambulance Charity Kent, Surrey and Sussex, Redhill, UK
- University Hospitals Sussex NHS Foundation Trust, Worthing, UK
| | - J Leung
- Air Ambulance Charity Kent, Surrey and Sussex, Redhill, UK
- East Kent Hospitals University NHS Foundation Trust, Canterbury, UK
| | - A Da Costa
- Medway Maritime Hospital NHS FT, Gillingham, UK
| | - K Ballantyne
- East Kent Hospitals University NHS Foundation Trust, Canterbury, UK
| | - R Davies
- South East Coast Ambulance Service NHS FT, Crawley, UK
| | - R M Lyon
- University of Surrey, Guildford, UK
- Air Ambulance Charity Kent, Surrey and Sussex, Redhill, UK
| |
Collapse
|
50
|
Rauchman SH, Pinkhasov A, Gulkarov S, Placantonakis DG, De Leon J, Reiss AB. Maximizing the Clinical Value of Blood-Based Biomarkers for Mild Traumatic Brain Injury. Diagnostics (Basel) 2023; 13:3330. [PMID: 37958226 PMCID: PMC10650880 DOI: 10.3390/diagnostics13213330] [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: 09/27/2023] [Revised: 10/23/2023] [Accepted: 10/25/2023] [Indexed: 11/15/2023] Open
Abstract
Mild traumatic brain injury (TBI) and concussion can have serious consequences that develop over time with unpredictable levels of recovery. Millions of concussions occur yearly, and a substantial number result in lingering symptoms, loss of productivity, and lower quality of life. The diagnosis may not be made for multiple reasons, including due to patient hesitancy to undergo neuroimaging and inability of imaging to detect minimal damage. Biomarkers could fill this gap, but the time needed to send blood to a laboratory for analysis made this impractical until point-of-care measurement became available. A handheld blood test is now on the market for diagnosis of concussion based on the specific blood biomarkers glial fibrillary acidic protein (GFAP) and ubiquitin carboxyl terminal hydrolase L1 (UCH-L1). This paper discusses rapid blood biomarker assessment for mild TBI and its implications in improving prediction of TBI course, avoiding repeated head trauma, and its potential role in assessing new therapeutic options. Although we focus on the Abbott i-STAT TBI plasma test because it is the first to be FDA-cleared, our discussion applies to any comparable test systems that may become available in the future. The difficulties in changing emergency department protocols to include new technology are addressed.
Collapse
Affiliation(s)
| | - Aaron Pinkhasov
- Department of Medicine and Biomedical Research Institute, NYU Grossman Long Island School of Medicine, Mineola, NY 11501, USA; (A.P.); (S.G.); (J.D.L.)
| | - Shelly Gulkarov
- Department of Medicine and Biomedical Research Institute, NYU Grossman Long Island School of Medicine, Mineola, NY 11501, USA; (A.P.); (S.G.); (J.D.L.)
| | | | - Joshua De Leon
- Department of Medicine and Biomedical Research Institute, NYU Grossman Long Island School of Medicine, Mineola, NY 11501, USA; (A.P.); (S.G.); (J.D.L.)
| | - Allison B. Reiss
- Department of Medicine and Biomedical Research Institute, NYU Grossman Long Island School of Medicine, Mineola, NY 11501, USA; (A.P.); (S.G.); (J.D.L.)
| |
Collapse
|