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Su YS, Schuster JM, Smith DH, Stein SC. Cost-Effectiveness of Biomarker Screening for Traumatic Brain Injury. J Neurotrauma 2019; 36:2083-2091. [PMID: 30547708 DOI: 10.1089/neu.2018.6020] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023] Open
Abstract
Intracranial hemorrhage after traumatic brain injury (TBI) can be life threatening and requires prompt diagnosis. Computed tomography (CT) scans are a rapid and accurate way to evaluate for hemorrhage. In patients with mild and moderate TBI, however, in whom the incidence of intracranial pathology is low, scanning every patient with CT can be costly. The Food and Drug Administration recently approved a novel biomarker screen, the Banyan Trauma Indicator (BTI), to help streamline the decision for CT scanning in mild to moderate TBI. The BTI screen diagnoses intracranial lesions with a sensitivity and specificity of 97.5% and 99.6%, respectively. We performed cost analyses of the BTI screen to determine the threshold of cost-effectiveness, compared with application of clinical decision rules or routine CT scans, for cases of mild or moderate TBI. With a 0.104 probability of an intracranial lesion in mild TBI, the biomarker screen is cost-effective if the cost is $308.96 or below per test. In moderate TBI, because of the greater prevalence of intracranial lesions at 0.663, there is a lower need for screening, and BTI becomes cost-effective up to $73.41 per test.
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Affiliation(s)
- YouRong Sophie Su
- Department of Neurosurgery, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - James M Schuster
- Department of Neurosurgery, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Douglas H Smith
- Department of Neurosurgery, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Sherman C Stein
- Department of Neurosurgery, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
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Cretin E, Pazart L, Rousseau MC, Noé A, Decavel P, Chassagne A, Godard-Marceau A, Trimaille H, Mathieu-Nicot F, Beaussant Y, Gabriel D, Daneault S, Aubry R. Exploring the perceptions of physicians, caregivers and families towards artificial nutrition and hydration for people in permanent vegetative state: How can a photo-elicitation method help? PLoS One 2017; 12:e0186776. [PMID: 29073185 PMCID: PMC5658072 DOI: 10.1371/journal.pone.0186776] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2017] [Accepted: 10/06/2017] [Indexed: 11/20/2022] Open
Abstract
The question of withdrawing artificial nutrition and hydration from people in a permanent vegetative state sparks considerable ethical and legal debate. Therefore, understanding the elements that influence such a decision is crucial. However, exploring perceptions of artificial nutrition and hydration is methodologically challenging for several reasons. First, because of the emotional state of the professionals and family members, who are facing an extremely distressing situation; second, because this question mirrors representations linked to a deep-rooted fear of dying of hunger and thirst; and third, because of taboos surrounding death. We sought to determine the best method to explore such complex situations in depth. This article aims to assess the relevance of the photo-elicitation interview method to analyze the perceptions and attitudes of health professionals and families of people in a permanent vegetative state regarding artificial nutrition and hydration. The photo-elicitation interview method consists in inserting one or more photographs into a research interview. An original set of 60 photos was built using Google Images and participants were asked to choose photos (10 maximum) and talk about them. The situations of 32 patients were explored in 23 dedicated centers for people in permanent vegetative state across France. In total, 138 interviews were conducted with health professionals and family members. We found that the photo-elicitation interview method 1) was well accepted by the participants and allowed them to express their emotions constructively, 2) fostered narration, reflexivity and introspection, 3) offered a sufficient "unusual angle" to allow participants to go beyond stereotypes and habits of thinking, and 4) can be replicated in other research areas. The use of visual methods currently constitutes an expanding area of research and this study stressed that this is of special interest to enhance research among populations facing end-of-life and ethical issues.
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Affiliation(s)
- Elodie Cretin
- Clinical Investigation Center, CIC 1431 Inserm, University Hospital of Besançon, Besançon, France
- Palliative Care Unit, University Hospital of Besançon, Besançon, France
- Department of Philosophy EA 2274, University of Bourgogne Franche-Comté, Besançon, France
- Department of Neurosciences EA 481, University of Bourgogne Franche-Comté, Besançon, France
- Regional Center for Medical Ethics Bourgogne / Franche-Comté (EREBFC), Besançon, France
- * E-mail:
| | - Lionel Pazart
- Clinical Investigation Center, CIC 1431 Inserm, University Hospital of Besançon, Besançon, France
- Department of Neurosciences EA 481, University of Bourgogne Franche-Comté, Besançon, France
| | | | - Alain Noé
- PVS/MCS Unit, Center for Functional Re-education and Rehabilitation Bretignier, Héricourt, France
| | - Pierre Decavel
- Department of Neurosciences EA 481, University of Bourgogne Franche-Comté, Besançon, France
- PVS/MCS Unit, Center for Functional Re-education and Rehabilitation Les Salins de Bregille, Besançon, France
| | - Aline Chassagne
- Clinical Investigation Center, CIC 1431 Inserm, University Hospital of Besançon, Besançon, France
- Palliative Care Unit, University Hospital of Besançon, Besançon, France
- Department of Socio-anthropology EA 3189, University of Bourgogne Franche-Comté, Besançon, France
| | - Aurélie Godard-Marceau
- Clinical Investigation Center, CIC 1431 Inserm, University Hospital of Besançon, Besançon, France
- Palliative Care Unit, University Hospital of Besançon, Besançon, France
- Department of Neurosciences EA 481, University of Bourgogne Franche-Comté, Besançon, France
| | - Hélène Trimaille
- Clinical Investigation Center, CIC 1431 Inserm, University Hospital of Besançon, Besançon, France
- Palliative Care Unit, University Hospital of Besançon, Besançon, France
| | - Florence Mathieu-Nicot
- Clinical Investigation Center, CIC 1431 Inserm, University Hospital of Besançon, Besançon, France
- Palliative Care Unit, University Hospital of Besançon, Besançon, France
- Department of Psychology EA 3188, University of Bourgogne Franche-Comté, Besançon, France
| | - Yvan Beaussant
- Clinical Investigation Center, CIC 1431 Inserm, University Hospital of Besançon, Besançon, France
- Palliative Care Unit, University Hospital of Besançon, Besançon, France
| | - Damien Gabriel
- Clinical Investigation Center, CIC 1431 Inserm, University Hospital of Besançon, Besançon, France
- Department of Neurosciences EA 481, University of Bourgogne Franche-Comté, Besançon, France
| | | | - Régis Aubry
- Clinical Investigation Center, CIC 1431 Inserm, University Hospital of Besançon, Besançon, France
- Palliative Care Unit, University Hospital of Besançon, Besançon, France
- Department of Neurosciences EA 481, University of Bourgogne Franche-Comté, Besançon, France
- Regional Center for Medical Ethics Bourgogne / Franche-Comté (EREBFC), Besançon, France
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Turner-Stokes L. A matter of life and death: controversy at the interface between clinical and legal decision-making in prolonged disorders of consciousness. JOURNAL OF MEDICAL ETHICS 2017; 43:469-475. [PMID: 27986800 PMCID: PMC5520010 DOI: 10.1136/medethics-2016-104057] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/17/2016] [Revised: 11/27/2016] [Accepted: 11/29/2016] [Indexed: 06/06/2023]
Abstract
Best interests decision-making and end-of-life care for patients in permanent vegetative or minimally conscious states (VS/MCS) is a complex area of clinical and legal practice, which is poorly understood by most clinicians, lawyers and members of the public. In recent weeks, the Oxford Shrieval lecture by Mr Justice Baker ('A Matter of Life and Death', 11 October 2016) and its subsequent reporting in the public press has sparked debate on the respective roles of clinicians, the Court of Protection and the Mental Capacity Act 2005 in decisions to withhold or withdraw life-sustaining treatments from patients with disorders of consciousness. The debate became polarised and confused by misquotation and inaccurate terminology, and highlighted a lack of knowledge about how patients in VS/MCS die in the absence of court approval. This article sets out the background and discussion and attempts to give a more accurate representation of the facts. In the spirit of transparency, I present a mortality review of all the patients in VS/MCS who have died under the care of my own unit in the last decade-with or without referral to the court, but always in accordance with the law. These data demonstrate that clinicians regularly undertake best interests decision-making in conjunction with families that may include life and death decisions (sometimes even the withdrawal or withholding of clinically assisted nutrition and hydration); and that these can be made within the current legal framework without necessarily involving the court in all cases. This is the first published case series of its kind.
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Affiliation(s)
- Lynne Turner-Stokes
- Faculty of Life Sciences and Medicine, Department of Palliative Care, Policy and Rehabilitation, King's College London, London, UK
- Regional/Hyper-acute Rehabilitation Unit, Northwick Park Hospital, Harrow, UK
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Abstract
Long-term survival after severe trauma is rarely addressed in German trauma journals although knowledge of life expectancy and identification of factors contributing to increased mortality are important for lifetime care management, development of service models, and targeting health promotion and prevention interventions. As reliable data in Germany are lacking, we compiled data mainly from the USA and Australia to describe life expectancy, risk factors, and predictors of outcome in patients experiencing traumatic spinal cord injury, traumatic brain injury, and polytrauma. Two years after trauma, life expectancy in all three categories was significantly lower than that of the general population. It depends strongly on severity of disability, age, and gender and is quantifiable. Whereas improvements in medical care have led to a marked decline in short-term mortality, surprisingly long-term survival in severe trauma has not changed over the past 30 years. Therefore, there is need to intensify long-term trauma patient care and to find new strategies to limit primary damage.
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Affiliation(s)
- W Mutschler
- Klinik für Allgemeine Unfall- und Wiederherstellungschirurgie, Ludwig-Maximilians-Universität München, Nußbaumstr. 20, 80336, München, Deutschland.
| | - M Mutschler
- Klinik für Orthopädie,Unfallchirurgie und Sporttraumatologie, Kliniken der Stadt Köln, Universität Witten-Herdecke Campus Köln-Merheim, Köln, Deutschland
| | - M Graw
- Institut für Rechtsmedizin, Ludwig-Maximilian-Universität München, München, Deutschland
| | - R Lefering
- Institut für Forschung in der Operativen Medizin, Universität Witten-Herdecke,Campus Köln-Merheim, Köln, Deutschland
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Pelizzo G, Calcaterra V, Carlini V, Fusillo M, Manuelli M, Klersy C, Pasqua N, Luka E, Albertini R, De Amici M, Cena H. Nutritional status and metabolic profile in neurologically impaired pediatric surgical patients. J Pediatr Endocrinol Metab 2017; 30:289-300. [PMID: 28222035 DOI: 10.1515/jpem-2016-0369] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/19/2016] [Accepted: 01/09/2017] [Indexed: 02/06/2023]
Abstract
BACKGROUND Malnutrition is reported in pediatric neuromotor disability and impacts the child's health. We described the nutritional and metabolic status in neurologically impaired (NI) children undergoing surgery. METHODS Anthropometry, body composition, hormonal and nutritional evaluations were performed in 44 NI subjects (13.7±8.0 years). Energy needs were calculated by Krick's formula. Metabolic syndrome (MS) was defined applying the following criteria (≥3 defined MS): fasting blood glucose >100 mg/dL and/or homeostasis model assessment for insulin resistance (HOMA-IR) >97.5th percentile, trygliceride level >95th percentile, high-density lipoprotein (HDL)-cholesterol level <5th percentile, systolic/diastolic pressure >95th percentile; whilebody mass index - standard deviation score (BMI-SDS) <2 and biochemical malnutrition markers (≥2) defined undernutrition. RESULTS Energy intake was not adequate in 73.8% of the patients; no correlation between energy intake and BMI was noted. Undernutrition was noted in 34.1% of patients and MS in 11.36% of subjects. Fifty percent of the patients presented with insulin resistance, which was not related to BMI, body composition or other MS components. CONCLUSIONS Nutritional and metabolic monitoring of disabled children and young adults is recommended to prevent adverse outcomes associated with malnutrition.
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Romaniello C, Bertoletti E, Matera N, Farinelli M, Pedone V. Morfeo Study II: Clinical Course and Complications in Patients With Long-Term Disorders of Consciousness. Am J Med Sci 2016; 351:563-9. [PMID: 27238917 DOI: 10.1016/j.amjms.2016.01.024] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2015] [Revised: 12/29/2015] [Accepted: 01/19/2016] [Indexed: 11/29/2022]
Abstract
BACKGROUND The life expectancy of patients with disorders of consciousness (DOCs) is ever-increasing, but little is known about their clinical course over late stages. Several issues (premorbid conditions, complications and pressure sores) are to be considered for their effect on clinical outcome, risk of death and recovery of functional performance. Unfortunately, in late stages of long-term rehabilitation, these aspects are still more neglected than in acute and postacute stages. The aim of this study was to investigate the clinical course and the complications of patients in the late stages of DOCs and to explore the relationship between mortality and specific biomarkers. MATERIALS AND METHODS A total of 112 patients, admitted over 10 years in a dedicated ward, were retrospectively studied. Sociodemographic data, preadmission and inpatient clinical features were collected. Disability Rating Scale scores, complications including pressure sores and blood markers were assessed monthly. Data were analyzed through descriptive statistics and correlations using SPSS. RESULTS Most patients were men older than 50 years with a nontraumatic etiology and a history of hypertension (42.86%). The most common complication was pneumonia (76.79%). No association was found between sex and mortality or between etiology and mortality (P > 0.05). Mortality correlated significantly with sepsis (ρ = 0.253), albumin (ρ = -0.558), hemoglobin (ρ = -0.354) and white blood cells (ρ = 0.243). Only 42% of patients remained unchanged at Disability Rating Scale evaluation. CONCLUSIONS These data confirmed that DOCs are not static conditions and they require ongoing monitoring and assessment of clinical status, level of consciousness and laboratory biomarkers.
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Affiliation(s)
| | | | | | - Marina Farinelli
- Clinical Psychology Service, Villa Bellombra Rehabilitation Hospital, Bologna, Italy
| | - Vincenzo Pedone
- Santa Viola Hospital, Bologna, Italy; Villa Bellombra Rehabilitation Hospital, Bologna, Italy
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Shavelle RM, Brooks JC, Strauss DJ, Paculdo DR. A note on survival after anoxic brain injury in adolescents and young adults. NeuroRehabilitation 2015; 36:379-82. [PMID: 26409341 DOI: 10.3233/nre-151226] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND Much is known about survival after traumatic brain injury (TBI), yet relatively little about survival after anoxic brain injury (ABI). OBJECTIVE To determine whether long-term survival after ABI is comparable to that after TBI. METHODS We identified 237 patients with ABI and 1,620 with TBI in California who were aged 15 to 35, survived at least 1 year post injury, and were injured in 1986 or later. We analyzed the long-term follow-up data using the Cox Proportional Hazards Regression Model, controlling for age, sex, and severity of disability. RESULTS After adjustment for risk factors, no significant differences in long-term survival between ABI and TBI were found (hazard ratio = 0.97; 95% c.i. 0.57-1.65). CONCLUSIONS In adolescents and young adults, long-term survival after ABI appears to be similar to that after TBI.
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Economic evaluation of decompressive craniectomy versus barbiturate coma for refractory intracranial hypertension following traumatic brain injury. Crit Care Med 2014; 42:2235-43. [PMID: 25054675 DOI: 10.1097/ccm.0000000000000500] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES Decompressive craniectomy and barbiturate coma are often used as second-tier strategies when intracranial hypertension following severe traumatic brain injury is refractory to first-line treatments. Uncertainty surrounds the decision to choose either treatment option. We investigated which strategy is more economically attractive in this context. DESIGN We performed a cost-utility analysis. A Markov Monte Carlo microsimulation model with a life-long time horizon was created to compare quality-adjusted survival and cost of the two treatment strategies, from the perspective of healthcare payer. Model parameters were estimated from the literature. Two-dimensional simulation was used to incorporate parameter uncertainty into the model. Value of information analysis was conducted to identify major drivers of decision uncertainty and focus future research. SETTING Trauma centers in the United States. SUBJECTS Base case was a population of patients (mean age = 25 yr) who developed refractory intracranial hypertension following traumatic brain injury. INTERVENTIONS We compared two treatment strategies: decompressive craniectomy and barbiturate coma. MEASUREMENTS AND MAIN RESULTS Decompressive craniectomy was associated with an average gain of 1.5 quality-adjusted life years relative to barbiturate coma, with an incremental cost-effectiveness ratio of $9,565/quality-adjusted life year gained. Decompressive craniectomy resulted in a greater quality-adjusted life expectancy 86% of the time and was more cost-effective than barbiturate coma in 78% of cases if our willingness-to-pay threshold is $50,000/quality-adjusted life year and 82% of cases at a threshold of $100,000/quality-adjusted life year. At older age, decompressive craniectomy continued to increase survival but at higher cost (incremental cost-effectiveness ratio = $197,906/quality-adjusted life year at mean age = 85 yr). CONCLUSIONS Based on available evidence, decompressive craniectomy for the treatment of refractory intracranial hypertension following traumatic brain injury provides better value in terms of costs and health gains than barbiturate coma. However, decompressive craniectomy might be less economically attractive for older patients. Further research, particularly on natural history of severe traumatic brain injury patients, is needed to make more informed treatment decisions.
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Pagani M, Leonardi M, Covelli V, Giovannetti AM, Sattin D. Risk factors for mortality in 600 patients in vegetative and minimally conscious states. J Neurol 2014; 261:1144-52. [DOI: 10.1007/s00415-014-7309-8] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2013] [Revised: 03/03/2014] [Accepted: 03/04/2014] [Indexed: 10/25/2022]
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Life expectancy following rehabilitation: a NIDRR Traumatic Brain Injury Model Systems study. J Head Trauma Rehabil 2013; 27:E69-80. [PMID: 23131972 DOI: 10.1097/htr.0b013e3182738010] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE To characterize overall and cause-specific mortality and life expectancy among persons who have completed inpatient traumatic brain injury rehabilitation and to assess risk factors for mortality. DESIGN Prospective cohort study. SETTING The Traumatic Brain Injury Model Systems. PARTICIPANTS A total of 8573 individuals injured between 1988 and 2009, with survival status per December 31, 2009, determined. INTERVENTIONS Not applicable. MAIN OUTCOME MEASURES Standardized mortality ratio (SMR), life expectancy, cause of death. RESULTS SMR was 2.25 overall and was significantly elevated for all age groups, both sexes, all race/ethnic groups (except Native Americans), and all injury severity groups. SMR decreased as survival time increased but remained elevated even after 10 years postinjury. SMR was elevated for all cause-of-death categories but especially so for seizures, aspiration pneumonia, sepsis, accidental poisonings, and falls. Life expectancy was shortened an average of 6.7 years. Multivariate Cox regression showed age at injury, sex, race/ethnic group, marital status and employment status at the time of injury year of injury, preinjury drug use, days unconscious, functional independence and disability on rehabilitation discharge, and comorbid spinal cord injury to be independent risk factors for death. CONCLUSION There is an increased risk of death after moderate or severe traumatic brain injury. Risk factors and causes of death have been identified that may be amenable to intervention.
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Leonardi M, Sattin D, Raggi A. An Italian population study on 600 persons in vegetative state and minimally conscious state. Brain Inj 2013; 27:473-84. [DOI: 10.3109/02699052.2012.750758] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
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Giovannetti AM, Leonardi M, Pagani M, Sattin D, Raggi A. Burden of caregivers of patients in Vegetative state and minimally conscious state. Acta Neurol Scand 2013; 127:10-8. [PMID: 22509952 DOI: 10.1111/j.1600-0404.2012.01666.x] [Citation(s) in RCA: 50] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/14/2012] [Indexed: 11/27/2022]
Abstract
OBJECTIVES To assess differences in the burden of caregivers of patients in Vegetative state (VS) and minimally conscious state (MCS). MATERIALS AND METHODS The Family Strain Questionnaire, Coping Orientations to Problem Experiences, Caregiver Needs Assessment, Short Form-12, Beck Depression Inventory and State-Trait Anxiety Inventory were used. Differences in psychological condition between caregivers of VS and MCS patients, with different disease duration and hosting facility were assessed with Kruskall-Wallis test and factors associated with the overall levels of burden with UNIANOVA. RESULTS In total, 487 participants were enrolled. Daily hours of care-giving is significantly associated with the overall level of burden perceived by caregivers (F = 4.099; P = 0.018). Strain, needs and frequency of use of coping strategies are substantially similar regardless of the patient's condition and distance from the acute event. Caregivers of post-acute patients reported low scores in mental health (median = 33.8; IQR = 23.1-47.6) and higher state of anxiety (median = 54; IQR = 45-62), whereas caregivers of long-term patients expressed more needs in social involvement (median = 19; IQR = 15-22). CONCLUSIONS Burden and distress were high for all caregivers of VS and MCS patients. As care-giving is a long-term commitment process, support to the caregiver should be guaranteed throughout the duration of the relative's disease despite the patient's diagnosis or place where the patient is hosted.
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Affiliation(s)
- A. M. Giovannetti
- Neurology; Public Health and Disability Unit, Scientific Directorate; Neurological Institute Carlo Besta IRCCS Foundation; Milan; Italy
| | - M. Leonardi
- Neurology; Public Health and Disability Unit, Scientific Directorate; Neurological Institute Carlo Besta IRCCS Foundation; Milan; Italy
| | - M. Pagani
- Neurology; Public Health and Disability Unit, Scientific Directorate; Neurological Institute Carlo Besta IRCCS Foundation; Milan; Italy
| | - D. Sattin
- Neurology; Public Health and Disability Unit, Scientific Directorate; Neurological Institute Carlo Besta IRCCS Foundation; Milan; Italy
| | - A. Raggi
- Neurology; Public Health and Disability Unit, Scientific Directorate; Neurological Institute Carlo Besta IRCCS Foundation; Milan; Italy
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Whitmore RG, Thawani JP, Grady MS, Levine JM, Sanborn MR, Stein SC. Is aggressive treatment of traumatic brain injury cost-effective? J Neurosurg 2012; 116:1106-13. [PMID: 22394292 DOI: 10.3171/2012.1.jns11962] [Citation(s) in RCA: 51] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
OBJECT The object of this study was to determine whether aggressive treatment of severe traumatic brain injury (TBI), including invasive intracranial monitoring and decompressive craniectomy, is cost-effective. METHODS A decision-analytical model was created to compare costs, outcomes, and cost-effectiveness of 3 strategies for treating a patient with severe TBI. The aggressive-care approach is compared with "routine care," in which Brain Trauma Foundation guidelines are not followed. A "comfort care" category, in which a single day in the ICU is followed by routine floor care, is included for comparison only. Probabilities of each treatment resulting in various Glasgow Outcome Scale (GOS) scores were obtained from the literature. The GOS scores were converted to quality-adjusted life years (QALYs), based on expected longevity and calculated quality of life associated with each GOS category. Estimated direct (acute and long-term medical care) and indirect (loss of productivity) costs were calculated from the perspective of society. Sensitivity analyses employed a 2D Monte Carlo simulation of 1000 trials, each with 1000 patients. The model was also used to estimate these values for patients 40, 60, and 80 years of age. RESULTS For the average 20-year-old, aggressive care yields 11.7 (± 1.6 [SD]) QALYs, compared with routine care (10.0 ± 1.5 QALYs). This difference is highly significant (p < 0.0001). Although the differences in effectiveness between the 2 strategies diminish with advancing age, aggressive care remains significantly better at all ages. When all costs are considered, aggressive care is also significantly less costly than routine care ($1,264,000 ± $118,000 vs $1,361,000 ± $107,000) for the average 20-year-old. Aggressive care remains significantly less costly until age 80, at which age it costs more than routine care. However, even in the 80-year-old, aggressive care is likely the more cost-effective approach. Comfort care is associated with poorer outcomes at all ages and with higher costs for all groups except 80-year-olds. CONCLUSIONS When all the costs of severe TBI are considered, aggressive treatment is a cost-effective option, even for older patients. Comfort care for severe TBI is associated with poor outcomes and high costs, and should be reserved for situations in which aggressive approaches have failed or testing suggests such treatment is futile.
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Affiliation(s)
- Robert G Whitmore
- Department of Neurosurgery, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania 19104, USA.
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Mortality Over Four Decades After Traumatic Brain Injury Rehabilitation: A Retrospective Cohort Study. Arch Phys Med Rehabil 2009; 90:1506-13. [DOI: 10.1016/j.apmr.2009.03.015] [Citation(s) in RCA: 120] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2008] [Revised: 03/05/2009] [Accepted: 03/07/2009] [Indexed: 11/22/2022]
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Routine Serial Computed Tomographic Scans in Mild Traumatic Brain Injury: When are They Cost-Effective? ACTA ACUST UNITED AC 2008; 65:66-72. [DOI: 10.1097/ta.0b013e318068d75f] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
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Shavelle RM, Strauss DJ, Katz RT. Survival of Persons With Locked-In Syndrome. Arch Phys Med Rehabil 2008; 89:1005; author reply 1005-6. [DOI: 10.1016/j.apmr.2008.03.004] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2008] [Accepted: 03/19/2008] [Indexed: 11/16/2022]
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Abstract
OBJECTIVE The number of children surviving in a persistent vegetative state is increasing with advances in medical technology. Caring for a neurologically devastated child presents unique challenges not previously described. Our objective was to gain an understanding of the pediatric nurse's experience of caring for children in a persistent vegetative state. DESIGN Qualitative phenomenologic study using in-depth interviews. SETTING Monitored step-down care unit of an academic children's hospital. PARTICIPANTS Eight registered nurses employed at a step-down care unit. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Nurses in this study described caring for children in a persistent vegetative state as a dynamic process with negative and positive aspects. Six themes emerged from this study: focusing on the parents, delivering sensorially offensive physical care, enduring conflicting emotions, suffering moral distress, finding relief and comfort, and gaining perspective. CONCLUSIONS Our qualitative study suggests that caring for a child in a persistent vegetative state is difficult. Pediatric nurses described the experience as emotionally stressful and ethically challenging. To cope with the demands of caring for the child in a persistent vegetative state, the nurses in this study modified the traditional concept of the pediatric nurse-patient relationship.
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Guidelines for Quality Management of Apallic Syndrome / Vegetative State. Eur J Trauma Emerg Surg 2007; 33:268-92. [PMID: 26814491 DOI: 10.1007/s00068-007-6138-1] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2006] [Accepted: 08/13/2006] [Indexed: 01/02/2023]
Abstract
INTRODUCTION Epidemiology in Europe shows constantly increasing figures for the apallic syndrome (AS)/vegetative state (VS) as a consequence of advanced rescue, emergency services, intensive care treatment after acute brain damage and high-standard activating home nursing for completely dependent end-stage cases secondary to progressive neurological disease. Management of patients in irreversible permanent AS/VS has been the subject of sustained scientific and moral-legal debate over the past decade. METHODS A task force on guidelines for quality management of AS/VS was set up under the auspices of the Scientific Panel Neurotraumatology of the European Federation of Neurological Societies to address key issues relating to AS/VS prevalence and quality management. Collection and analysis of scientific data on class II (III) evidence from the literature and recommendations based on the best practice as resulting from the task force members' expertise are in accordance with EFNS Guidance regulations. FINDINGS The overall incidence of new AS/VS full stage cases all etiology is 0.5-2/100.000 population per year. About one third are traumatic and two thirds non traumatic cases. Increasing figures for hypoxic brain damage and progressive neurological disease have been noticed. The main conceptual criticism is based on the assessment and diagnosis of all different AS/VS stages based solely on behavioural findings without knowing the exact or uniform pathogenesis or neuropathological findings and the uncertainty of clinical assessment due to varying inclusion criteria. No special diagnostics, no specific medical management can be recommended for class II or III AS treatment and rehabilitation. This is why sine qua non diagnostics of the clinical features and appropriate treatment of AS/VS patients of "AS full, remission, defect and end stages" require further professional training and expertise for doctors and rehabilitation personnel. INTERPRETATION Management of AS aims at the social reintegration of patients or has to guarantee humanistic active nursing if treatment fails. Outcome depends on the cause and duration of AS/VS as well as patient's age. There is no single AS/VS specific laboratory investigation, no specific regimen or stimulating intervention to be recommended for improving higher cerebral functioning. Quality management requires at least 3 years of advanced training and permanent education to gain approval of qualification for AS/VS treatment and expertise. Sine qua non areas covering AS/VS institutions for early and long-term rehabilitation are required on a population base (prevalence of 2/100.000/year) to quicken functional restoration and to prevent or treat complications. Caring homes are needed for respectful humane nursing including basal sensor-motor stimulating techniques. Passive euthanasia is considered an act of mercy by physicians in terms of withholding treatment; however, ethical and legal issues with regard to withdrawal of nutrition and hydration and end of life discussions raise deep concerns. The aim of the guideline is to provide management guidance (on the best medical evidence class II and III or task force expertise) for neurologists, neurosurgeons, other physicians working with AS/VS patients, neurorehabilitation personnel, patients, next-of-kin, and health authorities.
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Strauss D, Shavelle R, Reynolds R, Rosenbloom L, Day S. Survival in cerebral palsy in the last 20 years: signs of improvement? Dev Med Child Neurol 2007; 49:86-92. [PMID: 17253993 DOI: 10.1111/j.1469-8749.2007.00086.x] [Citation(s) in RCA: 97] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
This study investigated the possibility of improved survival in cerebral palsy (CP) over a 20-year period. Participants were 47 259 persons with CP receiving services from the State of California between 1983 and 2002. The person-year approach was used. This asks whether the probability of dying in a given calendar year changes over the study period after age and severity of disability are taken into account. An appreciable improvement over time was found in children with severe disabilities and in adults who required gastrostomy feeding. In these groups, mortality rates fell by 3.4% per year. Therefore, life expectancies reported in earlier studies should be increased by approximately 5 years if adjustments to 2002 mortality rates are made. For other persons with CP there was, at most, a small improvement over the 20-year period. The results suggest there have been improvements in the treatment and care of the most medically fragile children. Gastrostomy feeding has become much more widespread over the past two decades, and the improved survival of persons with gastrostomies may reflect better understanding of their requirements.
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Affiliation(s)
- David Strauss
- Life Expectancy Project, San Francisco, CA 94122-3402, USA.
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Shavelle RM, Devivo MJ, Paculdo DR, Vogel LC, Strauss DJ. Long-term survival after childhood spinal cord injury. J Spinal Cord Med 2007; 30 Suppl 1:S48-54. [PMID: 17874687 PMCID: PMC2031987 DOI: 10.1080/10790268.2007.11753969] [Citation(s) in RCA: 39] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/05/2006] [Accepted: 01/10/2007] [Indexed: 10/21/2022] Open
Abstract
OBJECTIVE To determine whether persons who incur a spinal cord injury as children are at increased risk of mortality compared with persons injured as adults given comparable current age, sex, and injury severity. METHODS A total of 25,340 persons admitted to the National Spinal Cord Injury Statistical Center database or the National Shriners Spinal Cord Injury database who were not ventilator dependent and who survived more than 2 years after injury were included in this study. These persons contributed 274,020 person-years of data, with 3844 deaths, over the 1973-2004 study period. Data were analyzed using pooled repeated observations analysis of person-years. For each person-year the outcome variable was survival/mortality, and the explanatory variables included current age, sex, race, cause of injury, severity of injury, and age at injury (the focus of the current analysis). RESULTS Other factors being equal, persons who were less than 16 years of age at time of injury had a 31% (95% CI = 3%-65%) increase in the annual odds of dying compared with persons injured at older ages (P= 0.013). This increased risk did not vary significantly by current age, sex, race, injury severity, or era of injury (P > 0.05). CONCLUSION Life expectancy for persons injured as children appears to be slightly lower than that of otherwise comparably injured persons who suffered their injuries as adults. Nonetheless, persons who are injured young can enjoy relatively long life expectancies, ranging from approximately 83% of normal life expectancy for persons with minimal deficit incomplete injuries to approximately 50% of normal in high-cervical-level injuries without ventilator dependence.
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Strauss DJ, Devivo MJ, Paculdo DR, Shavelle RM. Trends in life expectancy after spinal cord injury. Arch Phys Med Rehabil 2006; 87:1079-85. [PMID: 16876553 DOI: 10.1016/j.apmr.2006.04.022] [Citation(s) in RCA: 226] [Impact Index Per Article: 12.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2005] [Accepted: 04/27/2006] [Indexed: 11/15/2022]
Abstract
OBJECTIVE To investigate whether there have been improvements in survival after spinal cord injury (SCI) over time, both in the critical first 2 years after injury and in the longer term. DESIGN Pooled repeated observations analysis of person-years. For each person-year, the outcome variable is survival and mortality, and the explanatory variables include age, level and grade of injury, and calendar year (the main focus of the analyses). The method can be viewed as a generalization of proportional hazards regression. SETTING Model spinal cord injury systems and hospital SCI units across the United States. PARTICIPANTS Persons (N=30,822) admitted to a Spinal Cord Injury Model Systems facility a minimum of 1 day after injury. Only persons over 10 years of age and known not to be ventilator dependent were included. These persons contributed 323,618 person-years of data, with 4980 deaths, over the 1973 to 2004 study period. INTERVENTIONS Not applicable. MAIN OUTCOME MEASURE Survival. RESULTS Other factors being equal, over the last 3 decades there has been a 40% decline in mortality during the critical first 2 years after injury. However, the decline in mortality over time in the post-2-year period is small and not statistically significant. CONCLUSIONS The absence of a substantial decline in mortality after the first 2 years postinjury is contrary to widely held impressions. Nevertheless, the finding is based on a large database and sensitive analytic methods and is consistent with previous research. Improvements in critical care medicine after spinal cord injury may explain the marked decline in short-term mortality. In contrast, although there have no doubt been improvements in long-term rehabilitative care, their effect in enhancing the life span of persons with SCI appears to have been overstated.
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Stein SC, Burnett MG, Glick HA. Indications for CT Scanning in Mild Traumatic Brain Injury: A Cost-Effectiveness Study. ACTA ACUST UNITED AC 2006; 61:558-66. [PMID: 16966987 DOI: 10.1097/01.ta.0000233766.60315.5e] [Citation(s) in RCA: 53] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
BACKGROUND There is considerable uncertainty about the indications for cranial computed tomography (CT) scanning in patient with minor traumatic brain injury (TBI). This analysis involves an evidence-based comparison of several strategies for selecting patients for CT with regard to effectiveness and cost. METHODS We performed a structured literature review of mild traumatic brain injury and constructed a cost-effectiveness model. The model estimated the impact of missed intracranial lesions on longevity, quality of life and costs. Using a 20-year-old patient for primary analysis, we compared the following strategies to screen for the need to perform a CT scan: observation in the emergency department or hospital floor, skull radiography, Selective CT based on the presence of additional risk factors and scanning all. RESULTS Outcome measures for each strategy included average years of life, quality of life and costs. Selective CT and the CT All policy performed significantly better than the alternatives with respect to outcome. They were also less expensive in terms of total direct health care costs, although the differences did not reach statistical significance. The model yielded similar, but smaller, differences between the selective imaging and other strategies when run for older patients. CONCLUSIONS Although the incidence of intracranial lesions, especially those that require surgery, is low in mild TBI, the consequences of delayed diagnosis are forbidding. Adverse outcome of an intracranial hematoma is so costly that it more than balances the expense of CT scans. In our cost-effectiveness model, the liberal use of CT scanning in mild TBI appears justified.
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Affiliation(s)
- Sherman C Stein
- Department of Neurosurgery, University of Pennsylvania School of Medicine, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania 19106, USA
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Shavelle RM, DeVivo MJ, Strauss DJ, Paculdo DR, Lammertse DP, Day SM. Long-term survival of persons ventilator dependent after spinal cord injury. J Spinal Cord Med 2006; 29:511-9. [PMID: 17274490 PMCID: PMC1949034 DOI: 10.1080/10790268.2006.11753901] [Citation(s) in RCA: 80] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/18/2006] [Accepted: 08/24/2006] [Indexed: 10/21/2022] Open
Abstract
BACKGROUND/OBJECTIVE Identify factors related to long-term survival, and quantify their effect on mortality and life expectancy. SETTING Model spinal cord injury systems of care across the United States. STUDY DESIGN Survival analysis of persons with traumatic spinal cord injury who are ventilator dependent at discharge from inpatient rehabilitation and who survive at least 1 year after injury. METHODS Logistic regression analysis on a data set of 1,986 person-years occurring among 319 individuals injured from 1973 through 2003. RESULTS The key factors related to long-term survival were age, time since injury, neurologic level, and degree of completeness of injury. The life expectancies were modestly lower than previous estimates. Pneumonia and other respiratory conditions remain the leading cause of death but account for only 31% of deaths of known causes. CONCLUSIONS Whereas previous research has suggested a dramatic improvement in survival over the last few decades in this population, this is only the case during the critical first few years after injury. There was no evidence for such a trend in the subsequent period.
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Ashwal S. Recovery of consciousness and life expectancy of children in a vegetative state. Neuropsychol Rehabil 2005; 15:190-7. [PMID: 16350962 DOI: 10.1080/09602010443000281] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
The vegetative state does occur in children and is most commonly due to acquired traumatic and non-traumatic injuries. However, neurometabolic and degenerative diseases, as well as certain developmental brain malformations such as anencephaly, can also cause this condition. There are limited data available in children concerning recovery of consciousness and function from the vegetative state as well as life expectancy. This review concentrates on these issues and is based primarily on the data published in the Multi-Society Task Force Report on PVS which was published in 1994 as well as other epidemiological studies. Children in a vegetative state do have a poor prognosis for recovery of consciousness and function and do have a shortened life expectancy. Further research is needed to better understand what variables might contribute to recovery and what therapies might be of benefit.
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Affiliation(s)
- Stephen Ashwal
- Department of Pediatrics, Loma Linda University School of Medicine, 11175 Campus Street, Loma Linda, CA 92350, USA.
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Giacino J, Whyte J. The vegetative and minimally conscious states: current knowledge and remaining questions. J Head Trauma Rehabil 2005; 20:30-50. [PMID: 15668569 DOI: 10.1097/00001199-200501000-00005] [Citation(s) in RCA: 125] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
In the last 2 decades, the minimally conscious state has been distinguished conceptually from the vegetative state and operational criteria for these diagnoses have been published. Standardized and individualized assessment tools have been developed to assist with the diagnosis of severe disorders of consciousness and the measurement of clinical improvement. The natural course of recovery and the importance of key prognostic predictors have been elucidated. Important advances have also been made in defining the similarities and differences in the pathophysiology of these two states, and functional imaging modalities have begun to explicate the neural substrate underlying the behavioral features of these disorders. Research on the efficacy of treatments for severe disorders of consciousness lags behind, due to the practical and ethical difficulties in executing large rigorously controlled clinical trials. The past and future scientific developments in this area provide an important background for continuing discussions of the ethical controversies surrounding end-of-life decision making and resource allocation.
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Affiliation(s)
- Joseph Giacino
- JFK Johnson Rehabilitation Institute, 65 James St, Edison, NJ, USA.
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Gladsjo JA, Breding J, Sine D, Wells R, Kalemkiarian S, Oak J, Vieira AS, Friedlander SF. Termination of life support after severe child abuse: the role of a guardian ad litem. Pediatrics 2004; 113:e141-5. [PMID: 14754984 DOI: 10.1542/peds.113.2.e141] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
Discontinuation of life-sustaining interventions often raises ethical concerns. In cases of severe child abuse with poor prognosis for recovery, accused parents may have a conflict of interest regarding medical decision-making for their child, because the outcome of such decisions may impact legal charges filed against them. The recently issued American Academy of Pediatrics guidelines for addressing such cases recommended the appointment of a guardian ad litem for medical decision-making. We present the case of an 8-month-old infant who was abused severely by her father, resulting in a persistent vegetative state. We describe our experience with appointing a guardian ad litem and the ethical issues involved.
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Affiliation(s)
- Julie Akiko Gladsjo
- University of California, San Diego School of Medicine, San Diego, California 92123, USA
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Abstract
Knowledge of accurate survival rates of children with neurologic disabilities is important for third-party insurance payers planning future medical expenses. This is of particular importance to pediatric skilled nursing facilities (SNFs) that depend on financial support from governmental sources. Eyman published survival rate results from California that were extremely pessimistic and not in keeping with our clinical impressions. This led us to conduct a thorough review of our survival rates, which were much better than those reported by Eyman. Since the publication of our study, a large number of reports have appeared from many different countries, as well as further information from California using an expanded database. The survival rate data that we obtained remain consistently better than that in most recent reports. In the California results, 10-year survival rates for the most-disabled group (group 1) were reported to be 32% in 1993 and 45% in 1998, compared with 73% in our study. Eight-year survival rates for group 1 from California were reported to be 38% in 1993 and 63% in 2000, compared with our finding of 73%. The reasons for our better survival rates include the fact that all of our patients were in SNFs, where prompt medical care for acute illnesses was always provided, whereas only 3.5% of the study group was in SNFs in California. Also, the California data contained many methodologic and statistical errors, which are reviewed here.
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Affiliation(s)
- Audrius V Plioplys
- Pediatric Long-Term Care Section, American Medical Directors' Association and Division of Neurology, Mercy Hospital and Medical Center, Chicago, IL, USA
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Abstract
The estimate of life expectancy following a personal injury is probably one of the most important factors in determining the final quantum of damages. It is a calculation fraught with difficulties. This article endeavours to outline some general factors that aid prediction of life expectancy, and also discusses the evidence from the few long-term studies currently available.
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Affiliation(s)
- Aine Carroll
- Academic Institute of Neurological Rehabilitation, Hunters Moor Regional Neurological Rehabilitation Centre, Hunters Road, Newcastle-upon-Tyne, NE2 4NR, UK.
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Abstract
We determined estimates of survival in children, 3-15 years of age, in the vegetative state (VS) (n = 564), immobile minimally conscious state (MCS) (n = 705), and mobile MCS (n = 3,806). Data were extracted from the annual Client Development Evaluation Reports of the California Department of Developmental Services between 1988 and 1997 using the operational definitions for these three states on the basis of 15 descriptive behavioral categories. Patients were also categorized according to the following four etiologies: acquired (traumatic and nontraumatic) brain injury; perinatal/genetic; degenerative; and unknown/undetermined. The percentage of patients surviving 8 years was 63%, 65%, and 81%, for the VS, immobile MCS, and mobile MCS, respectively. Children in the VS and MCSs with acquired brain injury had lower mortality rates and those with degenerative diseases the highest mortality rates. We observed little difference in survival between patients in the VS and immobile MCS, suggesting that the presence of consciousness is not a critical variable in determining life expectancy. Furthermore, survival was much greater for patients in the mobile MCS than for those in the immobile MCS, suggesting that mobility is more important in predicting survival than the level of consciousness.
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Affiliation(s)
- D J Strauss
- Department of Statistics, University of California, Riverside, Riverside, California, USA
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