Prognosis of Traumatic Head Injury in South Tunisia: A Multivariate Analysis of 437 Cases

Comparison of Glasgow Coma Scale and Full Outline of UnResponsiveness score for prediction of in-hospital mortality in traumatic brain injury patients: a systematic review and meta-analysis

BACKGROUND

Currently, Glasgow Coma Scale (GCS) is used to assess patients' level of consciousness. Although this tool is highly popular in clinical settings, it has various limitations that reduce its applicability in certain situations. This had led researchers to look for alternative scoring systems. This study aims to compare the value of GCS and Full Outline of UnResponsiveness (FOUR) score for prediction of mortality in traumatic brain injury (TBI) patients through a systematic review and meta-analysis.

METHOD

Online databases of Medline, Embase, Scopus, and Web of Science were searched until the end of July 2022 for studies that had compared GCS and FOUR score in TBI patients. Interested outcomes were mortality and unfavorable outcome (mortality + disability). Findings are reported as area under the curve (AUC) sensitivity, specificity, and diagnostic odds ratio.

RESULTS

20 articles (comprised of 2083 patients) were included in this study. AUC of GCS and FOUR score for prediction of in-hospital mortality after TBI was 0.92 (95% CI 0.80-0.91) and 0.91 (95% CI 0.88-0.93) respectively. The diagnostic odds ratio of the two scores for prediction of in-hospital mortality after TBI was 44.51 (95% CI 23.58-84.03) for GCS and 45.16 (95% CI 24.25-84.09) for FOUR score. As for prediction of unfavorable outcome after TBI, AUC of GCS and FOUR score were 0.95 (95% CI 0.93 to 0.97) and 0.93 (95% CI 0.91-0.95), respectively. The diagnostic odds ratios for prediction of unfavorable outcome after TBI were 66.31 (95% CI 35.05-125.45) for GCS and 45.39 (95% CI 23.09-89.23) for FOUR score.

CONCLUSION

Moderate level of evidence showed that the value of GCS and FOUR score in the prediction of in-hospital mortality and unfavorable outcome is comparable. The similar performance of these scores in assessment of TBI patients gives the medical staff the option to use either one of them according to the situation at hand.

Prediction of In-Hospital Mortality in Patients With Traumatic Brain Injury Using the Rotterdam and Marshall CT Scores: A Retrospective Study From Western India

Objective Head trauma of any severity, including concussions and skull fractures, can cause a traumatic brain injury (TBI). Prognostication plays a vital role in the scenario of urgency put forth by TBI. The application of CT-based scoring systems developed by the Rotterdam CT score and Marshall classification system appears to be appropriate for the early and precise prediction of clinical outcomes in TBI patients. The present study was designed to determine the predictive value of the Rotterdam CT score and Marshall classification system for in-hospital mortality in patients with TBI. Methods All adult patients (≥ 18 years) with acute traumatic brain injury presented over a period from February 2019 to November 2022 were included. Only those patients who had undergone a plain CT scan of the brain during the initial presentation at the emergency department (ED) were considered. Patients who presented with penetrating brain injury as well as those who died on arrival or who died prior to the initial CT scan of the brain were excluded. A total of 127 patients were included in the final data analysis. Based on initial CT-scan findings, the Rotterdam CT score and Marshall classification system were calculated in order to predict in-hospital mortality. Results The study was dominated by male patients (85.8%) as compared to female patients (14.2%). The overall mortality rate was 32.3% (n = 41). The mortality rate among males and females was 30.3% (33/109) and 44.4% (8/18), respectively. As per the Glasgow Coma Scale (GCS) classification, the severity of the injury was mild in 12.6% of the study subjects, moderate in 22%, and severe in 65.4%. The mortality rate among the patients with mild severity was 12.5% (2/16), while it was 28.6% in moderate (8/28) and 37.3% (31/83) in the severe category group. The best cut-off point of the Rotterdam score for predicting mortality was >4 (as per the Youden Index), which had a sensitivity and specificity of 60.98% and 90.70%, respectively, while the cut-off point of the Marshall CT classification for predicting mortality was >3 (as per the Youden Index), which had a sensitivity of 82.93% and a specificity of 75.58%. There was only a minor difference in the area under the curve (AUC) value of the receiver operating characteristic curve (ROC) curve between the Rotterdam CT score (0.827) and the Marshall classification system (0.833). Conclusion The Rotterdam and Marshall CT scores have demonstrated significant independent prognostic value and may serve as a useful initial evaluation tool for risk stratification of in-hospital mortality among patients with TBI.

Platelet-to-lymphocyte ratio predicts short-term mortality in patients with moderate to severe traumatic brain injury

An easily accessible biomarker with good diagnostic power for patients with traumatic brain injury (TBI) was needed to predict the short-term mortality. Studies have shown that platelet-to-lymphocyte ratio (PLR) is a biomarker for patients with tumor. This study aimed to identify the relationship between PLR and short-term mortality in patients with moderate to severe TBI. This is a retrospective cohort study. We selected patients with moderate to severe TBI who were admitted to the emergency department of The First Affiliated Hospital of Zhengzhou University. Biomarkers were collected within 24 h after admission. To investigate their relationship with short-term mortality, Cox proportional hazards regression and ROC curve analysis were performed. A total number of 170 patients was included. 47 (27.6%) patients had died and 123 (72.4%) patients were survived by the end of the study. Patients with different Rotterdam CT score (HR = 1.571, 95%CI 1.232–2.002, p < 0.001) or PLR levels (HR = 1.523, 95%CI 1.110–2.090, p = 0.009) had significant different mortality rates. The AUC curve analysis showed that the AUC of Rotterdam CT score and PLR groups were 0.729 (95%CI 0.638–0.821, p < 0.001) and 0.711 (95%CI 0.618–0.803 p < 0.001), respectively. PLR level is an independent biomarker with great diagnostic power for short-term mortality in patients with moderate to severe brain injury.

Early death prediction in children with traumatic brain injury using computed tomography scoring systems

PURPOSE

Marshall and Rotterdam are the most commonly used CT scoring systems to predict the outcome following traumatic brain injury (TBI). Although several studies have compared the performance of the two scoring systems in adult patients, none of these studies has evaluated the performance of the two scoring systems in pediatric patients. This study aimed to determine the predictive value of the Marshall and Rotterdam scoring systems in pediatric patients with TBI.

METHODS

This retrospective study included 105 children with admission GCS < 12, with a mean age of 6.2 (±3.5) years. Their initial CT and status at hospital discharge (dead or alive) were reviewed, and both the Marshall and Rotterdam scores were calculated. We examined whether each score was related to the early death of pediatric patients.

RESULTS

The pediatric patients with higher Marshall and Rotterdam scores had a higher mortality rate. There was a good correlation between the Marshall and Rotterdam scoring systems (Spearman's rho = 0.618, significant at the 0.05 level). Both systems demonstrated a high degree of discrimination when predicting early mortality. The Marshall scoring system had reasonable discrimination (AUC 0.782), and the Rotterdam scoring system had good discrimination (AUC 0.729). Comparing the two CT scoring systems, the Marshall scoring system provided a better positive predictive value (90%) for early mortality than the Rotterdam scoring system (78%).

CONCLUSIONS

Both the Marshall and Rotterdam scoring systems have good predictability for assessing mortality in pediatric patients with TBI. The performance of the Marshall scoring system was equal to or slightly better than that of the Rotterdam scoring system.

Outcome Prediction in Patients of Traumatic Brain Injury Based on Midline Shift on CT Scan of Brain

Background Clinicians treating patients with head injury often take decisions based on their assessment of prognosis. Assessment of prognosis could help communication with a patient and the family. One of the most widely used clinical tools for such prediction is the Glasgow coma scale (GCS); however, the tool has a limitation with regard to its use in patients who are under sedation, are intubated, or under the influence of alcohol or psychoactive drugs. CT scan findings such as status of basal cistern, midline shift, associated traumatic subarachnoid hemorrhage (SAH), and intraventricular hemorrhage are useful indicators in predicting outcome and also considered as valid options for prognostication of the patients with traumatic brain injury (TBI), especially in emergency setting.

Materials and Methods 108 patients of head injury were assessed at admission with clinical examination, history, and CT scan of brain. CT findings were classified according to type of lesion and midline shift correlated to GCS score at admission. All the subjects in this study were managed with an identical treatment protocol. Outcome of these patients were assessed on GCS score at discharge.

Results Among patients with severe GCS, 51% had midline shift. The degree of midline shift in CT head was a statistically significant determinant of outcome (p = 0.023). Seventeen out of 48 patients (35.4%) with midline shift had poor outcome as compared with 8 out of 60 patients (13.3%) with no midline shift.

Conclusion In patients with TBI, the degree of midline shift on CT scan was significantly related to the severity of head injury and resulted in poor clinical outcome.

Rotterdam and Marshall Scores for Prediction of in-hospital Mortality in Patients with Traumatic Brain Injury: An observational study

Background: We aimed to assess the prognostic value of Rotterdam and Marshall scoring systems to predict in-hospital mortality in patients with traumatic brain injury (TBI).Methods: A retrospective analysis was conducted for patients with TBI who underwent head computerized tomography (CT) scan at a Level I trauma center between 2011 and 2018. Receiver operating characteristic (ROC) curves were used to determine the cutoff values for predicting in-hospital mortality.Results: A total of 1035 patients with TBI were included with a mean age of 30 years. The mean Rotterdam and Marshall scores were higher among non-survivors (p = .001). Patients with higher Rotterdam (>3) or Marshall (>2) CT scores were older, had higher injury severity scores and in-hospital mortality and had lower GCS and blood ethanol levels than those with lower scores. The cutoff point of Rotterdam score was 3.5 (sensitivity, 61.2%; specificity, 85.6%) and Marshall score was 2.5 (74.3% sensitivity and 76.3% specificity). Multivariable logistic regression analyses showed that Marshall and Rotterdam scoring systems were independent predictors of mortality (odds ratio 8.4; 95% confidence interval 4.95-14.17 and odds ratio 4.4; 95% confidence interval 2.36-9.39, respectively).Conclusion: Rotterdam and Marshall CT scores have independent prognostic values in patients with TBI even in alcoholic patients.

First Report of Traumatic Brain Injury in Luanda, Angola

BACKGROUND

Traumatic brain injury (TBI) is a global problem and is the greatest contributor to death and disability among all trauma-related injuries worldwide. Road traffic accidents are an important cause of TBI. The purpose of this paper is to present the first data on TBI in Angola.

METHODS

This was a retrospective study of the clinical and radiologic profile of patients admitted to the intensive care unit of a tertiary hospital in Luanda, Angola, from January 2018 to December 2018. The medical records of patients with moderate and severe TBI admitted to the intensive care unit were reviewed. The inclusion criteria were adult patients who suffered from TBI. The exclusion criteria were incomplete medical records, pediatric age, and mild TBI.

RESULTS

We included 29 patients (6 female) with a mean age of 31 years. Of them, 31% visited the hospital without an ambulance (using private or commercial vehicles), 58.6% suffered from severe TBI, and the mortality rate in our sample was 34.5%. Road accident was the most frequent cause of trauma.

CONCLUSIONS

This first report of TBI in Angola reveals major problems with TBI management, road accident prevention, prehospital management, and loss of lives of young patients.

Thefeasibility, appropriateness, and applicability of trauma scoring systems in low and middle-income countries: a systematic review

Background

About 5.8 million people die each year as a result of injuries, and nearly 90% of these deaths occur in low and middle-income countries (LMIC). Trauma scoring is a cornerstone of trauma quality improvement (QI) efforts, and is key to organizing and evaluating trauma services. The objective of this review was to assess the appropriateness, feasibility, and QI applicability of traditional trauma scoring systems in LMIC settings.

Materials and methods

This systematic review searched PubMed, Scopus, CINAHL, and trauma-focused journals for articles describing the use of a standardized trauma scoring system to characterize holistic health status. Studies conducted in high-income countries (HIC) or describing scores for isolated anatomic locations were excluded. Data reporting a score’s capacity to discriminate mortality, feasibility of implementation, or use for QI were extracted and synthesized.

Results

Of the 896 articles screened, 336 were included. Over half of studies (56%) reported Glasgow Coma Scale, followed by Injury Severity Score (ISS; 51%), Abbreviated Injury Scale (AIS; 24%), Revised Trauma Score (RTS; 19%), Trauma and Injury Severity Score (TRISS; 14%), and Kampala Trauma Score (7%). While ISS was overwhelmingly predictive of mortality, 12 articles reported limited feasibility of ISS and/or AIS. RTS consistently underestimated injury severity. Over a third of articles (37%) reporting TRISS assessmentsobserved mortality that was greater than that predicted by TRISS. Several articles cited limited human resources as the key challenge to feasibility.

Conclusions

The findings of this review reveal that implementing systems designed for HICs may not be relevant to the burden and resources available in LMICs. Adaptations or alternative scoring systems may be more effective.

PROSPERO registration number

CRD42017064600.

[Epidemiology of home accidents in childhood: experience in the Division of General Pediatrics in Southern Tunisia]

Les accidents domestiques représentent un problème sérieux de santé publique en pédiatrie. Ils sont responsables d’une lourde morbidité et mortalité parmi la population pédiatrique. Nous avons mené une étude rétrospective colligeant 231 cas d’accidents domestiques chez l’enfant au Service de Pédiatrie de l’Hôpital Hédi Chaker de Sfax durant une période de 5 ans (2008 - 2012). Durant la période d’étude, nous avons colligé 231 cas d’accidents domestiques. Il s’agissait de 124 garçons (53,7%) et 107 filles (46,3%). L’âge moyen était de 2 ans avec des extrêmes de 1 jour et 14 ans. Les enfants âgés de moins de 4 ans étaient les plus exposés (88,7%). Les intoxications accidentelles étaient les accidents les plus fréquents (105 cas). Les caustiques étaient les agents toxiques les plus fréquents (33 cas), suivis par les médicaments (28 cas) puis les hydrocarbures (16 cas). Les accidents par corps étrangers ont représenté le deuxième mécanisme accidentel (64 cas). Il s’agissait de 43 cas d’inhalation de corps étrangers et 21 cas d’ingestion de corps étranger. Nous avons enregistré 28 cas de traumatismes; il s’agissait d’une chute d’une certaine hauteur dans 25 cas. Nous avons recensé 26 cas d’envenimations scorpioniques, 5 noyades, 2 cas de brulure et un seul cas d’électrisation. Les intoxications accidentelles et les accidents par corps étrangers représentent les principaux accidents domestiques dans notre série et la tranche d’âge entre 1 et 4 ans est la plus exposée aux accidents domestiques.

Correlation between cerebral co-oximetry (rSO2) and outcomes in traumatic brain injury cases: A prospective, observational study

BACKGROUND

Traumatic brain injury (TBI) is known to be an important reason for the increase in disabilities and deaths worldwide. Studies have demonstrated that brain tissue oxygen (PO2) monitoring reduces mortality significantly but is a invasive method of monitoring. Therefore, there is a need to monitor cerebral ischemia in TBI by noninvasive methods. The study aims to correlate cerebral co-oximetry and possible outcomes in patients with TBI.

METHODS

The study included 78 patients with TBI admitted in intensive care unit (ICU) with glascow coma scale (GCS) of 8 or less than 8. Near-infrared spectroscopy monitor is applied to the patients immediately after admission to ICU; readings are noted every 4 hours up to first 48 hours, and outcomes studied as survival or neurological deficit are noted at 28 days.

RESULTS

A total of 12 (15.4%) deaths were seen in this study. Survived patients were further divided into good recovery 33 (42.3%), moderate disability 21(26.9%), major disability 8 (10.3%), and persistent vegetative state 4 (5.1%). The rSO2 values in surviving patients were ranging from mean of 60.74% (standard deviation [SD] 4.38) to a mean of 64.98% (SD 5.01), and the mean rSO2 values in patients who died were ranging from a mean of 52.17% (SD 4.11) to a mean of 37.17% (SD 12.48). Lower rSO2 values were correlating significantly with worse neurological outcome or death by using two independent sample t-test (p < 0.001).

CONCLUSION

Cerebral co-oximetry is a simple noninvasive method for predicting the outcomes in TBI and can be used to guide the management of these patients.

Estimating the global incidence of traumatic brain injury

OBJECTIVE

Traumatic brain injury (TBI)-the "silent epidemic"-contributes to worldwide death and disability more than any other traumatic insult. Yet, TBI incidence and distribution across regions and socioeconomic divides remain unknown. In an effort to promote advocacy, understanding, and targeted intervention, the authors sought to quantify the case burden of TBI across World Health Organization (WHO) regions and World Bank (WB) income groups.

METHODS

Open-source epidemiological data on road traffic injuries (RTIs) were used to model the incidence of TBI using literature-derived ratios. First, a systematic review on the proportion of RTIs resulting in TBI was conducted, and a meta-analysis of study-derived proportions was performed. Next, a separate systematic review identified primary source studies describing mechanisms of injury contributing to TBI, and an additional meta-analysis yielded a proportion of TBI that is secondary to the mechanism of RTI. Then, the incidence of RTI as published by the Global Burden of Disease Study 2015 was applied to these two ratios to generate the incidence and estimated case volume of TBI for each WHO region and WB income group.

RESULTS

Relevant articles and registries were identified via systematic review; study quality was higher in the high-income countries (HICs) than in the low- and middle-income countries (LMICs). Sixty-nine million (95% CI 64-74 million) individuals worldwide are estimated to sustain a TBI each year. The proportion of TBIs resulting from road traffic collisions was greatest in Africa and Southeast Asia (both 56%) and lowest in North America (25%). The incidence of RTI was similar in Southeast Asia (1.5% of the population per year) and Europe (1.2%). The overall incidence of TBI per 100,000 people was greatest in North America (1299 cases, 95% CI 650-1947) and Europe (1012 cases, 95% CI 911-1113) and least in Africa (801 cases, 95% CI 732-871) and the Eastern Mediterranean (897 cases, 95% CI 771-1023). The LMICs experience nearly 3 times more cases of TBI proportionally than HICs.

CONCLUSIONS

Sixty-nine million (95% CI 64-74 million) individuals are estimated to suffer TBI from all causes each year, with the Southeast Asian and Western Pacific regions experiencing the greatest overall burden of disease. Head injury following road traffic collision is more common in LMICs, and the proportion of TBIs secondary to road traffic collision is likewise greatest in these countries. Meanwhile, the estimated incidence of TBI is highest in regions with higher-quality data, specifically in North America and Europe.

Determinants of emergency department disposition of patients with traumatic brain injury in Uganda: results from a registry

Background

Traumatic brain injuries (TBIs) are a common cause of emergency department (ED) visits and hospital admissions in Kampala, Uganda. The objective of this study was to assess determinants of ED discharge disposition based on patient demographic and injury characteristics. Four ED outcomes were considered: discharge home, hospital admission, death, and others.

Methods

This prospective study was conducted at Mulago National Referral Hospital, Kampala, Uganda, from May 2016 to July 2017. Patients of all age groups presenting with TBI were included. Patient demographics, external causes of injury, TBI characteristics, and disposition from EDs were noted. Injury severity was estimated using the Glasgow Coma Scale (GCS), Kampala Trauma Score (KTS), and the Revised Trauma Score (RTS). A multinomial logistic regression model was used to estimate conditional ORs of hospital admission, death, and other dispositions compared with the reference category “discharged home”.

Results

A total of 3944 patients were included in the study with a male versus female ratio of 5.5:1 and a mean age of 28.5 years (SD=14.2). Patients had closed head injuries in 62.9% of cases. The leading causes of TBIs were road traffic crashes (58.8%) and intentional injuries (28.7%). There was no significant difference between the four discharge categories with respect to age, sex, mode of arrival, cause of TBI, place of injury, type of head injury, transport time, and RTS (p>0.05). There were statistically significant differences between the four discharge categories for a number of serious injuries, GCS on arrival, change in GCS, and KTS. In a multinomial logistic regression model, change in GCS, area of residence, number of serious injuries, and KTS were significant predictors of ED disposition.

Discussion

This study provides evidence that ED disposition of patients with TBI is differentially affected by injury characteristics and is largely dependent on injury severity and change in GCS during ED stay.

Level of evidence

Level II.

Central versus Local Radiological Reading of Acute Computed Tomography Characteristics in Multi-Center Traumatic Brain Injury Research

Observer variability in local radiological reading is a major concern in large-scale multi-center traumatic brain injury (TBI) studies. A central review process has been advocated to minimize this variability. The aim of this study is to compare central with local reading of TBI imaging datasets and to investigate the added value of central review. A total of 2050 admission computed tomography (CT) scans from subjects enrolled in the Collaborative European NeuroTrauma Effectiveness Research in Traumatic Brain Injury (CENTER-TBI) study were analyzed for seven main CT characteristics. Kappa statistics were used to calculate agreement between central and local evaluations and a center-specific analysis was performed. The McNemar test was used to detect whether discordances were significant. Central interobserver and intra-observer agreement was calculated in a subset of patients. Good agreement was found between central and local assessment for the presence or absence of structural pathology (CT+, CT-, κ = 0.73) and most CT characteristics (κ = 0.62 to 0.71), except for traumatic axonal injury lesions (κ = 0.37). Despite good kappa values, discordances were significant in four of seven CT characteristics (i.e., midline shift, contusion, traumatic subarachnoid hemorrhage, and cisternal compression; p = 0.0005). Central reviewers showed substantial to excellent interobserver and intra-observer agreement (κ = 0.73 to κ = 0.96), contrasted by considerable variability in local radiological reading. Compared with local evaluation, a central review process offers a more consistent radiological reading of acute CT characteristics in TBI. It generates reliable, reproducible data and should be recommended for use in multi-center TBI studies.

Benefits of the tranexamic acid in head trauma with no extracranial bleeding: a prospective follow-up of 180 patients

INTRODUCTION

Tranexamic acid (TXA) is one of the debated therapies in the management of traumatic brain injury (TBI). We conducted this study to evaluate the benefits of TXA in TBI on the mortality and its safety in these patients.

METHODS

This was a prospective randomized open-label trial including all patients, aged at 18 years or older, hospitalized in the emergency room during a 13-month period, for TBI. After the realization of the body CT scan, the patients were included if they had intracranial bleeding, and were then randomized according to their medical file number to receive or not the TXA. The eligibility criteria were based on the uncertainty principle, patients with significant extracranial bleeding were excluded since there was evidence that TXA improve their outcome.

RESULTS

We enrolled 180 patients aged at 42 ± 20 years, with an 88% men-proportion. Subarachnoid haemorrhage was the most frequent lesion in the brain CT-scan (67.5%). After randomization, 96 patients were in the TXA group (53%). Demographic data, clinical, biological and radiological features were statistically comparable in the two groups of patients ('TXA' and 'noTXA'). The needs of transfusion or neurosurgery, the mortality rate, the in-hospital length of stay and the dependency at 28-post-traumatic day were similar in the two groups of patients. However, pulmonary embolism was statistically more frequent in 'TXA' group (11.5 versus 2.4%, p = 0.02).

CONCLUSION

TXA is an interesting treatment in haemorrhagic shock. Its efficiency in head trauma is still debated and controversial. Its impact on the mortality and the needs of transfusion or surgery were not demonstrated in this study. Nevertheless, its safety worth to be studied in larger samples as we found a higher rate of pulmonary embolism in the treated group.

Traumatic brain injury in Uganda: exploring the use of a hospital based registry for measuring burden and outcomes

Objective

Lack of data on traumatic brain injuries (TBI) hinders the appreciation of the true magnitude of the TBI burden. This paper describes a scientific approach for hospital based systematic data collection in a low-income country. The registry is based on the evaluation framework for injury surveillance systems which comprises a four-step approach: (1) identifying characteristics that assess a surveillance system, (2) review of the identified variables based on adopted specific, measurable, assignable, realistic, and time-related criteria, (3) assessment of the proposed variables and system characteristics by an expert panel, and (4) development and application of a rating system.

Results

The electronic hospital-based TBI registry is designed through a collaborative approach to capture comprehensive, yet context specific, information on each TBI case, from the time of injury until death or discharge from the hospital. It includes patients’ demographics, pre-hospital and hospital assessment and care, TBI causes, injury severity, and patient outcomes. The registry in Uganda will open the opportunity to replicate the process in other similar context and contribute to a better understanding of TBI in these settings, and feed into the global agenda of reducing deaths and disabilities from TBI in low-and middle-income countries.

Electronic supplementary material

The online version of this article (10.1186/s13104-018-3419-1) contains supplementary material, which is available to authorized users.

A systematic scoping review on the consequences of stress-related hyperglycaemia

Background

Stress-related hyperglycaemia (SHG) is commonly seen in acutely ill patients and has been associated with poor outcomes in many studies performed in different acute care settings. We aimed to review the available evidence describing the associations between SHG and different outcomes in acutely ill patients admitted to an ICU. Study designs, populations, and outcome measures used in observational studies were analysed.

Methods

We conducted a systematic scoping review of observational studies following the Joanna Briggs methodology. Medline, Embase, and the Cochrane Library were searched for publications between January 2000 and December 2015 that reported on SHG and mortality, infection rate, length of stay, time on ventilation, blood transfusions, renal replacement therapy, or acquired weakness.

Results

The search yielded 3,063 articles, of which 43 articles were included (totalling 536,476 patients). Overall, the identified studies were heterogeneous in study conduct, SHG definition, blood glucose measurements and monitoring, treatment protocol, and outcome reporting. The most frequently reported outcomes were mortality (38 studies), ICU and hospital length of stay (23 and 18 studies, respectively), and duration of mechanical ventilation (13 studies). The majority of these studies (40 studies) compared the reported outcomes in patients who experienced SHG with those who did not. Fourteen studies (35.9%) identified an association between hyperglycaemia and increased mortality (odds ratios ranging from 1.13 to 2.76). Five studies identified hyperglycaemia as an independent risk factor for increased infection rates, and one identified it as an independent predictor of increased ICU length of stay.

Discussion

SHG was consistently associated with poor outcomes. However, the wide divergences in the literature mandate standardisation of measuring and monitoring SHG and the creation of a consensus on SHG definition. A better comparability between practices will improve our knowledge on SHG consequences and management.

Clinical characteristics and prognosis of traumatic head injury following road traffic accidents admitted in ICU "analysis of 694 cases"

BACKGROUND

The aim of the present study is to analyze the clinical and epidemiological characteristics of Traumatic Brain Injury (TBI) following Road Traffic Accidents (RTAs). Moreover, we aim to evaluate the outcome of the TBI victims referred to our medico-surgical Intensive Care Unit (ICU), and to define predictive factors associated with poor prognosis.

METHODS

A retrospective study over a 4-year period (2009 to 2012) of 694 patients with head injuries, incurred during road traffic accidents, admitted to the Intensive Care Unit (ICU) of a university hospital (Sfax-Tunisia). Basic demographic, clinical, biological, and radiological data were recorded on admission and during the ICU stay.

RESULTS

There were 592 males (85.3%), and 102 female patients. The mean age was at 31.8 ± 17.8 years (range 1-91). The mechanism of the accident was detailed in 666 patients (96%). The majority of the victims were motorcycle riders and/or passengers (40.5%), followed by pedestrians (29.1%). Extra-cranial pathology was present in 452 patients (65%). A total of 677 patients (97.6%) required intubation, mechanical ventilation, and sedation. Mean ICU stay was 16 ± 17.4 days. A total of 187 patients (26.9%) died during their hospital stay. The GOS performed within a mean delay of 6 months after hospital discharge was as follows: 198 deaths (28.5%), 13 vegetative state (1.9%), and 349 (50.3%) good recovery and/or moderate disability. A multivariate analysis showed that the factors which correlated with a poor prognosis (mortality and severe disability) were: age > 38 years, Glasgow coma scale score < 8, subdural hematoma, and development of secondary systemic insults (respiratory, circulatory, and metabolic).

CONCLUSION

In Tunisia, traumatic brain injury due to RTAs is a frequent cause of ICU admission, especially among young adults, and is associated with high mortality and morbidity rates. The majority of the victims were motorcycle riders and/or passengers and pedestrians. The factors associated with a poor outcome were: age > 38 years, Glasgow Coma Scale score < 8, subdural hematoma, and development of secondary systemic insults (respiratory, circulatory, and metabolic). As a consequence, prevention is highly warranted.

[Posttraumatic thromboembolic complications: Incidence, risk factors, pathophysiology and prevention]

Venous thromboembolism (VTE) remains a major challenge in critically ill patients. Subjects admitted in intensive care unit (ICU), in particular trauma patients, are at high-risk for both deep vein thrombosis (DVT) and pulmonary embolism (PE). The rate of symptomatic PE in injured patients has been reported previously ranging from 1 to 6%. The high incidence of posttraumatic venous thromboembolic events is well known. In fact, major trauma is a hypercoagulable state. Several factors placing the individual patient at a higher risk for the development of DVT and PE have been suggested: high ISS score, meningeal hemorrhage and spinal cord injuries have frequently been reported as a significant risk factor for VTEs after trauma. Posttraumatic pulmonary embolism traditionally occurs after a period of at least 5 days from trauma. The prevention can reduce the incidence and mortality associated with the pulmonary embolism if it is effective. There is no consensus is now available about the prevention of venous thromboembolism in trauma patients.

Prognostic model for patients with traumatic brain injuries and abnormal computed tomography scans

Traumatic brain injury (TBI) is an important cause of death and disability worldwide. The prognosis evaluation is a challenge when many variables are involved. The authors aimed to develop prognostic model for assessment of survival chances after TBI based on admission characteristics, including extracranial injuries, which would allow application of the model before in-hospital therapeutic interventions. A cohort study evaluated 1275 patients with TBI and abnormal CT scans upon admission to the emergency unit of Hospital das Clinicas of University of Sao Paulo and analyzed the final outcome on mortality. A logistic regression analysis was undertaken to determine the adjusted weigh of each independent variable in the outcome. Four variables were found to be significant in the model: age (years), Glasgow Coma Scale (3-15), Marshall Scale (MS, stratified into 2,3 or 4,5,6; according to the best group positive predictive value) and anysochoria (yes/no). The following formula is in a logistic model (USP index to head injury) estimates the probability of death of patients according to characteristics that influence on mortality. We consider that our mathematical probability model (USP Index) may be applied to clinical prognosis in patients with abnormal CT scans after severe traumatic brain injury.

Role of computed tomography scores and findings to predict early death in patients with traumatic brain injury: A reappraisal in a major tertiary care hospital in Nepal

Background:

Glasgow Coma Scale has been a long sought model to classify patients with head injury. However, the major limitation of the score is its assessment in the patients who are either sedated or under the influence of drugs or intubated for airway protection. The rational approach for prognostication of such patients is the utility of scoring system based on the morphological criteria based on radiological imaging. Among the current armamentarium, a scoring system based on computed tomography (CT) imaging holds the greatest promise in conquering our conquest for the same.

Methods:

We included a total of 634 consecutive neurosurgical trauma patients in this series, who presented with mild-to-severe traumatic brain injury (TBI) from January 2013 to April 2014 at a tertiary care center in rural Nepal. All pertinent medical records (including all available imaging studies) were reviewed by the neurosurgical consultant and the radiologist on call. Patients’ worst CT image scores and their outcome at 30 days were assessed and recorded. We then assessed their independent performance in predicting the mortality and also tried to seek the individual variables that had significant interplay for determining the same.

Results:

Both imaging score (Marshall) and clinical score (Rotterdam) can be used to reliably predict mortality in patients with acute TBI with high prognostic accuracy. Other specific CT characteristics that can be used to predict early mortality are traumatic subarachnoid hemorrhage, midline shift, and status of the peri-mesencephalic cisterns.

Conclusion:

We demonstrated in this cohort that though the Marshall score has the high predictive power to determine the mortality, better discrimination could be sought through the application of the Rotterdam score that encompasses various individual CT parameters. We thereby recommend the use of such comprehensive prognostic model so as to augment our predictive power for properly dichotomizing the prognosis of the patients with TBI. In the future, it will therefore be important to develop prognostic models that are applicable for the majority of patients in the world they live in, and not just a privileged few who can use resources not necessarily representative of their societal environment.

Comparison of Glasgow Coma Scale, Full Outline of Unresponsiveness and Acute Physiology and Chronic Health Evaluation in Prediction of Mortality Rate Among Patients With Traumatic Brain Injury Admitted to Intensive Care Unit

Background

Traumatic brain injury (TBI) is a common cause of mortality and disability worldwide. Choosing an appropriate diagnostic tool is critical in early stage for appropriate decision about primary diagnosis, medical care and prognosis.

Objectives

This study aimed to compare the Glasgow coma scale (GCS), full outline of unresponsiveness (FOUR) and acute physiology and chronic health evaluation (APACHE II) with respect to prediction of the mortality rate of patients with TBI admitted to intensive care unit.

Patients and Methods

This diagnostic study was conducted on 80 patients with TBI in educational hospitals. The scores of APACHE II, GCS and FOUR were recorded during the first 24 hours of admission of patients. In this study, early mortality means the patient death before 14 days and delayed mortality means the patient death 15 days after admitting to hospital. The collected data were analyzed using descriptive and inductive statistics.

Results

The results showed that the mean age of the patients was 33.80 ± 12.60. From a total of 80 patients with TBI, 16 (20%) were females and 64 (80%) males. The mortality rate was 15 (18.7%). The results showed no significant difference among three tools. In prediction of early mortality, the areas under the curve (AUCs) were 0.92 (CI = 0.95. 0.81 - 0.97), 0.90 (CI = 0.95. 0.74 - 0.94), and 0.96 (CI = 0.95. 0.87 - 0.9) for FOUR, APACHE II and GCS, respectively. In delayed mortality, the AUCs were 0.89 (CI = 0.95. 0.81-0.94), 0.94 (CI = 0.95. 0.74 - 0.97) and 0.90 (CI = 0.95. 0.87 - 0.95) for FOUR, APACHE II and GCS, respectively.

Conclusions

Considering that GCS is easy to use and the FOUR can diagnose a locking syndrome along same values of subscales. These two subscales are superior to APACHI II in prediction of early mortality. Conversation APACHE II is more punctual in the prediction of delayed mortality.

Outcome and Predicting Factor Following Severe Traumatic Brain Injury: A Retrospective Cross-Sectional Study

INTRODUCTION

Severe traumatic brain injury (TBI) is a major and challenging problem in critical care medicine.

AIM

To assess the outcome and predicting factor following severe TBI.

MATERIALS AND METHODS

This is a retrospective and cross-sectional study. Data were collected from two sections; one section consisting of a questionnaire answered by the patients and other section from the patient records. The instruments used included the Glasgow Outcome Scale (GOS), SF-36 and the Hospital Anxiety and Depression Scale (HAD).

RESULTS

The mortality rate of the patients was 46.2%. The quality of life (QOL) of the patients in most dimension were impaired and (58%) of patients had unfavourable QOL. About (37.5%) of patients with anxiety and (27.5%) had a depression. A significant correlation was found between age, GCS arrival, length of ICU stay, mechanical ventilation, VAP & ARDS and pupil reactivity with QOL, GOS, HAD-A and HAD-D (p<0.05, p< 0.001). GCS arrival a predicate factor for QOL and GOS (p <0.001, OR: 1.75, 1.94 respectively); length of ICU stay a predicate factor for QOL and GOS (p <0.05, OR : 1.11, 1.28 respectively); mechanical ventilation a predicate factor for GOS (p <0.001, OR : 1.78); ventilation associated pneumonia (VAP) & acute respiratory distress syndrome (ARDS) and pupil reactivity a predicate factor for GOS (p <0.05, OR : 1.36; p<0.001, OR: 1.94 respectively). The GCS arrival and ICU stay a predicate factor for HAD-A (p<0.05, OR: 1.73, 1.38 respectively).

CONCLUSION

With respect to results advanced in pre hospital, medical and surgical care for the decrease in mortality rates of Head trauma (HT), the use of trauma triage tools and strict enforcement of traffic rules are necessary.

A comparative study between Marshall and Rotterdam CT scores in predicting early deaths in patients with traumatic brain injury in a major tertiary care hospital in Nepal

PURPOSE

CT plays a crucial role in the early assessment of patients with traumatic brain injury (TBI). Marshall and Rotterdam are the mostly used scoring systems, in which CT findings are grouped differently. We sought to determine the values of the scoring system and initial CT findings in predicting the death at hospital discharge (early death) in patients with TBI.

METHODS

There were consecutive 634 traumatic neurosurgical patients with mild-to-severe TBI admitted to the emergency department of College of Medical Sciences. Their initial CT and status at hospital discharge (dead or alive) were reviewed, and both CT scores were calculated. We examined whether each score is related to early death; compared the two scoring systems' performance in predicting early death, and identified the CT findings that are independent predictors for early death.

RESULTS

Both imaging score (Marshall) and clinical score (Rotterdam) can be used to reliably predict mortality in patients with acute traumatic brain injury with high prognostic accuracy. Other specific CT characteristics that can be used to predict early mortality are traumatic subarachnoid hemorrhage, midline shift and status of the peri-mesencephalic cisterns.

CONCLUSIONS

Marshall CT classification has strong predictive power, but greater discrimination can be obtained if the individual CT parameters underlying the CT classification are included in a prognostic model as in Rotterdam score. Consequently, for prognostic purposes, we recommend the use of individual characteristics rather than the CT classification. Performance of CT models for predicting outcome in TBI can be significantly improved by including more details of variables and by adding other variables to the models.

Multimodality monitoring consensus statement: monitoring in emerging economies

The burden of disease and so the need for care is often greater at hospitals in emerging economies. This is compounded by frequent restrictions in the delivery of good quality clinical care due to resource limitations. However, there is substantial heterogeneity in this economically defined group, such that advanced brain monitoring is routinely practiced at certain centers that have an interest in neurocritical care. It also must be recognized that significant heterogeneity in the delivery of neurocritical care exists even within individual high-income countries (HICs), determined by costs and level of interest. Direct comparisons of data between HICs and the group of low- and middle-income countries (LAMICs) are made difficult by differences in patient demographics, selection for ICU admission, therapies administered, and outcome assessment. Evidence suggests that potential benefits of multimodality monitoring depend on an appropriate environment and clinical expertise. There is no evidence to suggest that patients in LAMICs where such resources exist should be treated any differently to patients from HICs. The potential for outcome benefits in LAMICs is arguably greater in absolute terms because of the large burden of disease; however, the relative cost/benefit ratio of such monitoring in this setting must be viewed in context of the overall priorities in delivering health care at individual institutions.

Epidemiology of work-related traumatic brain injury: a systematic review

OBJECTIVE

This systematic review aimed to describe the burden and risk factors of work-related traumatic brain injury (wrTBI) and evaluate methodological quality of existing literature on wrTBI.

METHODS

A search of electronic databases (MEDLINE, EMBASE, PsycINFO, and CINAHL) was conducted to identify articles published between 1980 and 2013 using a combination of terms for work, TBI, and epidemiology, without geographical limitations.

RESULTS

Ninety-eight studies were included in this review, of which 24 specifically focused on wrTBI. In general, male workers, those in the youngest and oldest age groups, and those working in the primary (e.g., agriculture, forestry, mining) or construction industries were more likely to sustain wrTBI, with falls being the most common mechanism of injury.

CONCLUSIONS

This review identified workers at highest risk of wrTBI, with implications for prevention efforts. Future research of better methodological quality is needed to provide a more complete picture of the epidemiology of wrTBI.

A comparison of the diagnostic power of the Full Outline of Unresponsiveness scale and the Glasgow coma scale in the discharge outcome prediction of patients with traumatic brain injury admitted to the intensive care unit

Background and Aim:

This study aimed to determine whether the Full Outline of Unresponsiveness (FOUR) score is an accurate predictorof discharge outcome in traumatic brain injury (TBI) patients and to compare its performanceto Glasgow coma scale (GCS).

Materials and Methods:

Thisis diagnostic study conducted prospectively on 53 TBI patients admitted to ICU of education hospitals of Medical Science University of Mazandaran during February 2013 to June 2013. Data collection was done with a checklist including biographic, clinical information and outcome. The FOUR score and GCS were determined by the researcher in the first 24 hours. Outcomes considered as in-hospital mortality and poor neurologic outcome (Glasgow Outcome Scale (GOS) 1-3) in discharge time from the hospital.

Results:

In terms of predictive power for in-hospital mortality, the area under the receiver operating characteristic (ROC) curve was 0/92 (95% CI. 0/81-0/97) for FOUR score and 0/96 (95% CI. 0/87-0/99) for GCS. In terms of predictive power of poor neurologic outcome, the area under the ROC curve was 0/95 (95% CI. 0/86-0/99) for FOUR score and 0/90 (95% CI.0/79-0/96) for GCS as evidenced by GOS 1-3. The cut-off of 6 showed sensitivity and specificity of total four score predicting poor outcome at 0/86 and 0/87 while the cut-off of 4 showed the value of in hospital mortality at 0/90 and 0/90. The total GCS score showed sensitivity and specificity 0/100 and 0/61 at cut-off 7 in predicting poor outcome while in predicting mortality at cut-off of 4 this range was 0/100 and 0/92.

Conclusion:

The FOUR score is an accurate predictor of discharge outcome in TBI patients. Thus, researchers recommend for therapeutic Schematizationto use in neurosurgical patients at admission day.

Trauma profile at a tertiary intensive care unit in Saudi Arabia

BACKGROUND AND OBJECTIVES

Trauma is a leading cause of death worldwide and in Saudi Arabia. This study describes the injury profiles and ICU outcomes of patients in a tertiary trauma care referral center in Riyadh, Saudi Arabia.

DESIGN AND SETTING

A retrospective analysis of ICU data collected prospectively over 5 years in a 21-bed medical and surgical intensive care unit (ICU) in a tertiary care teaching hospital.

PATIENTS AND METHODS

We collected ICU data on all patients admitted secondary to motor vehicle accidents (MVAs), excluding patients younger than 18 years, brain dead patients and readmissions. We collected data on age, gender, and Glasgow coma scale score at admission, injury severity scores, Acute Physiology and Chronic Health Evaluation II (APACHE II) score, and other data. Multivariate logistic regression was used to identify predictors of mortality.

RESULTS

During the study period, of 1659 patients, MVA was the most common cause of injury (78.4%), followed by pedestrian accident (12.7%). ICU mortality included 221 patients (13.3%) during the study period. Severe head injury, age > 60 years, Glascow coma scale score, injury severity scores, APACHE II and international normalized ratio were independent predictors of mortality.

CONCLUSION

MVA is very common in our country and leads to significant mortality and morbidity. Public education and strict law enforcement are needed to reduce these adverse events.

Hospitalised and fatal head injuries in Viti Levu, Fiji: findings from an island-wide trauma registry (TRIP 4)

Background

Globally, head injury is a substantial cause of mortality and morbidity. A disproportionately greater burden is borne by low- and middle-income countries. The incidence and characteristics of fatal and hospitalised head injuries in Fiji are unknown.

Methods

Using prospective data from the Fiji Injury Surveillance in Hospital system, the epidemiology of fatal and hospitalised head injuries was investigated (2004–2005).

Results

In total, 226 hospital admissions and 50 fatalities (66% died prior to admission) with a principal diagnosis of head injury were identified (crude annual rates of 34.7 and 7.7/100,000, respectively). Males were more likely to die and be hospitalised as a result of head injury than females. The highest fatality rate was among those in the 30–44-year age group. Road traffic crashes were the leading causes of injuries resulting in death (70%), followed by ‘hit by person or object’ and falls (14% each). Among people admitted to hospital, road traffic crashes (34.5%) and falls (33.2%) were the leading causes of injury. The leading cause of head injuries in children was falls, in 15–29-year-olds road traffic crashes, and in adults aged 30–44 years or 45 years and older ‘hit by person or object’. Among the two major ethnic groups, Fijians had higher rates of falls and ‘hit by person or object’ and Indians higher rates for road traffic crashes. There were no statistically significant differences between the overall rates of head injuries or the fatal and non-fatal rates among Fijians or Indians by gender following age standardisation to the total Fijian national population.

Conclusion

Despite underestimating the overall burden, this study identified head injury to be a major cause of death and hospitalisation in Fiji. The predominance of males and road traffic-related injuries is consistent with studies on head injuries conducted in other low- and middle-income countries. The high fatality rate among those aged 30–44 years in this study has not been noted previously. The high case fatality rate prior to admission to the hospital requires urgent attention.

Outcome analysis and outcome predictors of traumatic head injury in childhood: Analysis of 454 observations

Aim:

To determine factors associated with poor outcome in children suffering traumatic head injury (HI).

Materials and Methods:

A retrospective study over an 8-year period including 454 children with traumatic HI admitted in the Intensive Care Unit of a university hospital (Sfax-Tunisia). Basic demographic, clinical, biological and radiological data were recorded on admission and during the ICU stay. Prognosis was defined according Glasgow outcome scale (GOS) performed after hospital discharge by ICU and pediatric physicians.

Results:

There were 313 male (68.9%) and 141 female patients. Mean age (±SD) was 7.2±3.8 years, the main cause of trauma was traffic accidents (69.4%). Mean Glasgow coma scale (GCS) score was 8±3, mean injury severity score (ISS) was 26.4±8.6, mean pediatric trauma score (PTS) was 4±2 and mean pediatric risk of mortality (PRISM) was 11.1±8. The GOS performed within a mean delay of 7 months after hospital discharge was as follow: 82 deaths (18.3%), 5 vegetative states (1.1%), 15 severe disabilities (3.3%), 71 moderate disabilities (15.6%) and 281 good recoveries (61.9%). Multivariate analysis showed that factors associated with poor outcome (death, vegetative state or severe disability) were: PRISM ≥24 (P=0.03; OR: 5.75); GCS ≤8 (P=0.04; OR:2.42); Cerebral edema (P=0.03; OR:2.23); lesion type VI according to Traumatic Coma Data Bank Classification (P=0.002; OR:55.95); Hypoxemia (P=0.02; OR:2.97) and sodium level >145 mmol/l (P=0.04; OR: 4.41).

Conclusions:

A significant proportion of children admitted with HI were found to have moderate disability at follow-up. We think that improving prehospital care, establishing trauma centers and making efforts to prevent motor vehicle crashes should improve the prognosis of HI in children.

Patterns and clinical correlates of pain among brain injury patients in critical care assessed with the critical care pain observation tool

This study was conducted to assess the patterns and clinical correlates of acute pain in brain injury patients during the critical care period using the Critical Care Pain Observation Tool (CPOT). Data were collected from 31 brain-injury patients admitted to an intensive care unit (ICU) at a university hospital located in Incheon, Republic of Korea. Glasgow Coma Scale and CPOT scores were assessed on days 1, 3, 6, 9, and 14 after ICU admission. Results showed that temporal changes in pain intensity displayed a consistent pattern in critical care patients with a brain injury during the first 14 days of ICU admission. Mean pain score was highest on day 1, decreased rapidly to reach a minimum on day 3 or 6, and then increased on day 9. In most patients, pain reduced slightly on day 14. Mean CPOT scores were significantly higher in the nonsurgery group than in the surgery group. There was also a nonsignificant trend of higher pain intensity scores among patients with moderate brain injury compared with those with severe injury. CPOT scores immediately after endotracheal suctioning were significantly higher than before endotracheal suctioning, but CPOT scores 20 minutes after suctioning were similar to those before suctioning. The present study may be meaningful in terms of presenting valid clinical information regarding the patterns and characteristics of acute pain in brain injury patients who are often unable to self-report on the presence and intensity of pain.

Isolated traumatic head injury in children: Analysis of 276 observations

BACKGROUND

To determine predictive factors of mortality among children after isolated traumatic brain injury.

MATERIALS AND METHODS

In this retrospective study, we included all consecutive children with isolated traumatic brain injury admitted to the 22-bed intensive care unit (ICU) of Habib Bourguiba University Hospital (Sfax, Tunisia). Basic demographic, clinical, biochemical, and radiological data were recorded on admission and during ICU stay.

RESULTS

There were 276 patients with 196 boys (71%) and 80 girls, with a mean age of 6.7 ± 3.8 years. The main cause of trauma was road traffic accident (58.3%). Mean Glasgow Coma Scale score was 8 ± 2, Mean Injury Severity Score (ISS) was 23.3 ± 5.9, Mean Pediatric Trauma Score (PTS) was 4.8 ± 2.3, and Mean Pediatric Risk of Mortality (PRISM) was 10.8 ± 8. A total of 259 children required mechanical ventilation. Forty-eight children (17.4%) died. Multivariate analysis showed that factors associated with a poor prognosis were PRISM > 24 (OR: 10.98), neurovegetative disorder (OR: 7.1), meningeal hemorrhage (OR: 2.74), and lesion type VI according to Marshall tomographic grading (OR: 13.26).

CONCLUSION

In Tunisia, head injury is a frequent cause of hospital admission and is most often due to road traffic injuries. Short-term prognosis is influenced by demographic, clinical, radiological, and biochemical factors. The need to put preventive measures in place is underscored.

A systematic review of factors contributing to outcomes in patients with traumatic brain injury

AIM AND OBJECTIVE

To review, systematically, factors contributing to outcomes in patients with traumatic brain injury.

BACKGROUND

Traumatic brain injury is a leading cause of death and disability. Several studies have determined the significant predictors of outcomes after traumatic brain injury. The comprehensive identification of these reliable factors for traumatic brain injury is critical to both clinical practice and research.

DESIGN

Systematic literature review.

METHODS

Eligible studies that combined at least two variables to predict outcomes in patient with traumatic brain injury were identified via electronic database searches, footnote chasing and contact with clinical experts. Quality of selected studies was assessed in terms of internal and external validity using 15 questions. Two reviewers independently examined titles, abstracts and whether each met the predefined inclusion criteria.

RESULTS

A total of 46 studies which met review criteria were finally selected. Most studies satisfied internal validity in terms of validity of research variables and multivariate analysis, but few were validated externally. The following factors were significantly associated with unfavourable outcomes: sociodemographic factors such as older age, male gender, lower level of education; clinical factors such as lower Glasgow Coma Scale score, injury caused by motor vehicle crash, hypotension, hypoxia, increased intracranial pressure, no pupil reaction, hypo- or hyperglycaemia, anaemia, coagulopathy, hypo- or hyperthermia, abnormal level of electrolytes, duration of coma; higher level of computed tomography classification by Marshall category; type of intracerebral lesions.

CONCLUSION

Further studies on integrating the sociodemographic factors, the course of the clinical condition and a unified CT scoring system, are recommended for the evaluation and improvement of the prognosis of traumatic brain injury.

RELEVANCE TO CLINICAL PRACTICE

A systematic review of factors contributing to outcome for patients with traumatic brain injury will be invaluable in triage criteria, injury prognostication, care and discharge planning, resource use and patient and family counselling.

150 years of treating severe traumatic brain injury: a systematic review of progress in mortality

Considerable effort and resources have been devoted to preserving life in patients with severe closed traumatic brain injury (TBI). We sought to identify temporal trends in mortality rates of these patients from the late 1800s to the present. We searched the literature for articles on severe TBI, abstracting numbers of patients studied, numbers of deaths, and years of patient entry. Mortality rates were calculated for each study, and meta-regression was used to pool data and to test for significant temporal trends. We reviewed 207 case series comprising more than 140,000 cases of severe closed TBI admitted to hospital over a span of almost 150 years. Since the late 1800s mortality has fallen by almost 50%. However, the rate has varied considerably among the four epochs chosen. Between 1885 and 1930, mortality decreased at a rate of 3% per decade. From 1970 to 1990, mortality declined at a rate of 9% per decade. Both changes are significant. There was no observed improvement in mortality between 1930 and 1970, nor is progress evident since 1990. The authors discuss possible reasons for the apparently intermittent progress in TBI survival over time.

Changes in the acute functional and cognitive disability states of severe hemorrhagic stroke patients

The purpose of this study was to characterize temporal patterns of functional and cognitive disability changes during the acute period in hemorrhagic stroke patients. The study subjects were 62 hemorrhagic stroke patients admitted to a surgical intensive care unit at a university hospital located in Incheon, South Korea. As outcome variables, functional disability, cognitive ability, and employment status were evaluated directly at 1, 3, and 6 months after admission. The results showed that significant improvements in functional and cognitive ability were observed between 1 and 6 months after admission. In terms of functional disability, subjects considered their overall functional ability (dependence on others) to be less recovered than the specific functional abilities (feeding, grooming, or toileting): 75% of the subjects stated that they were completely independent on others, whereas 92.9%, 83.9%, and 83.9% of subjects indicated that they were completely independent for feeding, grooming, and toileting at the 6-month assessments, respectively. In terms of cognitive ability, attention, communication, and memory recovery rates were found to be relatively good. However, the proportion of subjects that achieved complete problem solving and safety and social behavior recovery were lower than those that achieved attention, communication, and memory recovery. Our findings can provide the empirical evidences when neuroscience nurses use educational and supportive strategies for rehabilitation of hemorrhagic stroke patients.

Initial predictive factors of outcome in severe non-accidental head trauma in children

OBJECT

The aim of this study is to evaluate the outcome of young children hospitalized for non-accidental head trauma in our PICU, to evaluate PRISM II score in this sub-population of pediatric trauma and to identify factors that might influence the short-term outcome.

MATERIALS AND METHODS

Files of all children less than 2 years old with the diagnosis of non-accidental head trauma over a 10-years period were systematically reviewed. We collected data on demographic information, medical history, clinical status, and management in the PICU. Three severity scores were then calculated: PRISM II, Glasgow Coma Scale (GCS), and Pediatric Trauma Score (PTS). Prognosis value of qualitative variables was tested with a univariate procedure analysis (anemia, diabetes insipidus...). Then, quantitative variables were tested with univariate procedure too (age, weight, PRISM II, GCS, Platelet count, fibrin, prothrombin time (PT)...). Potential association between variables and death was tested using univariate procedure. Variables identified by univariate analysis were then analyzed with multivariate analysis through a forward-stepping logistic regression.

RESULTS

Thirty-six children were included. Mean age was 5.5 months (8 days-21.5 months). Mortality rate was 27.8%. At admission, PTS, PRISM II, GCS, PT, PTT, and diabetes insipidus were significantly altered or more frequent in non survivors. Cutoff value for PRISM II at which risk of mortality increased was 17.5 (sensitivity = 0.8; specificity = 0.88).

CONCLUSION

PRISM II is a reliable and easy performing tool for assessing the prognosis of non-accidental cranial traumatism in young children. GCS and PTS, scores even simpler than PRISM II, showed good accuracy regarding survival prediction.

Relationship of aggressive monitoring and treatment to improved outcomes in severe traumatic brain injury

OBJECT

Despite being common practice for decades and being recommended by national guidelines, aggressive monitoring and treatment of patients with severe traumatic brain injury (TBI) have not been supported by convincing evidence.

METHODS

The authors reviewed trials and case series reported after 1970 in which patients were treated for severe closed TBI, and mortality rates and favorable outcomes at 6 months after injury were analyzed. The patient groups were divided into those with and without intracranial pressure (ICP) monitoring and intensive therapy, and the authors performed a meta-analysis to assess the effects of treatment intensity on outcome.

RESULTS

Although the mortality rate fell during the years reviewed, it was consistently approximately 12% lower among patients in the intense treatment group (p < 0.001). Favorable outcomes did not change significantly over time, and were 6% higher among the aggressively treated patients (p = 0.0105).

CONCLUSIONS

Aggressive ICP monitoring and treatment of patients with severe TBI is associated with a statistically significant improvement in outcome. This improvement occurs independently of temporal effects.

Early prognosis in traumatic brain injury: from prophecies to predictions

Traumatic brain injury (TBI) is a heterogeneous condition that encompasses a broad spectrum of disorders. Outcome can be highly variable, particularly in more severely injured patients. Despite the association of many variables with outcome, prognostic predictions are notoriously difficult to make. Multivariable analysis has identified age, clinical severity, CT abnormalities, systemic insults (hypoxia and hypotension), and laboratory variables as relevant factors to include in models to predict outcome in individual patients. Advances in statistical modelling and the availability of large datasets have facilitated the development of prognostic models that have greater performance and generalisability. Two prediction models are currently available, both of which have been developed on large datasets with state-of-the-art methods, and offer new opportunities. We see great potential for their use in clinical practice, research, and policy making, as well as for assessment of the quality of health-care delivery. Continued development, refinement, and validation is advocated, together with assessment of the clinical impact of prediction models, including treatment response.