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McNamara CR, Even KM, Kalinowski A, Horvat CM, Gaines BA, Richardson WM, Simon DW, Kochanek PM, Berger RP, Fink EL. Multiorgan Dysfunction Syndrome in Abusive and Accidental Pediatric Traumatic Brain Injury. Neurocrit Care 2024; 40:1099-1108. [PMID: 38062303 PMCID: PMC11147737 DOI: 10.1007/s12028-023-01887-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2023] [Accepted: 10/27/2023] [Indexed: 01/05/2024]
Abstract
BACKGROUND Abusive head trauma (AHT) is a mechanism of pediatric traumatic brain injury (TBI) with high morbidity and mortality. Multiorgan dysfunction syndrome (MODS), defined as organ dysfunction in two or more organ systems, is also associated with morbidity and mortality in critically ill children. Our objective was to compare the frequency of MODS and evaluate its association with outcome between AHT and accidental TBI (aTBI). METHODS This was a single center, retrospective cohort study including children under 3 years old admitted to the pediatric intensive care unit with nonpenetrating TBI between 2014 and 2021. Presence or absence of MODS on days 1, 3, and 7 using the Pediatric Logistic Organ Dysfunction-2 score and new impairment status (Functional Status Scale score change > 1 compared with preinjury) at hospital discharge (HD), short-term timepoint, and long-term timepoint were abstracted from the electronic health record. Multiple logistic regression was performed to examine the association between MODS and TBI mechanism with new impairment status. RESULTS Among 576 children, 215 (37%) had AHT and 361 (63%) had aTBI. More children with AHT had MODS on days 1 (34% vs. 23%, p = 0.003), 3 (28% vs. 6%, p < 0.001), and 7 (17% vs. 3%, p < 0.001) compared with those with aTBI. The most common organ failures were cardiovascular ([AHT] 66% vs. [aTBI] 66%, p = 0.997), neurologic (33% vs. 16%, p < 0.001), and respiratory (34% vs. 15%, p < 0.001). MODS was associated with new impairment in multivariable logistic regression at HD (odds ratio 19.1 [95% confidence interval 9.8-38.6, p < 0.001]), short-term discharge (7.4 [3.7-15.2, p < 0.001]), and long-term discharge (4.3 [2.0-9.4, p < 0.001])]. AHT was also associated with new impairment at HD (3.4 [1.6-7.3, p = 0.001]), short-term discharge (2.5 [1.3-4.7, p = 0.005]), and long-term discharge (2.1 [1.1-4.1, p = 0.036]). CONCLUSIONS Abusive head trauma as a mechanism was associated with MODS following TBI. Both AHT mechanism and MODS were associated with new impairment at all time points.
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Affiliation(s)
- Caitlin R McNamara
- Department of Pediatric Critical Care Medicine, University of Pittsburgh, Pittsburgh, PA, USA.
| | - Katelyn M Even
- Department of Pediatric Critical Care Medicine, Pennsylvania State University, State College, PA, USA
| | - Anne Kalinowski
- Department of Pediatric Critical Care Medicine, University of Pittsburgh, Pittsburgh, PA, USA
| | - Christopher M Horvat
- Department of Pediatric Critical Care Medicine, University of Pittsburgh, Pittsburgh, PA, USA
| | - Barbara A Gaines
- Division of Pediatric Surgery, Department of Surgery, University of Texas Southwestern, Dallas, TX, USA
| | - Ward M Richardson
- Department of Pediatric Surgery, University of Pittsburgh, Pittsburgh, PA, USA
| | - Dennis W Simon
- Department of Pediatric Critical Care Medicine, University of Pittsburgh, Pittsburgh, PA, USA
| | - Patrick M Kochanek
- Department of Pediatric Critical Care Medicine, University of Pittsburgh, Pittsburgh, PA, USA
| | - Rachel P Berger
- Department of Pediatric Critical Care Medicine, University of Pittsburgh, Pittsburgh, PA, USA
| | - Ericka L Fink
- Department of Pediatric Critical Care Medicine, University of Pittsburgh, Pittsburgh, PA, USA
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Chou CC, Hou JY, Chou IJ, Lan SY, Kong SS, Huang MH, Weng YC, Lin YY, Kuo CY, Hsieh MY, Chou ML, Hung PC, Wang HS, Lin KL, Wang YS, Lin JJ. Electroencephalogram pattern predicting neurological outcomes of children with seizures secondary to abusive head trauma. Pediatr Neonatol 2024; 65:249-254. [PMID: 38012896 DOI: 10.1016/j.pedneo.2023.05.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/13/2022] [Revised: 04/22/2023] [Accepted: 05/19/2023] [Indexed: 11/29/2023] Open
Abstract
BACKGROUND The clinical presentations of abusive head trauma can abruptly worsen, so the occurrence of seizures and changes of EEG can be variable according to patients' conditions. Since the changes of EEG background waves reflect the cortical function of children, we aimed to find out whether the timing of EEG background, epileptiform discharges and seizure patterns were associated with the outcomes of patients with AHT. MATERIAL AND METHODS Using seizure type and acute stage electroencephalographic (EEG) characteristics to assess adverse neurological outcomes in children with seizures secondary to abusive head trauma (AHT). Children who were hospitalized with AHT at a tertiary referral hospital from October 2000 to April 2010 were evaluated retrospectively. A total of 50 children below 6 years of age admitted due to AHT were included. KOSCHI outcome scale was used to evaluate the primary outcome and neurological impairment was used as secondary outcome after 6 months discharge. RESULTS Children with apnea, cardiac arrest, reverse blood flow and skull fracture in clinic had a higher mortality rate even in the no-seizure group (3/5 [60%] vs. 3/45 [6.7%], odds ratio [OR] = 11; 95% CI = 2.3-52; p = 0.025). Seizure occurrence reduced mostly at the second day after admission in seizure groups; but children with persistent seizures for 1 week showed poor neurological outcomes. The occurrence of initial seizure was frequency associated with younger age; focal seizure, diffuse cortical dysfunction in acute-stage EEG, and low Glasgow Coma Scale (GCS) score were significantly related to poor outcomes after 6 months. Diffuse cortical dysfunction was also associated with motor, speech, and cognitive dysfunction. CONCLUSIONS Diffuse cortical dysfunction in acute-stage EEG combined with low GCS score and focal seizure may related to poor outcomes and neurological dysfunctions in children with AHT.
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Affiliation(s)
- Cheng-Che Chou
- Division of Pediatric Neurology, Department of Pediatrics, Taipei Medical University Shuang Ho Hospital, New Taipei City, Taiwan; Ph.D. Program in Medical Neuroscience, College of Medical Science and Technology, Taipei Medical University, Taiwan
| | - Ju-Yin Hou
- Division of Pediatric Neurology, Department of Pediatrics, Chang Gung Memorial Hospital at Linko, Taoyuan, Taiwan
| | - I-Jun Chou
- Division of Pediatric Neurology, Department of Pediatrics, Chang Gung Memorial Hospital at Linko, Taoyuan, Taiwan
| | - Shih-Yun Lan
- Division of Pediatric Neurology, Department of Pediatrics, New Taipei City Hospital, New Taipei City, Taiwan
| | - Shu-Sing Kong
- Division of Pediatric Neurology, Department of Pediatrics, Taipei Medical University Shuang Ho Hospital, New Taipei City, Taiwan
| | - Man-Hsu Huang
- Department of Pathology, Taipei Medical University Shuang Ho Hospital, New Taipei City, Taiwan
| | - Yu-Chieh Weng
- College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Yi-Yu Lin
- College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Cheng-Yen Kuo
- Division of Pediatric Neurology, Department of Pediatrics, Chang Gung Memorial Hospital at Linko, Taoyuan, Taiwan
| | - Meng-Ying Hsieh
- Division of Pediatric Neurology, Department of Pediatrics, Chang Gung Memorial Hospital at Linko, Taoyuan, Taiwan
| | - Min-Liang Chou
- Division of Pediatric Neurology, Department of Pediatrics, Chang Gung Memorial Hospital at Linko, Taoyuan, Taiwan
| | - Po-Cheng Hung
- Division of Pediatric Neurology, Department of Pediatrics, Chang Gung Memorial Hospital at Linko, Taoyuan, Taiwan
| | - Huei-Shyong Wang
- Division of Pediatric Neurology, Department of Pediatrics, Chang Gung Memorial Hospital at Linko, Taoyuan, Taiwan
| | - Kuang-Lin Lin
- Division of Pediatric Neurology, Department of Pediatrics, Chang Gung Memorial Hospital at Linko, Taoyuan, Taiwan
| | - Yi-Shan Wang
- Division of Pediatric Neurology, Department of Pediatrics, Chang Gung Memorial Hospital at Linko, Taoyuan, Taiwan
| | - Jainn-Jim Lin
- Division of Pediatric Neurology, Department of Pediatrics, Chang Gung Memorial Hospital at Linko, Taoyuan, Taiwan; College of Medicine, Chang Gung University, Taoyuan, Taiwan; Division of Pediatric Critical Care Medicine, Department of Pediatrics, Chang Gung Memorial Hospital at Linko, Taoyuan, Taiwan.
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Yock-Corrales A, Lee JH, Domínguez-Rojas JÁ, Caporal P, Roa JD, Fernandez-Sarmiento J, González-Dambrauskas S, Zhu Y, Abbas Q, Kazzaz Y, Dewi DS, Chong SL. A Multicenter Study on the Clinical Characteristics and Outcomes Among Children With Moderate to Severe Abusive Head Trauma. J Pediatr Surg 2024; 59:494-499. [PMID: 37867044 DOI: 10.1016/j.jpedsurg.2023.09.038] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/21/2023] [Revised: 09/11/2023] [Accepted: 09/24/2023] [Indexed: 10/24/2023]
Abstract
INTRODUCTION We aimed to identify clinical characteristics, risk factors for diagnosis, and describe outcomes among children with AHT. METHODS We performed an observational cohort study in tertiary care hospitals from 14 countries across Asia and Ibero-America. We included patients <5 years old who were admitted to participating pediatric intensive care units (PICUs) with moderate to severe traumatic brain injury (TBI). We performed descriptive analysis and multivariable logistic regression for risk factors of AHT. RESULTS 47 (12%) out of 392 patients were diagnosed with AHT. Compared to those with accidental injuries, children with AHT were more frequently < 2 years old (42, 89.4% vs 133, 38.6%, p < 0.001), more likely to arrive by private transportation (25, 53.2%, vs 88, 25.7%, p < 0.001), but less likely to have multiple injuries (14, 29.8% vs 158, 45.8%, p = 0.038). The AHT group was more likely to suffer subdural hemorrhage (SDH) (39, 83.0% vs 89, 25.8%, p < 0.001), require antiepileptic medications (41, 87.2% vs 209, 60.6%, p < 0.001), and neurosurgical interventions (27, 57.40% vs 143, 41.40%, p = 0.038). Mortality, PICU length of stay, and functional outcomes at 3 months were similar in both groups. In the multivariable logistic regression, age <2 years old (aOR 8.44, 95%CI 3.07-23.2), presence of seizures (aOR 3.43, 95%CI 1.60-7.36), and presence of SDH (aOR 9.58, 95%CI 4.10-22.39) were independently associated with AHT. CONCLUSIONS AHT diagnosis represented 12% of our TBI cohort. Overall, children with AHT required more neurosurgical interventions and the use of anti-epileptic medications. Children younger than 2 years and with SDH were independently associated with a diagnosis of AHT. TYPE OF STUDY Observational cohort study. LEVEL OF EVIDENCE III.
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Affiliation(s)
- Adriana Yock-Corrales
- Emergency Department.Hospital Nacional de Niños ¨Dr. Carlos Sáenz Herrera. CCSS San José, Costa Rica.
| | - Jan Hau Lee
- Children's Intensive Care Unit, KK Women's and Children's Hospital. Singapore
| | | | - Paula Caporal
- Hospital Interzonal Especializado en Pediatría "Sor María Ludovica", Buenos Aires, Argentina
| | - Juan D Roa
- Fundación Homi, Universidad Nacional de Colombia - FUCS, Bogotá, Colombia
| | - Jaime Fernandez-Sarmiento
- Department of Critical Care Medicine and Pediatrics, Universidad de La Sabana. Fundación Cardioinfantil-Instituto de Cardiología, Bogotá, Colombia
| | - Sebastián González-Dambrauskas
- Departamento de Pediatría y Unidad de Cuidados Intensivos de Niños del Centro Hospitalario Pereira Rossell, Facultad de Medicina, Universidad de la República Montevideo, Uruguay
| | - Yanan Zhu
- Singapore Clinical Research Institute, Consortium for Clinical Research and Innovation. Singapore
| | - Qalab Abbas
- Department of Paediatrics and Child Health Aga Khan University Karachi Pakistan Karachi, Karachi City, Sindh, Pakistan
| | - Yasser Kazzaz
- Department of Paediatrics, Ministry of National Guards Health Affairs, College of Medicine, King Saud bin Abdulaziz University for Health Sciences, King Abdullah International Medical Research Centre Riyadh, Saudi Arabia
| | - Dianna Sri Dewi
- KK Research Centre, KK Women's and Children's Hospital, Singapore
| | - Shu-Ling Chong
- Department of Emergency Medicine, KK Women's and Children's Hospital, Singapore
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McNamara CR, Kalinowski A, Horvat CM, Gaines BA, Richardson WM, Simon DW, Kochanek PM, Berger RP, Fink EL. New Functional Impairment After Hospital Discharge by Traumatic Brain Injury Mechanism in Younger Than 3 Years Old Admitted to the PICU in a Single Center Retrospective Study. Pediatr Crit Care Med 2024; 25:250-258. [PMID: 38088760 DOI: 10.1097/pcc.0000000000003417] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2024]
Abstract
OBJECTIVES Children who suffer traumatic brain injury (TBI) are at high risk of morbidity and mortality. We hypothesized that in patients with TBI, the abusive head trauma (AHT) mechanism vs. accidental TBI (aTBI) would be associated with higher frequency of new functional impairment between baseline and later follow-up. DESIGN Retrospective single center cohort study. SETTING AND PATIENTS Children younger than 3 years old admitted with TBI to the PICU at a level 1 trauma center between 2014 and 2019. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Patient characteristics, TBI mechanism, and Functional Status Scale (FSS) scores at baseline, hospital discharge, short-term (median, 10 mo [interquartile range 3-12 mo]), and long-term (median, 4 yr [3-6 yr]) postdischarge were abstracted from the electronic health record. New impairment was defined as an increase in FSS greater than 1 from baseline. Patients who died were assigned the highest score (30). Multivariable logistic regression was performed to determine the association between TBI mechanism with new impairment. Over 6 years, there were 460 TBI children (170 AHT, 290 aTBI), of which 13 with AHT and four with aTBI died. Frequency of new impairment by follow-up interval, in AHT vs. aTBI patients, were as follows: hospital discharge (42/157 [27%] vs. 27/286 [9%]; p < 0.001), short-term (42/153 [27%] vs. 26/259 [10%]; p < 0.001), and long-term (32/114 [28%] vs. 18/178 [10%]; p < 0.001). Sensory, communication, and motor domains were worse in AHT patients at the short- and long-term timepoint. On multivariable analysis, AHT mechanism was associated with greater odds (odds ratio [95% CI]) of poor outcome (death and new impairment) at hospital discharge (4.4 [2.2-8.9]), short-term (2.7 [1.5-4.9]), and long-term timepoints (2.4 [1.2-4.8]; p < 0.05). CONCLUSIONS In patients younger than 3 years old admitted to the PICU after TBI, the AHT mechanism-vs. aTBI-is associated with greater odds of poor outcome in the follow-up period through to ~5 years postdischarge. New impairment occurred in multiple domains and only AHT patients further declined in FSS over time.
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Affiliation(s)
- Caitlin R McNamara
- Department of Pediatric Critical Care Medicine, University of Pittsburgh, Pittsburgh, PA
| | - Anne Kalinowski
- Department of Pediatric Critical Care Medicine, University of Pittsburgh, Pittsburgh, PA
| | - Christopher M Horvat
- Department of Pediatric Critical Care Medicine, University of Pittsburgh, Pittsburgh, PA
| | - Barbara A Gaines
- Department of Pediatric Surgery, University of Pittsburgh, Pittsburgh, PA
| | - Ward M Richardson
- Department of Pediatric Surgery, University of Pittsburgh, Pittsburgh, PA
| | - Dennis W Simon
- Department of Pediatric Critical Care Medicine, University of Pittsburgh, Pittsburgh, PA
| | - Patrick M Kochanek
- Department of Pediatric Critical Care Medicine, University of Pittsburgh, Pittsburgh, PA
| | - Rachel P Berger
- Department of Child Advocacy, University of Pittsburgh, Pittsburgh, PA
| | - Ericka L Fink
- Department of Pediatric Critical Care Medicine, University of Pittsburgh, Pittsburgh, PA
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Gao S, Treble-Barna A, Fabio A, Beers SR, Kelly MK, Rosario BL, Bell MJ, Wisniewski SR. Effects of inpatient rehabilitation after acute care on motor, neuropsychological and behavioral outcomes in children with severe traumatic brain injury. Disabil Rehabil 2024:1-10. [PMID: 38166467 DOI: 10.1080/09638288.2023.2297920] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2023] [Accepted: 12/16/2023] [Indexed: 01/04/2024]
Abstract
PURPOSE An observational study of children with severe traumatic brain injury (TBI) (Approaches and Decisions in Acute Pediatric TBI [ADAPT] Trial) demonstrated the benefits of inpatient rehabilitation on functional outcomes for those with more severely impaired consciousness when medically stable. We conducted a secondary analysis to assess whether using an inpatient rehabilitation or skilled nursing facility after acute hospitalization was associated with better motor, neuropsychological, and behavioral outcomes compared to receiving only non-inpatient rehabilitation among children with severe TBI. MATERIALS AND METHODS We included 180 children who used an inpatient rehabilitation or skilled nursing facility and 74 children who only received non-inpatient rehabilitation from the ADAPT trial. At 12 months post-injury, children underwent tests of motor skills, intellectual functioning, verbal learning, memory, processing speed, and cognitive flexibility. Parents/guardians rated children's executive function and behaviors. We performed inverse probability weighting to adjust for potential confounders. RESULTS No significant differences were found in any motor, neuropsychological, or behavioral measures between children receiving inpatient rehabilitation and children receiving only non-inpatient rehabilitation. CONCLUSIONS Analyses of comprehensive outcomes did not show differences between children receiving inpatient rehabilitation and children receiving only non-inpatient rehabilitation, suggesting a need for more research on specific components of the rehabilitation process.
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Affiliation(s)
- Shiyao Gao
- Department of Epidemiology, Epidemiology Data Center, University of Pittsburgh, Pittsburgh, PA, USA
| | - Amery Treble-Barna
- Department of Physical Medicine and Rehabilitation, University of Pittsburgh, Pittsburgh, PA, USA
| | - Anthony Fabio
- Department of Epidemiology, Epidemiology Data Center, University of Pittsburgh, Pittsburgh, PA, USA
| | - Sue R Beers
- Department of Psychiatry, University of Pittsburgh, Pittsburgh, PA, USA
| | - M Kathleen Kelly
- Department of Physical Therapy, University of Pittsburgh, Pittsburgh, PA, USA
| | - Bedda L Rosario
- Department of Epidemiology, Epidemiology Data Center, University of Pittsburgh, Pittsburgh, PA, USA
| | - Michael J Bell
- Department of Pediatrics, Division of Critical Care Medicine, Children's National Hospital, WA, DC, USA
| | - Stephen R Wisniewski
- Department of Epidemiology, Epidemiology Data Center, University of Pittsburgh, Pittsburgh, PA, USA
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Bozer JJ, Gruber MD, Letson MM, Crichton KG, Rice CE, Qureshi N, Leonard JR, Sribnick EA. Long-Term Functional Outcome Following Neurosurgical Intervention for Suspected Abusive Head Trauma. Pediatr Neurol 2023; 148:101-107. [PMID: 37699270 DOI: 10.1016/j.pediatrneurol.2023.08.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/05/2023] [Revised: 08/04/2023] [Accepted: 08/14/2023] [Indexed: 09/14/2023]
Abstract
BACKGROUND The purpose of this study was to evaluate the long-term functional and neurodevelopmental outcomes in pediatric patients who underwent neurosurgical intervention following suspected abusive head trauma (AHT). METHODS We performed a single-center retrospective review (January 1, 2007, to December 31, 2019) of patients aged less than three years who had intracranial injury suspicious for AHT and received a neurosurgical procedure. Long-term functional outcome was measured using the Pediatric Cerebral Performance Category (PCPC), Pediatric Overall Performance Category (POPC), and the Mullen Scales of Early Learning (MSEL). RESULTS Seventy-seven patients were identified; 53 survived to discharge and had at least one-year follow-up. To examine long-term functional outcome, PCPC at the last available visit was examined and found to be 1 or 2 (normal to mild disability) for 64% of patients and 3 or 4 (moderate to severe disability) for 36%. The last available MSEL composite score for neurodevelopmental assessment also demonstrated that 13% of patients scored in the "average" range, 17% in the "below average" range, and 70% in the "very low" range. There was no statistical difference in the last available PCPC or POPC score or the last available MSEL score for patients who received a craniotomy when compared with those who received an intracranial shunt. CONCLUSIONS For patients with AHT who survived to discharge, functional improvements over time were noted in both patients who received craniotomy or who simply required shunt placement. These results suggest that, for patients who survive to discharge, operative management of AHT can lead to reasonable long-term functional outcomes.
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Affiliation(s)
- Jordan J Bozer
- College of Medicine, The Ohio State University, Columbus, Ohio
| | - Maxwell D Gruber
- Department of Pediatric Neurosurgery, Nationwide Children's Hospital, Columbus, Ohio
| | - Megan M Letson
- Department of Pediatrics, The Ohio State University Wexner Medical Center, Columbus, Ohio; Department of Pediatrics, Nationwide Children's Hospital, Columbus, Ohio
| | - Kristin G Crichton
- Department of Pediatrics, The Ohio State University Wexner Medical Center, Columbus, Ohio; Department of Pediatrics, Nationwide Children's Hospital, Columbus, Ohio
| | - Courtney E Rice
- Psychiatry and Behavioral Health, Nationwide Children's Hospital, Columbus, Ohio
| | | | - Jeffrey R Leonard
- Department of Pediatric Neurosurgery, Nationwide Children's Hospital, Columbus, Ohio; Department of Neurosurgery, The Ohio State University Wexner Medical Center, Columbus, Ohio
| | - Eric A Sribnick
- Department of Pediatric Neurosurgery, Nationwide Children's Hospital, Columbus, Ohio; Department of Neurosurgery, The Ohio State University Wexner Medical Center, Columbus, Ohio.
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Lee EP, Hsia SH, Lin JJ, Chan OW, Wu HP. Predictors of neurologic outcomes and mortality in physically abused and unintentionally injured children: a retrospective observation study. Eur J Med Res 2023; 28:441. [PMID: 37848955 PMCID: PMC10580634 DOI: 10.1186/s40001-023-01430-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2023] [Accepted: 10/03/2023] [Indexed: 10/19/2023] Open
Abstract
OBJECTIVES This study aimed to identify the predictors of neurologic outcomes and mortality in physically abused and unintentionally injured children admitted to intensive care units (ICUs). METHODS All maltreated children were admitted to pediatric, neurosurgical, and trauma ICUs between 2001 and 2019. Clinical factors, including age, sex, season of admission, identifying settings, injury severity score, etiologies, length of stay in the ICU, neurologic outcomes, and mortality, were analyzed and compared between the physically abused and unintentionally injured groups. Neurologic assessments were conducted using the Pediatric Cerebral Performance Category scale. The study was approved by the Institutional Review Board of Chang Gung Memorial Hospital and the Ethics Committee waived the requirement for informed consent because of the anonymized nature of the data. RESULTS A total of 2481 children were investigated; of them, there were 480 (19.3%) victims admitted to the ICUs, including 156 physically abused and 324 unintentionally injured. Age, history of prematurity, clinical outcomes, head injury, neurosurgical interventions, clinical manifestations, brain computed tomography findings, and laboratory findings significantly differed between them (all p < 0.05). Traumatic brain injury was the major etiology for admission to the ICU. The incidence of abusive head trauma was 87.1% among the physically abused group. Only 46 (29.4%) and 268 (82.7%) cases achieved favorable neurologic outcomes in the physically abused and unintentionally injured groups, respectively. Shock within 24 h, spontaneous hypothermia (body temperature, < 35 °C), and post-traumatic seizure were strongly associated with poor neurologic outcomes and mortality in both groups. CONCLUSIONS Initial presentation with shock, spontaneous hypothermia at ICU admission, and post-traumatic seizure were associated with poor neurologic outcomes and mortality in physically abused and unintentionally injured children.
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Affiliation(s)
- En-Pei Lee
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, Linko Chang Gung Memorial Hospital, Taoyuan, Taiwan
- College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Shao-Hsuan Hsia
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, Linko Chang Gung Memorial Hospital, Taoyuan, Taiwan
- College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Jainn-Jim Lin
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, Linko Chang Gung Memorial Hospital, Taoyuan, Taiwan
- College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Oi-Wa Chan
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, Linko Chang Gung Memorial Hospital, Taoyuan, Taiwan
- College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Han-Ping Wu
- Department of Pediatrics, Chiayi Chang-Gung Memorial Hospital, No. 6, W. Sec., Jiapu Rd., Puzi City, Chiayi County, Taiwan.
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Gao S, Treble-Barna A, Fabio A, Kelly MK, Beers SR, Rosario BL, Bell MJ, Wisniewski SR. Effects of inpatient rehabilitation after acute care on functional and quality-of-life outcomes in children with severe traumatic brain injury. Brain Inj 2022; 36:1280-1287. [PMID: 36101488 PMCID: PMC9890641 DOI: 10.1080/02699052.2022.2120211] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2021] [Revised: 04/02/2022] [Accepted: 08/28/2022] [Indexed: 02/03/2023]
Abstract
OBJECTIVE Few studies have assessed the effectiveness of the rehabilitation process in children surviving severe traumatic brain injury (TBI). We evaluated whether receiving inpatient rehabilitation after acute hospitalization was associated with better functional outcomes compared to receiving only non-inpatient rehabilitation in children with severe TBI and explored an effect modification for Glasgow Coma Scale (GCS) score at hospital discharge. METHODS We included 254 children who received rehabilitation following severe TBI from a multinational observational study. The Pediatric Glasgow Outcome Scale - Extended (GOS-E Peds), parent/guardian-reported and child-reported Pediatric Quality of Life Inventory (PedsQL) at 12 months post-injury were assessed and described using summary statistics. Unadjusted and propensity score-weighted linear/ordinal logistic regression modeling were also performed. RESULTS 180 children received inpatient rehabilitation and 74 children received only non-inpatient rehabilitation after acute hospitalization. Among children with a GCS<13 at discharge, those receiving inpatient rehabilitation had a more favorable GOS-E Peds score (OR = 0.12, p = 0.045). However, no such association was observed in children with a higher GCS. We found no differences in PedsQL scores between rehabilitation groups. CONCLUSIONS Future studies are warranted to confirm the benefits of inpatient rehabilitation for children with more severely impaired consciousness when medically stable.
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Affiliation(s)
- Shiyao Gao
- Epidemiology Data Center, University of Pittsburgh, Pittsburgh, USA
| | - Amery Treble-Barna
- Department of Physical Medicine and Rehabilitation, University of Pittsburgh, Pittsburgh, USA
| | - Anthony Fabio
- Epidemiology Data Center, University of Pittsburgh, Pittsburgh, USA
| | - M. Kathleen Kelly
- Department of Physical Therapy, University of Pittsburgh, Pittsburgh, USA
| | - Sue R. Beers
- Department of Psychiatry, School of Medicine, University of Pittsburgh, Pittsburgh, USA
| | - Bedda L. Rosario
- Epidemiology Data Center, University of Pittsburgh, Pittsburgh, USA
| | - Michael J. Bell
- Department of Pediatrics, Division of Critical Care Medicine, Children’s National Hospital, Washington, D.C., USA
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Kennedy L, Nuno M, Gurkoff GG, Nosova K, Zwienenberg M. Moderate and severe TBI in children and adolescents: The effects of age, sex, and injury severity on patient outcome 6 months after injury. Front Neurol 2022; 13:741717. [PMID: 35989939 PMCID: PMC9382186 DOI: 10.3389/fneur.2022.741717] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2021] [Accepted: 06/14/2022] [Indexed: 11/13/2022] Open
Abstract
The interaction of age, sex, and outcomes of children with head injury remains incompletely understood and these factors need rigorous evaluation in prognostic models for pediatric head injury. We leveraged our large institutional pediatric TBI population to evaluate age and sex along with a series of predictive factors used in the acute care of injury to describe the response and outcome of children and adolescents with moderate to severe injury. We hypothesized that younger age at injury and male sex would be associated with adverse outcomes and that a novel GCS-based scale incorporating pupillary response (GCS-P) would have superior performance in predicting 6-month outcome. GCS and GCS-P along with established CT scan variables associated with neurologic outcomes were retrospectively reviewed in children (age birth to 18 years) with moderate or severe head injury. GOS-E was prospectively collected 6 months after injury; 570 patients were enrolled in the study, 520 with TBI and 50 with abusive head trauma, each analyzed separately. In the TBI cohort, the median age of patients was 8 years and 42.7% had a severe head injury. Multiple predictors of outcome were identified in univariate analysis; however, based on a multivariate analysis, the GCS was identified as most reliable, outperforming GCS-P, pupil score, and other clinical and CT scan predictors. After stratifying patients for severity of injury by GCS, no age- or sex-related effects were observed in our patient population, except for a trend toward worse outcomes in the neonatal group. Patients with abusive head trauma were more likely to have severe injury on presentation, increased mortality rate, and unfavorable outcome. Additionally, there was clear evidence that secondary injuries, including hypoxia, hypotension, and hypothermia were significantly associated with lower GCS and higher mortality in both AHT and TBI populations. Our findings support the use of GCS to guide clinical decision-making and prognostication in addition to emphasizing the need to stratify head injuries for severity when undertaking outcome studies. Finally, secondary injuries are a clear predictor of poor outcome and how we record and manage these events need to be considered moving forward.
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Affiliation(s)
- Lori Kennedy
- Center for Nursing Science, University of California Davis Health, Sacramento, CA, United States
| | - Miriam Nuno
- Public Health Sciences, Medical Sciences 1-C, University of California, Davis, Davis, CA, United States
| | - Gene G. Gurkoff
- Department of Neurological Surgery, University of California, Davis, Davis, CA, United States
- Center for Neuroscience, University of California, Davis, Davis, CA, United States
| | - Kristin Nosova
- Department of Neurological Surgery, University of California, Davis, Davis, CA, United States
| | - Marike Zwienenberg
- Department of Neurological Surgery, University of California, Davis, Davis, CA, United States
- *Correspondence: Marike Zwienenberg
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10
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Ferguson NM, Rebsamen S, Field AS, Guerrero JM, Rosario BL, Broman AT, Rathouz PJ, Bell MJ, Alexander AL, Ferrazzano PA. Magnetic Resonance Imaging Findings in Infants with Severe Traumatic Brain Injury and Associations with Abusive Head Trauma. CHILDREN (BASEL, SWITZERLAND) 2022; 9:children9071092. [PMID: 35884076 PMCID: PMC9322188 DOI: 10.3390/children9071092] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/08/2022] [Revised: 07/16/2022] [Accepted: 07/19/2022] [Indexed: 11/16/2022]
Abstract
Young children with severe traumatic brain injury (TBI) have frequently been excluded from studies due to age and/or mechanism of injury. Magnetic resonance imaging (MRI) is now frequently being utilized to detect parenchymal injuries and early cerebral edema. We sought to assess MRI findings in infants with severe TBI, and to determine the association between specific MRI findings and mechanisms of injury, including abusive head trauma (AHT). MRI scans performed within the first 30 days after injury were collected and coded according to NIH/NINDS Common Data Elements (CDEs) for Neuroimaging in subjects age < 2 years old with severe TBI enrolled in the Approaches and Decisions in Acute Pediatric Traumatic Brain Injury Trial. Demographics and injury characteristics were analyzed. A total of 81 children were included from ADAPT sites with MRI scans. Median age was 0.77 years and 57% were male. Most common MRI finding was ischemia, present in 57/81 subjects (70%), in a median of 7 brain regions per subject. Contusion 46/81 (57%) and diffuse axonal injury (DAI) 36/81 (44.4%) subjects followed. Children were dichotomized based on likelihood of AHT with 43/81 subjects classified as AHT. Ischemia was found to be significantly associated with AHT (p = 0.001) and “inflicted” injury mechanism (p = 0.0003). In conclusion, the most common intracerebral injury seen on MRI of infants with severe TBI was ischemia, followed by contusion and DAI. Ischemia was associated with AHT, and ischemia affecting > 4 brain regions was predictive of AHT.
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Affiliation(s)
- Nikki Miller Ferguson
- Department of Pediatrics, Virginia Commonwealth University, Richmond, VA 23298, USA;
| | - Susan Rebsamen
- Department of Radiology, University of Wisconsin, Madison, WI 53792, USA; (S.R.); (A.S.F.)
| | - Aaron S. Field
- Department of Radiology, University of Wisconsin, Madison, WI 53792, USA; (S.R.); (A.S.F.)
| | - Jose M. Guerrero
- Waisman Center, University of Wisconsin, Madison, WI 53705, USA; (J.M.G.); (A.L.A.)
- Department of Medical Physics, University of Wisconsin, Madison, WI 53705, USA
- Waisman Brain Imaging Laboratory, University of Wisconsin, Madison, WI 53705, USA
| | - Bedda L. Rosario
- Department of Epidemiology, School of Medicine, University of Pittsburgh, Pittsburgh, PA 15213, USA;
| | - Aimee T. Broman
- Department of Biostatistics and Medical Informatics, University of Wisconsin, Madison, WI 53705, USA;
| | - Paul J. Rathouz
- Department of Population Health, University of Texas at Austin Dell Medical School, Austin, TX 78712, USA;
| | - Michael J. Bell
- Department of Pediatrics, Children’s National Medical Center, Washington, DC 20010, USA;
| | - Andrew L. Alexander
- Waisman Center, University of Wisconsin, Madison, WI 53705, USA; (J.M.G.); (A.L.A.)
- Department of Medical Physics, University of Wisconsin, Madison, WI 53705, USA
- Waisman Brain Imaging Laboratory, University of Wisconsin, Madison, WI 53705, USA
- Department of Psychiatry, University of Wisconsin, Madison, WI 53705, USA
| | - Peter A. Ferrazzano
- Waisman Center, University of Wisconsin, Madison, WI 53705, USA; (J.M.G.); (A.L.A.)
- Department of Pediatrics, University of Wisconsin, Madison, WI 53705, USA
- Correspondence: ; Tel.: +1-608-265-4839
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11
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Bell MJ, Rosario BL, Kochanek PM, Adelson PD, Morris KP, Au AK, Schober M, Butt W, Edwards RJ, Zimmerman J, Pineda J, Le TM, Dean N, Whalen MJ, Figaji A, Luther J, Beers SR, Gupta DK, Carpenter J, Buttram S, Wisniewski SR. Comparative Effectiveness of Diversion of Cerebrospinal Fluid for Children With Severe Traumatic Brain Injury. JAMA Netw Open 2022; 5:e2220969. [PMID: 35802371 PMCID: PMC9270700 DOI: 10.1001/jamanetworkopen.2022.20969] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
IMPORTANCE Diversion of cerebrospinal fluid (CSF) has been used for decades as a treatment for children with severe traumatic brain injury (TBI) and is recommended by evidenced-based guidelines. However, these recommendations are based on limited studies. OBJECTIVE To determine whether CSF diversion is associated with improved Glasgow Outcome Score-Extended for Pediatrics (GOS-EP) and decreased intracranial pressure (ICP) in children with severe TBI. DESIGN, SETTING, AND PARTICIPANTS This observational comparative effectiveness study was performed at 51 clinical centers that routinely care for children with severe TBI in 8 countries (US, United Kingdom, Spain, the Netherlands, Australia, New Zealand, South Africa, and India) from February 2014 to September 2017, with follow-up at 6 months after injury (final follow-up, October 22, 2021). Children with severe TBI were included if they had Glasgow Coma Scale (GCS) scores of 8 or lower, had intracranial pressure (ICP) monitor placed on-site, and were aged younger than 18 years. Children were excluded if they were pregnant or an ICP monitor was not placed at the study site. Consecutive children were screened and enrolled, data regarding treatments were collected, and at discharge, consent was obtained for outcomes testing. Propensity matching for pretreatment characteristics was performed to develop matched pairs for primary analysis. Data analyses were completed on April 18, 2022. EXPOSURES Clinical care followed local standards, including the use of CSF diversion (or not), with patients stratified at the time of ICP monitor placement (CSF group vs no CSF group). MAIN OUTCOMES AND MEASURES The primary outcome was GOS-EP at 6 months, while ICP was considered as a secondary outcome. CSF vs no CSF was treated as an intention-to-treat analysis, and a sensitivity analysis was performed for children who received delayed CSF diversion. RESULTS A total of 1000 children with TBI were enrolled, including 314 who received CSF diversion (mean [SD] age, 7.18 [5.45] years; 208 [66.2%] boys) and 686 who did not (mean [SD] age, 7.79 [5.33] years; 437 [63.7%] boys). The propensity-matched analysis included 98 pairs. In propensity score-matched analyses, there was no difference between groups in GOS-EP (median [IQR] difference, 0 [-3 to 1]; P = .08), but there was a decrease in overall ICP in the CSF group (mean [SD] difference, 3.97 [0.12] mm Hg; P < .001). CONCLUSIONS AND RELEVANCE In this comparative effectiveness study, CSF diversion was not associated with improved outcome at 6 months after TBI, but a decrease in ICP was observed. Given the higher quality of evidence generated by this study, current evidence-based guidelines related to CSF diversion should be reconsidered.
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Affiliation(s)
- Michael J. Bell
- Division of Critical Care Medicine, Department of Pediatrics, Children’s National Medical Center, Washington, District of Columbia
| | - Bedda L. Rosario
- Department of Epidemiology, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Patrick M. Kochanek
- Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - P. David Adelson
- Barrow Neurological Institute at Phoenix Children’s Hospital, Phoenix, Arizona
| | - Kevin P. Morris
- Division of Pediatric Critical Care, Birmingham Children’s Hospital NHS Foundation, Birmingham, United Kingdom
| | - Alicia K. Au
- Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Michelle Schober
- Division of Pediatric Critical Care Medicine, University of Utah, Salt Lake City
| | - Warwick Butt
- Division of Pediatric Critical Care Medicine, The Royal Children’s Hospital, Melbourne, Australia
| | - Richard J. Edwards
- Division of Paediatric Neurosurgery, Bristol Royal Hospital for Children, Bristol, United Kingdom
| | - Jerry Zimmerman
- Division of Pediatric Critical Care Medicine, Harborview Medical Center, Seattle, Washington
| | - Jose Pineda
- Division of Pediatric Critical Care Medicine, St Louis Children’s Hospital, St Louis, Missouri
| | - Truc M. Le
- Division of Critical Care Medicine, Department of Pediatrics, Vanderbilt University, Nashville, Tennessee
| | - Nathan Dean
- Division of Critical Care Medicine, Department of Pediatrics, Children’s National Medical Center, Washington, District of Columbia
| | - Michael J. Whalen
- Division of Pediatric Critical Care Medicine, Massachusetts General Hospital, Boston
| | - Anthony Figaji
- Department of Neurosurgery, Red Cross War Memorial Children’s Hospital, Cape Town, South Africa
| | - James Luther
- Department of Epidemiology, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Sue R. Beers
- Department of Psychiatry, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Deepak K. Gupta
- Department of Neurosurgery, All India Institute of Medical Sciences, New Delhi, India
| | | | - Sandra Buttram
- Barrow Neurological Institute at Phoenix Children’s Hospital, Phoenix, Arizona
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12
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Rogers MB, Simon D, Firek B, Silfies L, Fabio A, Bell MJ, Yeh A, Azar J, Cheek R, Kochanek PM, Peddada SD, Morowitz MJ. Temporal and Spatial Changes in the Microbiome Following Pediatric Severe Traumatic Brain Injury. Pediatr Crit Care Med 2022; 23:425-434. [PMID: 35283451 PMCID: PMC9203870 DOI: 10.1097/pcc.0000000000002929] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES The microbiome may be affected by trauma and critical illness. Many studies of the microbiome in critical illness are restricted to a single body site or time point and confounded by preexisting conditions. We report temporal and spatial alterations in the microbiome of previously healthy children with severe traumatic brain injury (TBI). DESIGN We collected oral, rectal, and skin swabs within 72 hours of admission and then twice weekly until ICU discharge. Samples were analyzed by 16S rRNA gene amplicon sequencing. Children undergoing elective outpatient surgery served as controls. Alpha and beta diversity comparisons were performed with Phyloseq, and differentially abundant taxa were predicted using Analysis of Composition of Microbiomes. SETTING Five quaternary-care PICUs. PATIENTS Patients less than 18 years with severe TBI requiring placement of an intracranial pressure monitor. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Three hundred twenty-seven samples were analyzed from 23 children with severe TBI and 35 controls. The community composition of initial oral (F = 3.2756, R2 = 0.0535, p = 0.012) and rectal (F = 3.0702, R2 = 0.0649, p = 0.007) samples differed between TBI and control patients. Rectal samples were depleted of commensal bacteria from Ruminococcaceae, Bacteroidaceae, and Lachnospiraceae families and enriched in Staphylococcaceae after TBI (p < 0.05). In exploratory analyses, antibiotic exposure, presence of an endotracheal tube, and occurrence of an infection were associated with greater differences of the rectal and oral microbiomes between TBI patients and healthy controls, whereas enteral nutrition was associated with smaller differences (p < 0.05). CONCLUSIONS The microbiome of children with severe TBI is characterized by early depletion of commensal bacteria, loss of site specificity, and an enrichment of potential pathogens. Additional studies are needed to determine the impact of these changes on clinical outcomes.
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Affiliation(s)
- Matthew B. Rogers
- Department of Surgery, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Dennis Simon
- Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
- Department of Pediatrics, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
- Safar Center for Resuscitation Research, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
- UPMC Children’s Hospital of Pittsburgh Neuroscience Institute, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Brian Firek
- Department of Surgery, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Laurie Silfies
- Department of Biostatistics, University of Pittsburgh Graduate School of Public Health, Pittsburgh, PA, USA
| | - Anthony Fabio
- Department of Biostatistics, University of Pittsburgh Graduate School of Public Health, Pittsburgh, PA, USA
| | - Michael J. Bell
- Division of Critical Care Medicine, Children’s National Medical Center, Washington, DC, USA
| | - Andrew Yeh
- Department of Surgery, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Justin Azar
- Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
- Department of Pediatrics, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Richard Cheek
- Department of Surgery, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Patrick M. Kochanek
- Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
- Safar Center for Resuscitation Research, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
- UPMC Children’s Hospital of Pittsburgh Neuroscience Institute, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Shyamal D. Peddada
- Department of Biostatistics, University of Pittsburgh Graduate School of Public Health, Pittsburgh, PA, USA
| | - Michael J. Morowitz
- Department of Surgery, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
- Center for Microbiome and Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
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13
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Kochanek PM, Adelson PD, Rosario BL, Hutchison J, Miller Ferguson N, Ferrazzano P, O’Brien N, Beca J, Sarnaik A, LaRovere K, Bennett TD, Deep A, Gupta D, Willyerd FA, Gao S, Wisniewski SR, Bell MJ. Comparison of Intracranial Pressure Measurements Before and After Hypertonic Saline or Mannitol Treatment in Children With Severe Traumatic Brain Injury. JAMA Netw Open 2022; 5:e220891. [PMID: 35267036 PMCID: PMC8914575 DOI: 10.1001/jamanetworkopen.2022.0891] [Citation(s) in RCA: 21] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
IMPORTANCE Hyperosmolar agents are cornerstone therapies for pediatric severe traumatic brain injury. Guideline recommendations for 3% hypertonic saline (HTS) are based on limited numbers of patients, and no study to date has supported a recommendation for mannitol. OBJECTIVES To characterize current use of hyperosmolar agents in pediatric severe traumatic brain injury and assess whether HTS or mannitol is associated with greater decreases in intracranial pressure (ICP) and/or increases in cerebral perfusion pressure (CPP). DESIGN, SETTING, AND PARTICIPANTS In this comparative effectiveness research study, 1018 children were screened and 18 were excluded; 787 children received some form of hyperosmolar therapy during the ICP-directed phase of care, with 521 receiving a bolus. Three of these children were excluded because they had received only bolus administration of both HTS and mannitol in the same hour, leaving 518 children (at 44 clinical sites in 8 countries) for analysis. The study was conducted from February 1, 2014, to September 31, 2017, with follow-up for 1 week after injury. Final analysis was performed July 20, 2021. INTERVENTIONS Boluses of HTS and mannitol were administered. MAIN OUTCOMES AND MEASURES Data on ICP and CPP were collected before and after medication administration. Statistical methods included linear mixed models and corrections for potential confounding variables to compare the 2 treatments. RESULTS A total of 518 children (mean [SD] age, 7.6 [5.4] years; 336 [64.9%] male; 274 [52.9%] White) were included. Participants' mean (SD) Glasgow Coma Scale score was 5.2 (1.8). Bolus HTS was observed to decrease ICP and increase CPP (mean [SD] ICP, 1.03 [6.77] mm Hg; P < .001; mean [SD] CPP, 1.25 [12.47] mm Hg; P < .001), whereas mannitol was observed to increase CPP (mean [SD] CPP, 1.20 [11.43] mm Hg; P = .009). In the primary outcome, HTS was associated with a greater reduction in ICP compared with mannitol (unadjusted β, -0.85; 95% CI, -1.53 to -0.19), but no association was seen after adjustments (adjusted β, -0.53; 95% CI, -1.32 to 0.25; P = .18). No differences in CPP were observed. When ICP was greater than 20 mm Hg, greater than 25 mm Hg, or greater than 30 mm Hg, HTS outperformed mannitol for each threshold in observed ICP reduction (>20 mm Hg: unadjusted β, -2.51; 95% CI, -3.86 to -1.15, P < .001; >25 mm Hg: unadjusted β, -3.88; 95% CI, -5.69 to -2.06, P < .001; >30 mm Hg: unadjusted β, -4.07; 95% CI, -6.35 to -1.79, P < .001), with results remaining significant for ICP greater than 25 mm Hg in adjusted analysis. CONCLUSIONS AND RELEVANCE In this comparative effectiveness research study, bolus HTS was associated with lower ICP and higher CPP, whereas mannitol was associated only with higher CPP. After adjustment for confounders, both therapies showed no association with ICP and CPP. During ICP crises, HTS was associated with better performance than mannitol.
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Affiliation(s)
- Patrick M. Kochanek
- Department of Critical Care Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - P. David Adelson
- Barrow Neurological Institute at Phoenix Children’s Hospital, Phoenix, Arizona
| | - Bedda L. Rosario
- Department of Epidemiology, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - James Hutchison
- Department of Critical Care Medicine, Toronto Sick Children’s Hospital, Toronto, Ontario, Canada
| | - Nikki Miller Ferguson
- Department of Pediatrics, Virginia Commonwealth University School of Medicine, Richmond
| | - Peter Ferrazzano
- Department of Pediatrics, University of Wisconsin School of Medicine, Madison
| | - Nicole O’Brien
- Department of Pediatrics, The Ohio State University School of Medicine, Columbus
| | - John Beca
- Department of Pediatrics, Starship Children’s Hospital, Auckland, New Zealand
| | - Ajit Sarnaik
- Department of Pediatrics, Wayne State University, Detroit, Michigan
| | - Kerri LaRovere
- Department of Neurology, Boston Children’s Hospital, Boston, Massachusetts
| | - Tellen D. Bennett
- Department of Pediatrics, University of Colorado School of Medicine, Aurora
| | - Akash Deep
- Department of Pediatrics, King’s College Hospital NHS Foundation Trust, London, UK
| | - Deepak Gupta
- Department of Neurosurgery, All India Institute of Medical Sciences, New Delhi
| | - F. Anthony Willyerd
- Barrow Neurological Institute at Phoenix Children’s Hospital, Phoenix, Arizona
| | - Shiyao Gao
- Department of Epidemiology, University of Pittsburgh, Pittsburgh, Pennsylvania
| | | | - Michael J. Bell
- Department of Pediatrics, Children’s National Hospital, Washington, DC
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14
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Weiss R, He CH, Khan S, Parsikia A, Mbekeani JN. Ocular Injuries in Pediatric Patients Admitted With Abusive Head Trauma. Pediatr Neurol 2022; 127:11-18. [PMID: 34922138 DOI: 10.1016/j.pediatrneurol.2021.11.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/12/2021] [Revised: 11/03/2021] [Accepted: 11/06/2021] [Indexed: 10/19/2022]
Abstract
BACKGROUND Pediatric abusive head trauma (AHT) refers to head injury from intentional blunt force or violent shaking in children aged five years or less. We sought to evaluate the epidemiology of ocular injuries in AHT. METHODS This retrospective analysis of the National Trauma Data Bank (2008 to 2014) identified children aged five years or less with AHT and ocular injuries using ICD-9-CM codes. Demographic data, types of ocular and nonocular/head injuries, geographic location, length of hospital admission, injury severity, and Glasgow Coma scores were tabulated and analyzed. RESULTS A total of 10,545 children were admitted with AHT, and 2550 (24.2%) had associated ocular injuries; 58.7% were female. The mean age was 0.5 (±1.0) years. Most (85.7%) were aged one year or less. Common ocular injuries included contusion of eye/adnexa (73.7%) and retinal edema (59.3%), and common head injuries were subdural hemorrhage (SDH) (72.8%) and subarachnoid hemorrhage (22.9%). Retinal hemorrhages occurred in 5.3%. About 42.8% of children had injury severity scores greater than 24 (very severe), and the mortality rate was 19.2%. Children aged one year or less had the greatest odds of retinal hemorrhages (odds ratio [OR] = 2.44; P = 0.008) and SDH (OR = 1.55; P < 0.001), and the two- to three-year-old group had the greatest odds of contusions (OR = 1.68; P = 0.001), intracerebral hemorrhages (OR = 1.55; P = 0.002), and mortality (OR = 1.78; P < 0.001). For all ages, SDH occurred most frequently with retinal edema compared with other ocular injuries (OR = 2.25; P < 0.001). CONCLUSIONS AND RELEVANCE Ocular injuries varied with age and were variably associated with nonocular injury. The youngest group was most frequently affected; however, the two- to three-year-old group was most likely to succumb to injuries.
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Affiliation(s)
- Rebecca Weiss
- Department of Ophthalmology & Visual Sciences, Montefiore Medical Center, Bronx, New York; Albert Einstein College of Medicine, Bronx, New York
| | | | - Sabine Khan
- Department of Ophthalmology & Visual Sciences, Montefiore Medical Center, Bronx, New York; Albert Einstein College of Medicine, Bronx, New York
| | - Afshin Parsikia
- Department of Surgery (Trauma), Jacobi Medical Center, Bronx, New York; Research Services, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Joyce N Mbekeani
- Albert Einstein College of Medicine, Bronx, New York; Department of Surgery (Ophthalmology), Jacobi Medical Center, Bronx, New York.
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15
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Gao S, Fabio A, Rosario BL, Kelly MK, Beers SR, Bell MJ, Wisniewski SR. Characteristics Associated with the Use of an Inpatient Rehabilitation or Skilled Nursing Facility after Acute Care in Children with Severe Traumatic Brain Injury. Dev Neurorehabil 2021; 24:466-477. [PMID: 33872126 PMCID: PMC8429094 DOI: 10.1080/17518423.2021.1908441] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
To characterize inpatient rehabilitation services for children with severe traumatic brain injury (TBI), we included 254 children, whose parents/guardians reported receipt of rehabilitation within a 12-month follow-up period, from a multinational observational study. Children discharged to an inpatient rehabilitation or skilled nursing facility after acute care were classified into the "inpatient rehabilitation" group, and children discharged home after acute care were classified into the "non-inpatient rehabilitation" group. Multivariable regression analyses determined the associations of sociodemographic and clinical characteristics with rehabilitation groups. Children receiving inpatient rehabilitation had a shorter length of acute hospitalization. Children from the UK were less likely to receive inpatient rehabilitation compared to children from the US. Future studies are warranted to extend current findings by identifying the reasons behind differential access to inpatient rehabilitation among children with severe TBI.
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Affiliation(s)
- Shiyao Gao
- Epidemiology Data Center, University of Pittsburgh
| | | | | | | | - Sue R. Beers
- Department of Psychiatry, University of Pittsburgh
| | - Michael J. Bell
- Department of Pediatrics, Division of Critical Care Medicine, Children’s National Hospital
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16
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Recidivism following childhood maltreatment necessitating inpatient care in the United States. Am J Surg 2021; 223:774-779. [PMID: 34325911 DOI: 10.1016/j.amjsurg.2021.07.039] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2021] [Revised: 06/06/2021] [Accepted: 07/20/2021] [Indexed: 11/22/2022]
Abstract
INTRODUCTION Non-accidental trauma (NAT) is one of the common causes of injury in children in the United States (US). Abuse and maltreatment affect 2 per 100,000 children annually and may go unrecognized. The aim of this study to quantify the recidivistic nature of NAT in the US pediatric population. METHODS The National Readmissions Database (2007-2015) was queried for pediatric (≤18y) trauma patients. Children presenting for non-accidental trauma were further identified. Data was obtained on demographic, clinical, and hospital-level characteristics. Body regions with an Abbreviated Injury Scale (AIS) greater than three were further identified. Multivariable logistic regression analysis (adjusting for age, gender, insurance status, year, Injury Severity Score [ISS], hospital region, and mechanism of injury) was utilized to determine factors influencing unintentional and intentional (assault) non-accidental traumatic injuries. RESULTS NAT represents 1.6% (n = 4,634/286,508) of all pediatric trauma. The median age of presentation was <1y [IQR:0-3] with a male predominance (56.2%). Median ISS was 9 [IQR:2-16]. 87.5% of incidents represented assault (intentional). The most commonly affected body region was the head and neck (32.8%), followed by the extremities (11.4%) and soft tissue trauma or burns (6.3%). Penetrating trauma accounted for 18% of these injuries. 3.2% were readmitted to the hospital for a recurrent episode. 85.5% presented to the hospital for their initial evaluation. Mortality rates were 3.8% for those re-admitted to the hospital. The most common perpetrators were other specified persons known to the family, followed by fathers and mothers. CONCLUSION Although uncommon, recidivism, after an initial episode of NAT, can have devastating consequences. The majority of the perpetrators of abuse are individuals known to the patient or family. Health policy aimed towards developing preventative strategies is needed to facilitate early recognition and tackle abuse in children. LEVEL OF EVIDENCE III. TYPE OF EVIDENCE Case Control Study.
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Pennell C, Aundhia M, Malik A, Poletto E, Grewal H, Atkinson N. Utility of skull radiographs in infants undergoing 3D head CT during evaluation for physical abuse. J Pediatr Surg 2021; 56:1180-1184. [PMID: 33771371 DOI: 10.1016/j.jpedsurg.2021.02.037] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/16/2021] [Accepted: 02/05/2021] [Indexed: 10/22/2022]
Abstract
BACKGROUND Clinical practice guidelines recommend performing head CT and skull radiographs (SR) when evaluating infants for physical abuse. We compared the accuracy of 3-dimensional CT (3DCT) and SR for detecting skull fractures. METHODS We reviewed children <12 months evaluated for physical abuse undergoing 3DCT and SR between January 2017 and December 2018. 3DCT and SR images were blindly read by 2 radiologists. Interrater reliability (IRR) was calculated. Diagnostic accuracy was compared using McNemar's test. RESULTS 158 infants with a mean age of 5.0 months underwent 3DCT and SR. Consensus reading identified 46 fractures (29.1%) on 3DCT and 40 fractures (25.3%) on SR. IRR was higher for 3DCT (κ = 0.95) than for SR (=0.65). 11 fractures were identified on 3DCT but not SR. 5 fractures were identified on SR but not 3DCT. There was no difference in the diagnostic accuracy of 3DCT and SR (χ2 = 1.56, p = 0.211). CONCLUSIONS We found no difference in the accuracy of 3DCT and SR for detecting skull fractures in infants. Because 3DCT has better IRR and evaluates for both bony and intracranial injuries it is superior to SR. Omitting SRs may be acceptable if a 3DCT is performed, and would reduce radiation exposure without compromising diagnostic accuracy.
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Affiliation(s)
- Christopher Pennell
- St. Christopher's Hospital for Children, Department of General, Thoracic, and Minimally Invasive Surgery, 160 East Erie Avenue, Philadelphia, PA 19123, USA.
| | - Minal Aundhia
- Sidney Kimmel Medical College, Thomas Jefferson University 1025 Walnut St, Philadelphia, PA 19107, USA
| | - Archana Malik
- St. Christopher's Hospital for Children, Department of Radiology, 160 East Erie Avenue, Philadelphia, PA 19123, USA; Drexel University College of Medicine, 2900 West Queen Lane, Philadelphia PA 19129, USA
| | - Erica Poletto
- St. Christopher's Hospital for Children, Department of Radiology, 160 East Erie Avenue, Philadelphia, PA 19123, USA; Drexel University College of Medicine, 2900 West Queen Lane, Philadelphia PA 19129, USA
| | - Harsh Grewal
- St. Christopher's Hospital for Children, Department of General, Thoracic, and Minimally Invasive Surgery, 160 East Erie Avenue, Philadelphia, PA 19123, USA; Drexel University College of Medicine, 2900 West Queen Lane, Philadelphia PA 19129, USA
| | - Norrell Atkinson
- Drexel University College of Medicine, 2900 West Queen Lane, Philadelphia PA 19129, USA; St. Christopher's Hospital for Children, Child Protection Program, 160 East Erie Avenue, Philadelphia, PA 19123, USA
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18
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Maiese A, Iannaccone F, Scatena A, Del Fante Z, Oliva A, Frati P, Fineschi V. Pediatric Abusive Head Trauma: A Systematic Review. Diagnostics (Basel) 2021; 11:diagnostics11040734. [PMID: 33924220 PMCID: PMC8074611 DOI: 10.3390/diagnostics11040734] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2021] [Revised: 04/16/2021] [Accepted: 04/19/2021] [Indexed: 02/03/2023] Open
Abstract
Abusive head trauma (AHT) represents a commonly misdiagnosed condition. In fact, there is no pathognomonic sign that allows the diagnosis in children. Therefore, it is such an important medico-legal challenge to evaluate reliable diagnostic tools. The aim of this review is to evaluate the current scientific evidence to assess what the best practice is in order to diagnose AHT. We have focused particularly on evaluating the importance of circumstantial evidence, clinical history, the use of postmortem radiological examinations (such as CT and MRI), and the performance of the autopsy. After autopsy, histological examination of the eye and brain play an important role, with attention paid to correlation with symptoms found in vivo.
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Affiliation(s)
- Aniello Maiese
- Department of Surgical Pathology, Medical, Molecular and Critical Area, Institute of Legal Medicine, University of Pisa, 56126 Pisa, Italy; (A.M.); (F.I.); (A.S.)
- IRCSS Neuromed Mediterranean Neurological Institute, Via Atinense 18, 86077 Pozzilli, Italy;
| | - Francesca Iannaccone
- Department of Surgical Pathology, Medical, Molecular and Critical Area, Institute of Legal Medicine, University of Pisa, 56126 Pisa, Italy; (A.M.); (F.I.); (A.S.)
| | - Andrea Scatena
- Department of Surgical Pathology, Medical, Molecular and Critical Area, Institute of Legal Medicine, University of Pisa, 56126 Pisa, Italy; (A.M.); (F.I.); (A.S.)
| | - Zoe Del Fante
- Department of Anatomical, Histological, Forensic and Orthopaedic Sciences, Sapienza University of Rome, Viale Regina Elena 336, 00161 Rome, Italy;
| | - Antonio Oliva
- Department of Health Surveillance and Bioethics, Section of Legal Medicine, Catholic University, Fondazione Policlinico A. Gemelli IRCCS, 00100 Rome, Italy;
| | - Paola Frati
- IRCSS Neuromed Mediterranean Neurological Institute, Via Atinense 18, 86077 Pozzilli, Italy;
- Department of Anatomical, Histological, Forensic and Orthopaedic Sciences, Sapienza University of Rome, Viale Regina Elena 336, 00161 Rome, Italy;
| | - Vittorio Fineschi
- IRCSS Neuromed Mediterranean Neurological Institute, Via Atinense 18, 86077 Pozzilli, Italy;
- Department of Anatomical, Histological, Forensic and Orthopaedic Sciences, Sapienza University of Rome, Viale Regina Elena 336, 00161 Rome, Italy;
- Correspondence: ; Tel.: +39-064-991-2722
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19
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Chong SL, Dang H, Ming M, Mahmood M, Zheng CQS, Gan CS, Lee OPE, Ji J, Chan LCN, Ong JSM, Kurosawa H, Lee JH. Traumatic Brain Injury Outcomes in 10 Asian Pediatric ICUs: A Pediatric Acute and Critical Care Medicine Asian Network Retrospective Study. Pediatr Crit Care Med 2021; 22:401-411. [PMID: 33027240 DOI: 10.1097/pcc.0000000000002575] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
OBJECTIVES Traumatic brain injury remains an important cause of death and disability. We aim to report the epidemiology and management of moderate to severe traumatic brain injury in Asian PICUs and identify risk factors for mortality and poor functional outcomes. DESIGN A retrospective study of the Pediatric Acute and Critical Care Medicine Asian Network moderate to severe traumatic brain injury dataset collected between 2014 and 2017. SETTING Patients were from the participating PICUs of Pediatric Acute and Critical Care Medicine Asian Network. PATIENTS We included children less than 16 years old with a Glasgow Coma Scale less than or equal to 13. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS We obtained data on patient demographics, injury circumstances, and PICU management. We performed a multivariate logistic regression predicting for mortality and poor functional outcomes. We analyzed 380 children with moderate to severe traumatic brain injury. Most injuries were a result of road traffic injuries (174 [45.8%]) and falls (160 [42.1%]). There were important differences in temperature control, use of antiepileptic drugs, and hyperosmolar agents between the sites. Fifty-six children died (14.7%), and 104 of 324 survivors (32.1%) had poor functional outcomes. Poor functional outcomes were associated with non-high-income sites (adjusted odds ratio, 1.90; 95% CI, 1.11-3.29), Glasgow Coma Scale less than 8 (adjusted odds ratio, 4.24; 95% CI, 2.44-7.63), involvement in a road traffic collision (adjusted odds ratio, 1.83; 95% CI, 1.04-3.26), and presence of child abuse (adjusted odds ratio, 2.75; 95% CI, 1.01-7.46). CONCLUSIONS Poor functional outcomes are prevalent after pediatric traumatic brain injury in Asia. There is an urgent need for further research in these high-risk groups.
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Affiliation(s)
- Shu-Ling Chong
- Department of Emergency Medicine, KK Women's and Children's Hospital, Singapore
- Duke-NUS Medical School, Singapore
| | - Hongxing Dang
- Department of Pediatric Intensive Care Unit, Children's Hospital of Chongqing Medical University, Chongqing, China
| | - Meixiu Ming
- Department of Pediatric Intensive Care Unit, Children's Hospital of Fudan University, Shanghai, China
| | - Maznisah Mahmood
- Department of Paediatrics, Institute of Paediatric, Kuala Lumpur, Malaysia
| | - Charles Q S Zheng
- Department of Epidemiology, Singapore Clinical Research Institute, Singapore
| | - Chin Seng Gan
- Department of Paediatrics, University Malaya Medical Centre, Kuala Lumpur, Malaysia
| | - Olive P E Lee
- Department of Paediatrics, Sarawak General Hospital, Sarawak, Malaysia
| | - Jian Ji
- Department of Pediatric Intensive Care Unit, Beijing Children's Hospital, Capital Medical University, Beijing, China
| | - Lawrence C N Chan
- Department of Paediatrics, Prince of Wales Hospital, The Chinese University of Hong Kong, Hong Kong
| | - Jacqueline S M Ong
- Khoo Teck Puat National University Children's Medical Institute, National University Hospital, Singapore
- Department of Paediatrics, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Hiroshi Kurosawa
- Department of Pediatric Critical Care Medicine, Hyogo Prefectural Kobe Children's Hospital, Kobe, Japan
| | - Jan Hau Lee
- Duke-NUS Medical School, Singapore
- Children's Intensive Care Unit, KK Women's and Children's Hospital, Singapore
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20
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Zusman BE, Kochanek PM, Bell MJ, Adelson PD, Wisniewski SR, Au AK, Clark RSB, Bayır H, Janesko-Feldman K, Jha RM. Cerebrospinal Fluid Sulfonylurea Receptor-1 is Associated with Intracranial Pressure and Outcome after Pediatric TBI: An Exploratory Analysis of the Cool Kids Trial. J Neurotrauma 2021; 38:1615-1619. [PMID: 33430695 DOI: 10.1089/neu.2020.7501] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023] Open
Abstract
Sulfonylurea receptor-1 (SUR1) is recognized increasingly as a key contributor to cerebral edema, hemorrhage progression, and possibly neuronal death in multiple forms of acute brain injury. SUR1 inhibition may be protective and is actively undergoing evaluation in Phase-2/3 trials of traumatic brain injury (TBI) and stroke. In adult TBI, SUR1 expression is associated with intracranial hypertension and contusion expansion; its role in pediatric TBI remains unexplored. We tested 61 cerebrospinal fluid (CSF) samples from 16 pediatric patients with severe TBI enrolled in the multicenter Phase-3 randomized controlled "Cool Kids" trial and seven non-brain injured pediatric controls for SUR1 expression by enzyme-linked immunosorbent assay. Linear mixed models evaluated associations between mean SUR1 and intracranial pressure (ICP) over the first seven days and pediatric Glasgow Outcome Scale-Extended (GOS-E Peds) over the initial year after injury. SUR1 was undetectable in control CSF and increased versus control in nine of 16 patients with TBI. Mean SUR1 was not associated with age, sex, or therapeutic hypothermia. Each 1-point increase in initial Glasgow Coma Score was associated with a 1.68 ng/mL decrease in CSF SUR1. The CSF SUR1 was associated with increased ICP over seven days (b = 0.73, p = 0.004) and worse (higher) GOS-E Peds score (b = 0.24, p = 0.004). In this exploratory pediatric study, CSF SUR1 was undetectable in controls and variably elevated in severe TBI. Mean CSF SUR1 concentration was associated with ICP and outcome. These findings are distinct from our previous report in adults with severe TBI, where SUR1 was detected universally. SUR1 may be a viable therapeutic target in a subset of pediatric TBI, and further study is warranted.
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Affiliation(s)
- Benjamin E Zusman
- Department of Neurosurgery, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA.,Department of Clinical and Translational Science Institute, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA.,Institute for Clinical Research Education, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Patrick M Kochanek
- Department of Clinical and Translational Science Institute, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA.,Department of Anesthesiology, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA.,Department of Pediatrics, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA.,Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA.,UPMC Children's Hospital of Pittsburgh, UPMC, Pittsburgh, Pennsylvania, USA.,Safar Center for Resuscitation Research, John G. Rangos Research Center, Pittsburgh, Pennsylvania, USA
| | | | - P David Adelson
- Barrow Neurological Institute at Phoenix Children's Hospital, Phoenix, Arizona, USA
| | - Stephen R Wisniewski
- University of Pittsburgh Graduate School of Publich Health, Pittsburgh, Pennsylvania, USA
| | - Alicia K Au
- Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Robert S B Clark
- Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA.,Safar Center for Resuscitation Research, John G. Rangos Research Center, Pittsburgh, Pennsylvania, USA
| | - Hülya Bayır
- Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA.,Safar Center for Resuscitation Research, John G. Rangos Research Center, Pittsburgh, Pennsylvania, USA
| | - Keri Janesko-Feldman
- Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA.,Safar Center for Resuscitation Research, John G. Rangos Research Center, Pittsburgh, Pennsylvania, USA
| | - Ruchira M Jha
- Department of Neurosurgery, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA.,Department of Clinical and Translational Science Institute, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA.,Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA.,Institute for Clinical Research Education, University of Pittsburgh, Pittsburgh, Pennsylvania, USA.,Safar Center for Resuscitation Research, John G. Rangos Research Center, Pittsburgh, Pennsylvania, USA
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21
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Kochanek PM, Jackson TC, Jha RM, Clark RS, Okonkwo DO, Bayır H, Poloyac SM, Wagner AK, Empey PE, Conley YP, Bell MJ, Kline AE, Bondi CO, Simon DW, Carlson SW, Puccio AM, Horvat CM, Au AK, Elmer J, Treble-Barna A, Ikonomovic MD, Shutter LA, Taylor DL, Stern AM, Graham SH, Kagan VE, Jackson EK, Wisniewski SR, Dixon CE. Paths to Successful Translation of New Therapies for Severe Traumatic Brain Injury in the Golden Age of Traumatic Brain Injury Research: A Pittsburgh Vision. J Neurotrauma 2020; 37:2353-2371. [PMID: 30520681 PMCID: PMC7698994 DOI: 10.1089/neu.2018.6203] [Citation(s) in RCA: 29] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
New neuroprotective therapies for severe traumatic brain injury (TBI) have not translated from pre-clinical to clinical success. Numerous explanations have been suggested in both the pre-clinical and clinical arenas. Coverage of TBI in the lay press has reinvigorated interest, creating a golden age of TBI research with innovative strategies to circumvent roadblocks. We discuss the need for more robust therapies. We present concepts for traditional and novel approaches to defining therapeutic targets. We review lessons learned from the ongoing work of the pre-clinical drug and biomarker screening consortium Operation Brain Trauma Therapy and suggest ways to further enhance pre-clinical consortia. Biomarkers have emerged that empower choice and assessment of target engagement by candidate therapies. Drug combinations may be needed, and it may require moving beyond conventional drug therapies. Precision medicine may also link the right therapy to the right patient, including new approaches to TBI classification beyond the Glasgow Coma Scale or anatomical phenotyping-incorporating new genetic and physiologic approaches. Therapeutic breakthroughs may also come from alternative approaches in clinical investigation (comparative effectiveness, adaptive trial design, use of the electronic medical record, and big data). The full continuum of care must also be represented in translational studies, given the important clinical role of pre-hospital events, extracerebral insults in the intensive care unit, and rehabilitation. TBI research from concussion to coma can cross-pollinate and further advancement of new therapies. Misconceptions can stifle/misdirect TBI research and deserve special attention. Finally, we synthesize an approach to deliver therapeutic breakthroughs in this golden age of TBI research.
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Affiliation(s)
- Patrick M. Kochanek
- Safar Center for Resuscitation Research, UPMC Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania, USA
- Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Travis C. Jackson
- Safar Center for Resuscitation Research, UPMC Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania, USA
- Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Ruchira M. Jha
- Safar Center for Resuscitation Research, UPMC Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania, USA
- Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Robert S.B. Clark
- Safar Center for Resuscitation Research, UPMC Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania, USA
- Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - David O. Okonkwo
- Department of Neurological Surgery, UPMC Presbyterian Hospital, Pittsburgh, Pennsylvania, USA
| | - Hülya Bayır
- Safar Center for Resuscitation Research, UPMC Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania, USA
- Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
- Department of Environmental and Occupational Health, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Samuel M. Poloyac
- Safar Center for Resuscitation Research, UPMC Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania, USA
- University of Pittsburgh School of Pharmacy, Pittsburgh, Pennsylvania, USA
| | - Amy K. Wagner
- Safar Center for Resuscitation Research, UPMC Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania, USA
- Department of Physical Medicine and Rehabilitation, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Philip E. Empey
- Safar Center for Resuscitation Research, UPMC Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania, USA
- Pharmacy and Therapeutics, University of Pittsburgh School of Pharmacy, Pittsburgh, Pennsylvania, USA
| | - Yvette P. Conley
- Health Promotion and Development, University of Pittsburgh School of Nursing, Pittsburgh, Pennsylvania, USA
| | - Michael J. Bell
- Department of Critical Care Medicine, Children's National Medical Center, Washington, DC, USA
| | - Anthony E. Kline
- Safar Center for Resuscitation Research, UPMC Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania, USA
- Department of Physical Medicine and Rehabilitation, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Corina O. Bondi
- Safar Center for Resuscitation Research, UPMC Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania, USA
- Department of Physical Medicine and Rehabilitation, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Dennis W. Simon
- Safar Center for Resuscitation Research, UPMC Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania, USA
- Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Shaun W. Carlson
- Safar Center for Resuscitation Research, UPMC Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania, USA
- Department of Neurological Surgery, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Ava M. Puccio
- Department of Neurological Surgery, UPMC Presbyterian Hospital, Pittsburgh, Pennsylvania, USA
| | - Christopher M. Horvat
- Safar Center for Resuscitation Research, UPMC Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania, USA
- Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Alicia K. Au
- Safar Center for Resuscitation Research, UPMC Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania, USA
- Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Jonathan Elmer
- Departments of Emergency Medicine and Critical Care Medicine, University of Pittsburgh School of Medicine, UPMC Presbyterian Hospital, Pittsburgh, Pennsylvania, USA
| | - Amery Treble-Barna
- Safar Center for Resuscitation Research, UPMC Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania, USA
- Department of Physical Medicine and Rehabilitation, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Milos D. Ikonomovic
- Department of Psychiatry, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
- Department of Neurology, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Lori A. Shutter
- Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - D. Lansing Taylor
- University of Pittsburgh Drug Discovery Institute, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Andrew M. Stern
- Drug Discovery Institute, Department of Computational and Systems Biology, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Steven H. Graham
- Geriatric Research Education and Clinical Center, VA Pittsburgh Healthcare System, Pittsburgh, Pennsylvania, USA
- Department of Neurology, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Valerian E. Kagan
- Department of Environmental and Occupational Health, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Edwin K. Jackson
- Department of Pharmacology and Chemical Biology, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Stephen R. Wisniewski
- University of Pittsburgh Graduate School of Public Health, Pittsburgh, Pennsylvania, USA
| | - C. Edward Dixon
- Department of Neurological Surgery, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
- Geriatric Research Education and Clinical Center, VA Pittsburgh Healthcare System, Pittsburgh, Pennsylvania, USA
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22
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Affiliation(s)
- Patrick M Kochanek
- Department of Critical Care Medicine, Safar Center for Resuscitation Research, John G. Rangos Research Center, UPMC Children's Hospital of Pittsburgh, University of Pittsburgh School of Medicine, 6th Floor, 4401 Penn Avenue, Pittsburgh, PA, 15224, USA.
- Department of Pediatrics, UPMC Children's Hospital of Pittsburgh, University of Pittsburgh School of Medicine, 4401 Penn Avenue, Pittsburgh, PA, USA.
| | - Ruchira M Jha
- Department of Critical Care Medicine, Safar Center for Resuscitation Research, John G. Rangos Research Center, UPMC Children's Hospital of Pittsburgh, University of Pittsburgh School of Medicine, 6th Floor, 4401 Penn Avenue, Pittsburgh, PA, 15224, USA
- Department of Neurosurgery, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
- Department of Neurology, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
- Clinical and Translational Science Institute, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Robert S B Clark
- Department of Critical Care Medicine, Safar Center for Resuscitation Research, John G. Rangos Research Center, UPMC Children's Hospital of Pittsburgh, University of Pittsburgh School of Medicine, 6th Floor, 4401 Penn Avenue, Pittsburgh, PA, 15224, USA
- Department of Pediatrics, UPMC Children's Hospital of Pittsburgh, University of Pittsburgh School of Medicine, 4401 Penn Avenue, Pittsburgh, PA, USA
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23
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Hung KL. Pediatric abusive head trauma. Biomed J 2020; 43:240-250. [PMID: 32330675 PMCID: PMC7424091 DOI: 10.1016/j.bj.2020.03.008] [Citation(s) in RCA: 31] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2020] [Revised: 03/05/2020] [Accepted: 03/16/2020] [Indexed: 02/08/2023] Open
Abstract
Abusive head trauma (AHT), used to be named shaken baby syndrome, is an injury to the skull and intracranial components of a baby or child younger than 5 years due to violent shaking and/or abrupt impact. It is a worldwide leading cause of fatal head injuries in children under 2 years. The mechanism of AHT includes shaking as well as impact, crushing or their various combinations through acceleration, deceleration and rotational force. The diagnosis of AHT should be based on the existence of multiple components including subdural hematoma, intracranial pathology, retinal hemorrhages as well as rib and other fractures consistent with the mechanism of trauma. The differential diagnosis must exclude those medical or surgical diseases that can mimic AHT such as traumatic brain injury, cerebral sinovenous thrombosis, and hypoxic-ischemic injury. As for the treatment, most of the care of AHT is supportive. Vital signs should be maintained. Intracranial pressure, if necessary, should be monitored and controlled to ensure adequate cerebral perfusion pressure. There are potential morbidity and mortality associated with AHT, ranging from mild learning disabilities to severe handicaps and death. The prognosis of patients with AHT correlates with the extent of injury identified on CT and MRI imaging. The outcome is associated with the clinical staging, the extent of increased intracranial pressure and the existence of neurological complications such as acquired hydrocephalus or microcephalus, cortical blindness, convulsive disorder, and developmental delay. AHT is a potentially preventable disease, therefore, prevention should be stressed in all encounters within the family, the society and all the healthcare providers.
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Affiliation(s)
- Kun-Long Hung
- Department of Pediatrics, Fu Jen Catholic University Hospital, New Taipei City, Taiwan; School of Medicine, Fu Jen Catholic University, New Taipei City, Taiwan; Department of Pediatrics, Cathay General Hospital, Taipei, Taiwan.
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24
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Iqbal O'Meara AM, Sequeira J, Miller Ferguson N. Advances and Future Directions of Diagnosis and Management of Pediatric Abusive Head Trauma: A Review of the Literature. Front Neurol 2020; 11:118. [PMID: 32153494 PMCID: PMC7044347 DOI: 10.3389/fneur.2020.00118] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2019] [Accepted: 02/03/2020] [Indexed: 12/16/2022] Open
Abstract
Abusive head trauma (AHT) is broadly defined as injury of the skull and intracranial contents as a result of perpetrator-inflicted force and represents a persistent and significant disease burden in children under the age of 4 years. When compared to age-matched controls with typically single occurrence accidental traumatic brain injury (TBI), mortality after AHT is disproportionately high and likely attributable to key differences between injury phenotypes. This article aims to review the epidemiology of AHT, summarize the current state of AHT diagnosis, treatment, and prevention as well as areas for future directions of study. Despite neuroimaging advances and an evolved understanding of AHT, early identification remains a challenge for contemporary clinicians. As such, the reported incidence of 10–30 per 100,000 infants per year may be a considerable underestimate that has not significantly decreased over the past several decades despite social campaigns for public education such as “Never Shake a Baby.” This may reflect caregivers in crisis for whom education is not sufficient without support and intervention, or dangerous environments in which other family members are at risk in addition to the child. Acute management specific to AHT has not advanced beyond usual supportive care for childhood TBI, and prevention and early recognition remain crucial. Moreover, AHT is frequently excluded from studies of childhood TBI, which limits the precise translation of important brain injury research to this population. Repeated injury, antecedent abuse or neglect, delayed medical attention, and high rates of apnea and seizures on presentation are important variables to be considered. More research, including AHT inclusion in childhood TBI studies with comparisons to age-matched controls, and translational models with clinical fidelity are needed to better elucidate the pathophysiology of AHT and inform both clinical care and the development of targeted therapies. Clinical prediction rules, biomarkers, and imaging modalities hold promise, though these have largely been developed and validated in patients after clinically evident AHT has already occurred. Nevertheless, recognition of warning signs and intervention before irreversible harm occurs remains the current best strategy for medical professionals to protect vulnerable infants and toddlers.
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Affiliation(s)
- A M Iqbal O'Meara
- Department of Pediatrics, Virginia Commonwealth University, Richmond, VA, United States
| | - Jake Sequeira
- Department of Pediatrics, Virginia Commonwealth University, Richmond, VA, United States
| | - Nikki Miller Ferguson
- Department of Pediatrics, Virginia Commonwealth University, Richmond, VA, United States
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25
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Abstract
OBJECTIVE Pediatric traumatic brain injury is a major public health problem in the United States. Hypertonic saline therapy is a well-established treatment in patients with severe traumatic brain injury (Glasgow Coma Scale ≤ 8) who have intracranial hypertension. In children, fluid overload is associated with increased mortality, ventilator duration, and length of PICU stay, even when controlling for severity of illness. This study reports prevalence of fluid overload in pediatric patients with severe traumatic brain injury treated with 3% hypertonic saline and effect on clinical outcomes. DESIGN Single-center retrospective chart review. SETTING PICUs at two tertiary children's hospitals. PATIENTS One hundred thirty-eight patients with traumatic brain injury with postresuscitation Glasgow Coma Scale less than or equal to 8 who received hypertonic saline from September 1, 2010, to February 28, 2016, and intracranial pressure monitoring and survived at least 24 hours from admission. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS We used fluid balance percentage greater than or equal to 10% as our definition of fluid overload. Ninety-one percent of patients less than 1 year old had fluid overload on day 10 of admission compared with 47% of patients greater than 1 year. Fluid overloaded patients did not have increased mortality, acute kidney injury, PICU length of stay, or ventilator days. Hypertonic saline was not the cause of fluid overload in these patients. CONCLUSIONS Patients with severe traumatic brain injury do have high rates of fluid overload. However, fluid overload did not contribute to mortality, longer days on the ventilator, increased risk of acute kidney injury, or increased PICU length of stay.
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26
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Lovett ME, Maa T, Moore-Clingenpeel M, O’Brien NF. Transcranial Doppler ultrasound findings in children with moderate-to-severe traumatic brain injury following abusive head trauma. Childs Nerv Syst 2020; 36:993-1000. [PMID: 31781914 PMCID: PMC7224000 DOI: 10.1007/s00381-019-04431-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/08/2019] [Accepted: 11/01/2019] [Indexed: 12/26/2022]
Abstract
PURPOSE Abusive head trauma (AHT) is the leading cause of fatal head injuries for children under 2 years. The objective was to evaluate, using transcranial Doppler ultrasound (TCD), whether children with AHT have a similar neurovascular response to injury compared with children without AHT. METHODS Retrospective sub-analysis of previously prospectively acquired data in a pediatric intensive care unit in a level 1 trauma hospital. TCD was performed daily until hospital day 8, discharge, or death. Neurologic outcome was assessed using the Glasgow Outcome Scale Extended (GOS-E Peds) at 1 month from initial injury. RESULTS Sixty-nine children aged 1 day to 17 years with moderate-to-severe traumatic brain injury were enrolled. Fifteen children suffered AHT and 54 had no suspicion for AHT. Fifteen children with AHT underwent 80 serial TCD examinations; 54 children without AHT underwent 308 exams. After standardization for age and gender normative values, there was no statistically significant difference in mean cerebral blood flow velocity of the middle cerebral artery (VMCA) between children with and without AHT. There was no difference in the incidence of extreme cerebral blood flow velocity (CBFV, greater or less than 2 standard deviations from normative value) between groups. Within the AHT group, there were no statistically significant differences in VMCA between children with a favorable (GOS-E Peds 1-4) versus unfavorable neurologic outcome (GOS-E Peds 5-8). CONCLUSION Children with AHT have no significant differences in VMCA or percentage of extreme CBFV in the middle cerebral artery compared to with those without AHT.
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Affiliation(s)
- Marlina E. Lovett
- grid.240344.50000 0004 0392 3476Division of Critical Care Medicine, Nationwide Children’s Hospital, 700 Children’s Dr., Columbus, OH 43205 USA ,grid.261331.40000 0001 2285 7943Department of Pediatrics, The Ohio State University, Columbus, OH USA
| | - Tensing Maa
- grid.240344.50000 0004 0392 3476Division of Critical Care Medicine, Nationwide Children’s Hospital, 700 Children’s Dr., Columbus, OH 43205 USA ,grid.261331.40000 0001 2285 7943Department of Pediatrics, The Ohio State University, Columbus, OH USA
| | - Melissa Moore-Clingenpeel
- grid.240344.50000 0004 0392 3476Biostatistics Core, Research Institute at Nationwide Children’s Hospital, Columbus, OH USA
| | - Nicole F. O’Brien
- grid.240344.50000 0004 0392 3476Division of Critical Care Medicine, Nationwide Children’s Hospital, 700 Children’s Dr., Columbus, OH 43205 USA ,grid.261331.40000 0001 2285 7943Department of Pediatrics, The Ohio State University, Columbus, OH USA
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Lehner M, Deininger S, Wendling-Keim D. Management des Schädel-Hirn-Traumas im Kindesalter. Monatsschr Kinderheilkd 2019. [DOI: 10.1007/s00112-019-00770-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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[Improving child protection in healthcare: peer counseling, education, and research using the example of abusive head trauma]. Bundesgesundheitsblatt Gesundheitsforschung Gesundheitsschutz 2019; 62:960-969. [PMID: 31263914 DOI: 10.1007/s00103-019-02982-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
Too often, diagnosis of maltreatment is missed by healthcare professionals - thus denying children in danger from necessary protection. Insufficient knowledge and insecurities towards professional confidentiality and how to approach child protection services may be the reasons for the failure to protect children effectively.In this article, we present how a comprehensive concept by the competence center of child protection in medicine of the state of Baden-Wurttemberg consisting of peer counseling, peer education, and research can add to the prevention of maltreatment. One component is peer counseling through a telephone helpline that is accessible 24/7, the medical child protection hotline. The requests to the helpline are analyzed and add to the generation of tailored content for the education of doctors, psychotherapists, nurses, and other healthcare professionals. As an example, we present the online course "Child protection in medicine - a basic course for all health professionals" (so far available only in German). One common issue when the child protection hotline is called for counseling is abusive head trauma. Research shows that sometimes a diagnosis of abusive head trauma might be missed. This condition is most prevalent in children under the age of 2 and represents one of the most severe forms of physical abuse with high mortality.Inquiries to the medical child protection hotline are constantly increasing, but making the service known nationwide to all healthcare professionals still poses a challenge. The online course is widely used and being constantly improved. The comprehensive concept of peer counseling, education, and research is an important contribution to the improvement of the prevention of child maltreatment.
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Appavu B, Foldes ST, Adelson PD. Clinical trials for pediatric traumatic brain injury: definition of insanity? J Neurosurg Pediatr 2019; 23:661-669. [PMID: 31153150 DOI: 10.3171/2019.2.peds18384] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2019] [Accepted: 02/04/2019] [Indexed: 11/06/2022]
Abstract
Traumatic brain injury (TBI) is a leading cause of morbidity and mortality in children both in the United States and throughout the world. Despite valiant efforts and multiple clinical trials completed over the last few decades, there are no high-level recommendations for pediatric TBI available in current guidelines. In this review, the authors explore key findings from the major pediatric clinical trials in children with TBI that have shaped present-day recommendations and the insights gained from them. The authors also offer a perspective on potential efforts to improve the efficacy of future clinical trials in children following TBI.
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Affiliation(s)
- Brian Appavu
- 1Barrow Neurological Institute at Phoenix Children's Hospital; and.,2University of Arizona College of Medicine-Phoenix, Department of Child Health, Phoenix, Arizona
| | - Stephen T Foldes
- 1Barrow Neurological Institute at Phoenix Children's Hospital; and
| | - P David Adelson
- 1Barrow Neurological Institute at Phoenix Children's Hospital; and.,2University of Arizona College of Medicine-Phoenix, Department of Child Health, Phoenix, Arizona
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Smith EB, Lee JK, Vavilala MS, Lee SA. Pediatric Traumatic Brain Injury and Associated Topics: An Overview of Abusive Head Trauma, Nonaccidental Trauma, and Sports Concussions. Anesthesiol Clin 2019; 37:119-134. [PMID: 30711225 DOI: 10.1016/j.anclin.2018.10.002] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
Pediatric traumatic brain injury (TBI) uniquely affects the pediatric population. Abusive head trauma (AHT) is a subset of severe pediatric TBI usually affecting children in the first year of life. AHT is a form of nonaccidental trauma. Sports-related TBI resulting in concussion is a milder form of TBI affecting older children. Current recommended perioperative management of AHT and sports concussions relies on general pediatric TBI guidelines. Research into more specific pediatric TBI screening and management goals is ongoing. This article reviews the epidemiology, mechanisms, clinical signs, and management of AHT and sports-related concussions.
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Affiliation(s)
- Erik B Smith
- Department of Anesthesiology and Critical Care Medicine, Division of Pediatric Anesthesiology, Johns Hopkins University, 1800 Orleans Street, Baltimore, MD 21287, USA.
| | - Jennifer K Lee
- Department of Anesthesiology and Critical Care Medicine, Division of Pediatric Anesthesiology, Johns Hopkins University, 1800 Orleans Street, Baltimore, MD 21287, USA
| | - Monica S Vavilala
- Department of Anesthesiology, University of Washington, Harborview Medical Center, 325 Ninth Avenue, Seattle, WA 98104, USA
| | - Sarah A Lee
- Department of Anesthesiology, University of Washington, Harborview Medical Center, 325 Ninth Avenue, Seattle, WA 98104, USA
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Berthold O, Witt A, Clemens V, Brähler E, Plener PL, Fegert JM. Do we get the message through? Difficulties in the prevention of abusive head trauma. Eur J Pediatr 2019; 178:139-146. [PMID: 30353222 DOI: 10.1007/s00431-018-3273-0] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/09/2018] [Revised: 10/15/2018] [Accepted: 10/17/2018] [Indexed: 12/20/2022]
Abstract
Many programs aim to prevent abusive head trauma throughout the USA, Europe, and in many other regions of the world. Most of these programs inform mothers shortly after delivery about the dangers of abusive head trauma. Effectiveness of these programs usually is measured by the increase of knowledge on abusive head trauma. Recent research showed, however that for effective primary prevention, a much broader approach might be necessary. But so far, there is no data that reports the knowledge on key messages on abusive head trauma in the general public as a baseline. We conducted a representative population-based survey on abusive head trauma knowledge in Germany. Whereas the dangers are generally well known, a majority might be ambivalent towards the recommendation to leave a crying infant alone for a few minutes when the caregiver becomes too stressed or frustrated. Furthermore, a majority prefers being informed on abusive head trauma before birth.Conclusion: Future preventive programs should focus on educating adolescents (potential baby sitters) and young adults when they do not yet have children of their own. What is known: • Most programs for primary prevention of abusive head trauma (AHT) focus on mothers shortly after delivery • There are no analyses so far of the quality of education programs in the general public, as educating mothers might not be sufficient to reduce incidence rates What is new: • Our study is the first population-based survey to measure the knowledge on AHT in a representative population sample and to provide the data base for targeted prevention programs. • The introduction of broader prevention programs might be necessary.
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Affiliation(s)
- Oliver Berthold
- Department of Child and Adolescent Psychiatry/Psychotherapy, University of Ulm, Steinhövelstr. 5, 89075, Ulm, Germany. .,Child Abuse Clinic, DRK Kliniken Berlin
- Westend, Spandauer Damm 130, Berlin, Germany.
| | - Andreas Witt
- Department of Child and Adolescent Psychiatry/Psychotherapy, University of Ulm, Steinhövelstr. 5, 89075, Ulm, Germany
| | - Vera Clemens
- Department of Child and Adolescent Psychiatry/Psychotherapy, University of Ulm, Steinhövelstr. 5, 89075, Ulm, Germany
| | - Elmar Brähler
- Department of Psychosomatic Medicine and Psychotherapy, University Medical Center of Johannes Gutenberg University of Mainz, Mainz, Germany.,Department of Medical Psychology and Medical Sociology, University of Leipzig, Leipzig, Germany
| | - Paul L Plener
- Department of Child and Adolescent Psychiatry/Psychotherapy, University of Ulm, Steinhövelstr. 5, 89075, Ulm, Germany.,Department of Child and Adolescent Psychiatry, Medical University of Vienna, Vienna, Austria
| | - Jörg M Fegert
- Department of Child and Adolescent Psychiatry/Psychotherapy, University of Ulm, Steinhövelstr. 5, 89075, Ulm, Germany
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Kochanek PM, Dixon CE, Mondello S, Wang KKK, Lafrenaye A, Bramlett HM, Dietrich WD, Hayes RL, Shear DA, Gilsdorf JS, Catania M, Poloyac SM, Empey PE, Jackson TC, Povlishock JT. Multi-Center Pre-clinical Consortia to Enhance Translation of Therapies and Biomarkers for Traumatic Brain Injury: Operation Brain Trauma Therapy and Beyond. Front Neurol 2018; 9:640. [PMID: 30131759 PMCID: PMC6090020 DOI: 10.3389/fneur.2018.00640] [Citation(s) in RCA: 39] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2018] [Accepted: 07/17/2018] [Indexed: 12/15/2022] Open
Abstract
Current approaches have failed to yield success in the translation of neuroprotective therapies from the pre-clinical to the clinical arena for traumatic brain injury (TBI). Numerous explanations have been put forth in both the pre-clinical and clinical arenas. Operation Brain Trauma Therapy (OBTT), a pre-clinical therapy and biomarker screening consortium has, to date, evaluated 10 therapies and assessed three serum biomarkers in nearly 1,500 animals across three rat models and a micro pig model of TBI. OBTT provides a unique platform to exploit heterogeneity of TBI and execute the research needed to identify effective injury specific therapies toward precision medicine. It also represents one of the first multi-center pre-clinical consortia for TBI, and through its work has yielded insight into the challenges and opportunities of this approach. In this review, important concepts related to consortium infrastructure, modeling, therapy selection, dosing and target engagement, outcomes, analytical approaches, reproducibility, and standardization will be discussed, with a focus on strategies to embellish and improve the chances for future success. We also address issues spanning the continuum of care. Linking the findings of optimized pre-clinical consortia to novel clinical trial designs has great potential to help address the barriers in translation and produce successes in both therapy and biomarker development across the field of TBI and beyond.
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Affiliation(s)
- Patrick M. Kochanek
- Safar Center for Resuscitation Research, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, United States
| | - C. Edward Dixon
- Safar Center for Resuscitation Research, Department of Neurological Surgery, University of Pittsburgh, Pittsburgh, PA, United States
| | - Stefania Mondello
- Department of Biomedical and Dental Sciences and Morphofunctional Imaging, University of Messina, Messina, Italy
- Oasi Research Institute (IRCCS), Troina, Italy
| | - Kevin K. K. Wang
- Program for Neuroproteomics and Biomarkers Research, Departments of Psychiatry, Neuroscience, and Chemistry, University of Florida, Gainesville, FL, United States
| | - Audrey Lafrenaye
- Department of Anatomy and Neurobiology, Virginia Commonwealth University, Richmond, VA, United States
| | - Helen M. Bramlett
- Department of Neurological Surgery, University of Miami Miller School of Medicine, Miami, FL, United States
| | - W. Dalton Dietrich
- Department of Neurological Surgery, University of Miami Miller School of Medicine, Miami, FL, United States
| | - Ronald L. Hayes
- Center for Innovative Research, Center for Neuroproteomics and Biomarkers Research, Banyan Biomarkers Research, Banyan Biomarkers, Inc., Alachua, FL, United States
| | - Deborah A. Shear
- Brain Trauma Neuroprotection and Neurorestoration Branch, Center for Military Psychiatry and Neuroscience, Walter Reed Army Institute of Research, Silver Spring, MD, United States
| | - Janice S. Gilsdorf
- Brain Trauma Neuroprotection and Neurorestoration Branch, Center for Military Psychiatry and Neuroscience, Walter Reed Army Institute of Research, Silver Spring, MD, United States
| | | | - Samuel M. Poloyac
- Department of Pharmacy and Therapeutics, Center for Clinical Pharmaceutical Sciences, University of Pittsburgh, Pittsburgh, PA, United States
| | - Philip E. Empey
- Department of Pharmacy and Therapeutics, Center for Clinical Pharmaceutical Sciences and the Clinical Translational Science Institute, University of Pittsburgh, Pittsburgh, PA, United States
| | - Travis C. Jackson
- Safar Center for Resuscitation Research, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, United States
| | - John T. Povlishock
- Department of Anatomy and Neurobiology, Virginia Commonwealth University, Richmond, VA, United States
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Robinson S, Winer JL, Chan LAS, Oppong AY, Yellowhair TR, Maxwell JR, Andrews N, Yang Y, Sillerud LO, Meehan WP, Mannix R, Brigman JL, Jantzie LL. Extended Erythropoietin Treatment Prevents Chronic Executive Functional and Microstructural Deficits Following Early Severe Traumatic Brain Injury in Rats. Front Neurol 2018; 9:451. [PMID: 29971038 PMCID: PMC6018393 DOI: 10.3389/fneur.2018.00451] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2018] [Accepted: 05/29/2018] [Indexed: 01/30/2023] Open
Abstract
Survivors of infant traumatic brain injury (TBI) are prone to chronic neurological deficits that impose lifelong individual and societal burdens. Translation of novel interventions to clinical trials is hampered in part by the lack of truly representative preclinical tests of cognition and corresponding biomarkers of functional outcomes. To address this gap, the ability of a high-dose, extended, post-injury regimen of erythropoietin (EPO, 3000U/kg/dose × 6d) to prevent chronic cognitive and imaging deficits was tested in a postnatal day 12 (P12) controlled-cortical impact (CCI) model in rats, using touchscreen operant chambers and regional analysis of diffusion tensor imaging (DTI). Results indicate that EPO prevents functional injury and MRI injury after infant TBI. Specifically, subacute DTI at P30 revealed widespread microstructural damage that is prevented by EPO. Assessment of visual discrimination on a touchscreen operant chamber platform demonstrated that all groups can perform visual discrimination. However, CCI rats treated with vehicle failed to pass reversal learning, and perseverated, in contrast to sham and CCI-EPO rats. Chronic DTI at P90 showed EPO treatment prevented contralateral white matter and ipsilateral lateral prefrontal cortex damage. This DTI improvement correlated with cognitive performance. Taken together, extended EPO treatment restores executive function and prevents microstructural brain abnormalities in adult rats with cognitive deficits in a translational preclinical model of infant TBI. Sophisticated testing with touchscreen operant chambers and regional DTI analyses may expedite translation and effective yield of interventions from preclinical studies to clinical trials. Collectively, these data support the use of EPO in clinical trials for human infants with TBI.
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Affiliation(s)
- Shenandoah Robinson
- Neurosurgery, Boston Children's Hospital, Harvard Medical School, Boston, MA, United States.,Neurology, Boston Children's Hospital, Harvard Medical School, Boston, MA, United States.,F.M. Kirby Center for Neurobiology, Boston Children's Hospital, Harvard Medical School, Boston, MA, United States
| | - Jesse L Winer
- Neurosurgery, Boston Children's Hospital, Harvard Medical School, Boston, MA, United States
| | - Lindsay A S Chan
- Neurosurgery, Boston Children's Hospital, Harvard Medical School, Boston, MA, United States
| | - Akosua Y Oppong
- Neurosurgery, Boston Children's Hospital, Harvard Medical School, Boston, MA, United States
| | | | - Jessie R Maxwell
- Department of Pediatrics, University of New Mexico, Albuquerque, NM, United States
| | - Nicholas Andrews
- F.M. Kirby Center for Neurobiology, Boston Children's Hospital, Harvard Medical School, Boston, MA, United States
| | - Yirong Yang
- Department of Pharmaceutical Sciences, University of New Mexico, Albuquerque, NM, United States
| | - Laurel O Sillerud
- Department of Neurology, University of New Mexico, Albuquerque, NM, United States
| | - William P Meehan
- Sports Medicine, Boston Children's Hospital, Harvard Medical School, Boston, MA, United States
| | - Rebekah Mannix
- Emergency Medicine, Boston Children's Hospital, Harvard Medical School, Boston, MA, United States
| | - Jonathan L Brigman
- Department of Neurosciences, University of New Mexico, Albuquerque, NM, United States
| | - Lauren L Jantzie
- Department of Pediatrics, University of New Mexico, Albuquerque, NM, United States.,Department of Neurosciences, University of New Mexico, Albuquerque, NM, United States
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Abstract
PURPOSE OF REVIEW Traumatic brain injury (TBI) is a leading cause of death and disability in children. Prognostication of outcome following TBI is challenging in this population and likely requires complex, multimodal models to achieve clinically relevant accuracy. This review highlights injury characteristics, physiological indicators, biomarkers and neuromonitoring modalities predictive of outcome that may be integrated for future development of sensitive and specific prognostic models. RECENT FINDINGS Paediatric TBI is responsible for physical, psychosocial and neurocognitive deficits that may significantly impact quality of life. Outcome prognostication can be difficult in the immature brain, but is aided by the identification of novel biomarkers (neuronal, astroglial, myelin, inflammatory, apoptotic and autophagic) and neuromonitoring techniques (electroencephalogram and MRI). Investigation in the future may focus on assessing the prognostic ability of combinations of biochemical, protein, neuroimaging and functional biomarkers and the use of mathematical models to develop multivariable predication tools to improve the prognostic ability following childhood TBI. SUMMARY Prognostication of outcome following paediatric TBI is multidimensional, influenced by injury severity, age, physiological factors, biomarkers, electroencephalogram and neuroimaging. Further development, integration and validation of combinatorial prognostic algorithms are necessary to improve the accuracy and timeliness of prognosis in a meaningful fashion.
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Maas AIR, Menon DK, Adelson PD, Andelic N, Bell MJ, Belli A, Bragge P, Brazinova A, Büki A, Chesnut RM, Citerio G, Coburn M, Cooper DJ, Crowder AT, Czeiter E, Czosnyka M, Diaz-Arrastia R, Dreier JP, Duhaime AC, Ercole A, van Essen TA, Feigin VL, Gao G, Giacino J, Gonzalez-Lara LE, Gruen RL, Gupta D, Hartings JA, Hill S, Jiang JY, Ketharanathan N, Kompanje EJO, Lanyon L, Laureys S, Lecky F, Levin H, Lingsma HF, Maegele M, Majdan M, Manley G, Marsteller J, Mascia L, McFadyen C, Mondello S, Newcombe V, Palotie A, Parizel PM, Peul W, Piercy J, Polinder S, Puybasset L, Rasmussen TE, Rossaint R, Smielewski P, Söderberg J, Stanworth SJ, Stein MB, von Steinbüchel N, Stewart W, Steyerberg EW, Stocchetti N, Synnot A, Te Ao B, Tenovuo O, Theadom A, Tibboel D, Videtta W, Wang KKW, Williams WH, Wilson L, Yaffe K, Adams H, Agnoletti V, Allanson J, Amrein K, Andaluz N, Anke A, Antoni A, van As AB, Audibert G, Azaševac A, Azouvi P, Azzolini ML, Baciu C, Badenes R, Barlow KM, Bartels R, Bauerfeind U, Beauchamp M, Beer D, Beer R, Belda FJ, Bellander BM, Bellier R, Benali H, Benard T, Beqiri V, Beretta L, Bernard F, Bertolini G, Bilotta F, Blaabjerg M, den Boogert H, Boutis K, Bouzat P, Brooks B, Brorsson C, Bullinger M, Burns E, Calappi E, Cameron P, Carise E, Castaño-León AM, Causin F, Chevallard G, Chieregato A, Christie B, Cnossen M, Coles J, Collett J, Della Corte F, Craig W, Csato G, Csomos A, Curry N, Dahyot-Fizelier C, Dawes H, DeMatteo C, Depreitere B, Dewey D, van Dijck J, Đilvesi Đ, Dippel D, Dizdarevic K, Donoghue E, Duek O, Dulière GL, Dzeko A, Eapen G, Emery CA, English S, Esser P, Ezer E, Fabricius M, Feng J, Fergusson D, Figaji A, Fleming J, Foks K, Francony G, Freedman S, Freo U, Frisvold SK, Gagnon I, Galanaud D, Gantner D, Giraud B, Glocker B, Golubovic J, Gómez López PA, Gordon WA, Gradisek P, Gravel J, Griesdale D, Grossi F, Haagsma JA, Håberg AK, Haitsma I, Van Hecke W, Helbok R, Helseth E, van Heugten C, Hoedemaekers C, Höfer S, Horton L, Hui J, Huijben JA, Hutchinson PJ, Jacobs B, van der Jagt M, Jankowski S, Janssens K, Jelaca B, Jones KM, Kamnitsas K, Kaps R, Karan M, Katila A, Kaukonen KM, De Keyser V, Kivisaari R, Kolias AG, Kolumbán B, Kolundžija K, Kondziella D, Koskinen LO, Kovács N, Kramer A, Kutsogiannis D, Kyprianou T, Lagares A, Lamontagne F, Latini R, Lauzier F, Lazar I, Ledig C, Lefering R, Legrand V, Levi L, Lightfoot R, Lozano A, MacDonald S, Major S, Manara A, Manhes P, Maréchal H, Martino C, Masala A, Masson S, Mattern J, McFadyen B, McMahon C, Meade M, Melegh B, Menovsky T, Moore L, Morgado Correia M, Morganti-Kossmann MC, Muehlan H, Mukherjee P, Murray L, van der Naalt J, Negru A, Nelson D, Nieboer D, Noirhomme Q, Nyirádi J, Oddo M, Okonkwo DO, Oldenbeuving AW, Ortolano F, Osmond M, Payen JF, Perlbarg V, Persona P, Pichon N, Piippo-Karjalainen A, Pili-Floury S, Pirinen M, Ple H, Poca MA, Posti J, Van Praag D, Ptito A, Radoi A, Ragauskas A, Raj R, Real RGL, Reed N, Rhodes J, Robertson C, Rocka S, Røe C, Røise O, Roks G, Rosand J, Rosenfeld JV, Rosenlund C, Rosenthal G, Rossi S, Rueckert D, de Ruiter GCW, Sacchi M, Sahakian BJ, Sahuquillo J, Sakowitz O, Salvato G, Sánchez-Porras R, Sándor J, Sangha G, Schäfer N, Schmidt S, Schneider KJ, Schnyer D, Schöhl H, Schoonman GG, Schou RF, Sir Ö, Skandsen T, Smeets D, Sorinola A, Stamatakis E, Stevanovic A, Stevens RD, Sundström N, Taccone FS, Takala R, Tanskanen P, Taylor MS, Telgmann R, Temkin N, Teodorani G, Thomas M, Tolias CM, Trapani T, Turgeon A, Vajkoczy P, Valadka AB, Valeinis E, Vallance S, Vámos Z, Vargiolu A, Vega E, Verheyden J, Vik A, Vilcinis R, Vleggeert-Lankamp C, Vogt L, Volovici V, Voormolen DC, Vulekovic P, Vande Vyvere T, Van Waesberghe J, Wessels L, Wildschut E, Williams G, Winkler MKL, Wolf S, Wood G, Xirouchaki N, Younsi A, Zaaroor M, Zelinkova V, Zemek R, Zumbo F. Traumatic brain injury: integrated approaches to improve prevention, clinical care, and research. Lancet Neurol 2017; 16:987-1048. [DOI: 10.1016/s1474-4422(17)30371-x] [Citation(s) in RCA: 822] [Impact Index Per Article: 117.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2016] [Revised: 07/06/2017] [Accepted: 09/27/2017] [Indexed: 12/11/2022]
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Gardner MT, O’Meara AMI, Miller Ferguson N. Pediatric Traumatic Brain Injury: an Update on Management. CURRENT PEDIATRICS REPORTS 2017. [DOI: 10.1007/s40124-017-0144-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
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Pre-clinical models in pediatric traumatic brain injury-challenges and lessons learned. Childs Nerv Syst 2017; 33:1693-1701. [PMID: 29149385 PMCID: PMC5909721 DOI: 10.1007/s00381-017-3474-2] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/16/2017] [Accepted: 05/30/2017] [Indexed: 12/31/2022]
Abstract
PURPOSE Despite the enormity of the problem and the lack of new therapies, research in the pre-clinical arena specifically using pediatric traumatic brain injury (TBI) models is limited. In this review, some of the key models addressing both the age spectrum of pediatric TBI and its unique injury mechanisms will be highlighted. Four topics will be addressed, namely, (1) unique facets of the developing brain important to TBI model development, (2) a description of some of the most commonly used pre-clinical models of severe pediatric TBI including work in both rodents and large animals, (3) a description of the pediatric models of mild TBI and repetitive mild TBI that are relatively new, and finally (4) a discussion of challenges, gaps, and potential future directions to further advance work in pediatric TBI models. METHODS This narrative review on the topic of pediatric TBI models was based on review of PUBMED/Medline along with a synthesis of information on key factors in pre-clinical and clinical developmental brain injury that influence TBI modeling. RESULTS In the contemporary literature, six types of models have been used in rats including weight drop, fluid percussion injury (FPI), impact acceleration, controlled cortical impact (CCI), mechanical shaking, and closed head modifications of CCI. In mice, studies are largely restricted to CCI. In large animals, FPI and rotational injury have been used in piglets and shake injury has also been used in lambs. Most of the studies have been in severe injury models, although more recently, studies have begun to explore mild and repetitive mild injuries to study concussion. CONCLUSIONS Given the emerging importance of TBI in infants and children, the morbidity and mortality that is produced, along with its purported link to the development of chronic neurodegenerative diseases, studies in these models merit greater systematic investigations along with consortium-type approaches and long-term follow-up to translate new therapies to the bedside.
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Griffiths H, Goyal MS, Pineda JA. Brain metabolism and severe pediatric traumatic brain injury. Childs Nerv Syst 2017; 33:1719-1726. [PMID: 29149384 DOI: 10.1007/s00381-017-3514-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/25/2017] [Accepted: 06/27/2017] [Indexed: 01/30/2023]
Abstract
Age-dependent changes in brain metabolism may influence the response to and tolerance of secondary insults, potentially affecting outcomes. More complete characterization of brain metabolism across the clinical trajectory of severe pediatric TBI is needed to improve our ability to measure and better mitigate the impact of secondary insults. Better management of secondary insults will impact clinical care and the probability of success of future neuroprotective clinical trials. Improved bedside monitoring and imaging technologies will be required to achieve these goals. Effective and sustained integration of brain metabolism information into the pediatric critical care setting will be equally challenging and important.
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Affiliation(s)
- Heidi Griffiths
- Department of Pediatrics, Washington University School of Medicine, St. Louis, MO, USA
| | - Manu S Goyal
- Department of Neuroradiology, Washington University School of Medicine, St. Louis, MO, USA
| | - Jose A Pineda
- Department of Pediatrics and Neurology, Washington University School of Medicine, St. Louis, MO, USA.
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Challenges and opportunities for pediatric severe TBI-review of the evidence and exploring a way forward. Childs Nerv Syst 2017; 33:1663-1667. [PMID: 29149394 DOI: 10.1007/s00381-017-3530-y] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/30/2017] [Accepted: 07/06/2017] [Indexed: 02/05/2023]
Abstract
Traumatic brain injury (TBI) is a leading killer of children in the developed and developing world. Despite evidence-based guidelines and several recent clinical trials, the progress in developing best practices for children with severe TBI has been slow. This article describes (i) the burden of the disease, (ii) the inadequacies of the evidence-based guidelines, (iii) the failure of the largest clinical trials to prove their primary hypotheses, and (iv) possible advances from an observational cohort study called the Approaches and Decisions for Acute Pediatric TBI (ADAPT) Trial that has recently completed enrollment.
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