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Zhang SY, Li CL, Yin J, Jiang M, Yang XF. Blood pressure variability and prognostic significance in traumatic brain injury: analysis of the eICU-CRD database. BMC Emerg Med 2024; 24:141. [PMID: 39112931 PMCID: PMC11305040 DOI: 10.1186/s12873-024-01054-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2024] [Accepted: 07/17/2024] [Indexed: 08/11/2024] Open
Abstract
BACKGROUND Preliminary evidence demonstrates that visit-to-visit systolic blood pressure (SBP) variability is a prognostic factor of TBI. However, literature regarding the impact of initial blood pressure management on the outcomes of TBI patients is limited. We aimed to further validate the clinical significance of BPV on the prognostic outcomes of patients with TBI. METHODS We performed the analysis by using individual patient-level data acquired from the eICU-CRD, which collected 200,859 ICU admissions of 139,367 patients in 2014 and 2015 from 208 US hospitals. Adult patients with traumatic intraparenchymal hemorrhage or contusion were included. The primary outcome was in-hospital mortality and the secondary outcome was discharge-home rate. Blood pressure variability (BPV) was calculated according to standard criteria: at least six measurements were taken in the first 24 h (hyperacute group) and 36 over days 2-7 (acute group). We estimated the associations between BPV and outcomes with logistic and proportional odds regression models. The key parameter for BPV was standard deviation (SD) of SBP, categorized into quintiles. We also calculated the average real variability (ARV), as well as maximum, minimum, and mean SBP for comparison in our analysis. RESULTS We studied 1486 patients in the hyperacute group and 857 in the acute group. SD of SBP had a significant association with the in-hospital mortality for both the hyperacute group (highest quintile adjusted OR 2.28 95% CI 1.18-4.42; ptrend<0.001) and the acute group (highest quintile adjusted OR 2.17, 95% CI 1.08-4.36; ptrend<0.001). The strongest predictors of primary outcome were SD of SBP in the hyperacute phase and minimum SBP in the acute phase. Associations were similar for the discharge-home rate (for the hyperacute group, highest quintile adjusted OR 0.58, 95% CI 0.37-0.89; ptrend<0.001; for the acute group OR 0.55, 95% CI 0.32-0.95; ptrend<0.001). CONCLUSION Systolic BPV seems to predict a poor outcome in patients with TBI. The benefits of early treatment to maintain appropriate SBP level might be enhanced by smooth and sustained control.
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Affiliation(s)
- Shao-Yang Zhang
- Emergency and Trauma Center, The First Affiliated Hospital, Zhejiang University School of Medicine, #79 Qingchun Road, Hangzhou, Zhejiang Province, 310003, China
| | - Chang-Li Li
- Department of FSTC Clinic, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, 310003, China
| | - Jian Yin
- Emergency and Trauma Center, The First Affiliated Hospital, Zhejiang University School of Medicine, #79 Qingchun Road, Hangzhou, Zhejiang Province, 310003, China
| | - Meng Jiang
- Emergency and Trauma Center, The First Affiliated Hospital, Zhejiang University School of Medicine, #79 Qingchun Road, Hangzhou, Zhejiang Province, 310003, China.
| | - Xiao-Feng Yang
- Emergency and Trauma Center, The First Affiliated Hospital, Zhejiang University School of Medicine, #79 Qingchun Road, Hangzhou, Zhejiang Province, 310003, China
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Wilson LD, Maiga AW, Lombardo S, Nordness MF, Haddad DN, Rakhit S, Smith LF, Rivera EL, Cook MR, Thompson JL, Raman R, Patel MB. Dynamic predictors of in-hospital and 3-year mortality after traumatic brain injury: A retrospective cohort study. Am J Surg 2023; 225:781-786. [PMID: 36372578 PMCID: PMC10750767 DOI: 10.1016/j.amjsurg.2022.10.003] [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: 08/11/2022] [Revised: 09/27/2022] [Accepted: 10/05/2022] [Indexed: 11/01/2022]
Abstract
BACKGROUND Mortality risks after Traumatic Brain Injury (TBI) are understudied in critical illness. We sought to identify risks of mortality in critically ill patients with TBI using time-varying covariates. METHODS This single-center, six-year (2006-2012), retrospective cohort study measured demographics, injury characteristics, and daily data of acute TBI patients in the Intensive Care Unit (ICU). Time-varying Cox proportional hazards models assessed in-hospital and 3-year mortality. RESULTS Post-TBI ICU patients (n = 2664) experienced 20% in-hospital mortality (n = 529) and 27% (n = 706) 3-year mortality. Glasgow Coma Scale motor subscore (hazard ratio (HR) 0.58, p < 0.001), pupil reactivity (HR 3.17, p < 0.001), minimum glucose (HR 1.44, p < 0.001), mSOFA score (HR 1.81, p < 0.001), coma (HR 2.26, p < 0.001), and benzodiazepines (HR 1.38, p < 0.001) were associated with in-hospital mortality. At three years, public insurance (HR 1.78, p = 0.011) and discharge disposition (HR 4.48, p < 0.001) were associated with death. CONCLUSIONS Time-varying characteristics influenced in-hospital mortality post-TBI. Socioeconomic factors primarily affect three-year mortality.
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Affiliation(s)
- Laura D Wilson
- Oxley College of Health Sciences, Communication Sciences and Disorders, The University of Tulsa, 800 S Tucker Dr, Tulsa, OK, 74104, USA
| | - Amelia W Maiga
- Critical Illness, Brain Dysfunction, & Survivorship Center, Vanderbilt Center for Health Services Research, Vanderbilt Institute for Medicine and Public Health, Vanderbilt University Medical Center, Suite 450, 4th Floor, 2525 West End Avenue Nashville, TN, 37203, USA; Division of Acute Care Surgery, Department of Surgery, Section of Surgical Sciences, Vanderbilt University Medical Center, 1211 21st Avenue South, Suite 404, Nashville, TN, 37212, USA
| | - Sarah Lombardo
- Division of Acute Care Surgery, Department of Surgery, Section of Surgical Sciences, Vanderbilt University Medical Center, 1211 21st Avenue South, Suite 404, Nashville, TN, 37212, USA; Section of Acute Care Surgery, Division of General Surgery, Department of Surgery, University of Utah Health, 30 N 1900 E, Salt Lake City, UT, 84132, USA
| | - Mina F Nordness
- Critical Illness, Brain Dysfunction, & Survivorship Center, Vanderbilt Center for Health Services Research, Vanderbilt Institute for Medicine and Public Health, Vanderbilt University Medical Center, Suite 450, 4th Floor, 2525 West End Avenue Nashville, TN, 37203, USA; Division of Acute Care Surgery, Department of Surgery, Section of Surgical Sciences, Vanderbilt University Medical Center, 1211 21st Avenue South, Suite 404, Nashville, TN, 37212, USA
| | - Diane N Haddad
- Critical Illness, Brain Dysfunction, & Survivorship Center, Vanderbilt Center for Health Services Research, Vanderbilt Institute for Medicine and Public Health, Vanderbilt University Medical Center, Suite 450, 4th Floor, 2525 West End Avenue Nashville, TN, 37203, USA; Division of Acute Care Surgery, Department of Surgery, Section of Surgical Sciences, Vanderbilt University Medical Center, 1211 21st Avenue South, Suite 404, Nashville, TN, 37212, USA; The Trauma Center at Penn, 51 North 39th ST, MOB Suite 120, Philadelphia, PA, 19104, USA
| | - Shayan Rakhit
- Critical Illness, Brain Dysfunction, & Survivorship Center, Vanderbilt Center for Health Services Research, Vanderbilt Institute for Medicine and Public Health, Vanderbilt University Medical Center, Suite 450, 4th Floor, 2525 West End Avenue Nashville, TN, 37203, USA; Division of Acute Care Surgery, Department of Surgery, Section of Surgical Sciences, Vanderbilt University Medical Center, 1211 21st Avenue South, Suite 404, Nashville, TN, 37212, USA
| | - Laney F Smith
- Critical Illness, Brain Dysfunction, & Survivorship Center, Vanderbilt Center for Health Services Research, Vanderbilt Institute for Medicine and Public Health, Vanderbilt University Medical Center, Suite 450, 4th Floor, 2525 West End Avenue Nashville, TN, 37203, USA; Georgetown Lombardi Comprehensive Cancer Center, 3800 Reservoir Rd, NW., Washington, D.C., 20057, USA
| | - Erika L Rivera
- Critical Illness, Brain Dysfunction, & Survivorship Center, Vanderbilt Center for Health Services Research, Vanderbilt Institute for Medicine and Public Health, Vanderbilt University Medical Center, Suite 450, 4th Floor, 2525 West End Avenue Nashville, TN, 37203, USA; Division of Acute Care Surgery, Department of Surgery, Section of Surgical Sciences, Vanderbilt University Medical Center, 1211 21st Avenue South, Suite 404, Nashville, TN, 37212, USA
| | - Madison R Cook
- Critical Illness, Brain Dysfunction, & Survivorship Center, Vanderbilt Center for Health Services Research, Vanderbilt Institute for Medicine and Public Health, Vanderbilt University Medical Center, Suite 450, 4th Floor, 2525 West End Avenue Nashville, TN, 37203, USA; Division of Acute Care Surgery, Department of Surgery, Section of Surgical Sciences, Vanderbilt University Medical Center, 1211 21st Avenue South, Suite 404, Nashville, TN, 37212, USA; Meharry Medical College, 1005 Dr DB Todd Jr Blvd, Nashville, TN, 37208, USA; Department of Surgery, Temple University Hospital, 3401 N. Broad Street, Parkinson Pavilion, Suite 400, Philadelphia, PA, 19140, USA
| | - Jennifer L Thompson
- Critical Illness, Brain Dysfunction, & Survivorship Center, Vanderbilt Center for Health Services Research, Vanderbilt Institute for Medicine and Public Health, Vanderbilt University Medical Center, Suite 450, 4th Floor, 2525 West End Avenue Nashville, TN, 37203, USA; Department of Biostatistics, Vanderbilt University Medical Center, Room 11133B, 2525 West End Avenue Nashville, TN, 37203, USA; Devoted Health, 221 Crescent St #202, Waltham, MA, 02453, USA
| | - Rameela Raman
- Critical Illness, Brain Dysfunction, & Survivorship Center, Vanderbilt Center for Health Services Research, Vanderbilt Institute for Medicine and Public Health, Vanderbilt University Medical Center, Suite 450, 4th Floor, 2525 West End Avenue Nashville, TN, 37203, USA; Department of Biostatistics, Vanderbilt University Medical Center, Room 11133B, 2525 West End Avenue Nashville, TN, 37203, USA
| | - Mayur B Patel
- Critical Illness, Brain Dysfunction, & Survivorship Center, Vanderbilt Center for Health Services Research, Vanderbilt Institute for Medicine and Public Health, Vanderbilt University Medical Center, Suite 450, 4th Floor, 2525 West End Avenue Nashville, TN, 37203, USA; Division of Acute Care Surgery, Department of Surgery, Section of Surgical Sciences, Vanderbilt University Medical Center, 1211 21st Avenue South, Suite 404, Nashville, TN, 37212, USA; Vanderbilt University Medical Center, Geriatric Research Education and Clinical Center, Surgical Services, Tennessee Valley Healthcare System, USA.
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Tran Q, Frederick H, Tran C, Baqai H, Lurie T, Solomon J, Aligabi A, Olexa J, Cardona S, Bodanapally U, Schwartzbauer G, Downing J. Blood Pressure Variability and Outcome in Traumatic Brain Injury: A Propensity Score Matching Study. West J Emerg Med 2022; 23:769-780. [PMID: 36205663 PMCID: PMC9541979 DOI: 10.5811/westjem.2022.6.55549] [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: 12/06/2021] [Accepted: 06/27/2022] [Indexed: 11/20/2022] Open
Abstract
Introduction Patients with tIPH (used here to refer to traumatic intraparenchymal hemorrhagic contusion) or intraparenchymal hemorrhage face high rates of mortality and persistent functional deficits. Prior studies have found an association between blood pressure variability (BPV) and neurologic outcomes in patients with spontaneous IPH. Our study investigated the association between BPV and discharge destination (a proxy for functional outcome) in patients with tIPH. Methods We retrospectively reviewed the charts of patients admitted to a Level I trauma center for ≥ 24 hours with tIPH. We examined variability in hourly BP measurements over the first 24 hours of hospitalization. Our outcome of interest was discharge destination (home vs facility). We performed 1:1 propensity score matching and multivariate regressions to identify demographic and clinical factors predictive of discharge home. Results We included 354 patients; 91 were discharged home and 263 to a location other than home. The mean age was 56 (SD 21), 260 (73%) were male, 22 (6%) were on anticoagulation, and 54 (15%) on antiplatelet therapy. Our propensity-matched cohorts included 76 patients who were discharged home and 76 who were discharged to a location other than home. One measure of BPV (successive variation in systolic BP) was identified as an independent predictor of discharge location in our propensity-matched cohorts (odds ratio 0.89, 95% confidence interval 0.8–0.98; P = 0.02). Our model demonstrated good goodness of fit (P-value for Hosmer-Lemeshow test = 0.88) and very good discriminatory capability (AUROC = 0.81). High Glasgow Coma Scale score at 24 hours and treatment with fresh frozen plasma were also associated with discharge home. Conclusion Our study suggests that increased BPV is associated with lower rates of discharge home after initial hospitalization among patients with tIPH. Additional research is needed to evaluate the impact of BP control on patient outcomes.
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Affiliation(s)
- Quincy Tran
- University of Maryland School of Medicine, Baltimore, Maryland; University of Maryland School of Medicine, Research Associate Program in Emergency Medicine & Critical Care, Department of Emergency Medicine, Baltimore, Maryland; The R. Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, Baltimore, Maryland; University of Maryland School of Medicine, Department of Emergency Medicine, Baltimore, Maryland
| | - Hannah Frederick
- University of Maryland School of Medicine, Research Associate Program in Emergency Medicine & Critical Care, Department of Emergency Medicine, Baltimore, Maryland
| | - Cecilia Tran
- University of Maryland School of Medicine, Baltimore, Maryland
| | - Hammad Baqai
- University of Maryland School of Medicine, Research Associate Program in Emergency Medicine & Critical Care, Department of Emergency Medicine, Baltimore, Maryland
| | - Tucker Lurie
- University of Maryland School of Medicine, Research Associate Program in Emergency Medicine & Critical Care, Department of Emergency Medicine, Baltimore, Maryland; Wellspan York Hospital, Department of Emergency Medicine, York, Pennsylvania
| | - Julianna Solomon
- University of Maryland School of Medicine, Research Associate Program in Emergency Medicine & Critical Care, Department of Emergency Medicine, Baltimore, Maryland
| | - Ayah Aligabi
- University of Maryland School of Medicine, Research Associate Program in Emergency Medicine & Critical Care, Department of Emergency Medicine, Baltimore, Maryland
| | - Joshua Olexa
- University of Maryland School of Medicine, Department of Neurosurgery, Baltimore, Maryland
| | - Stephanie Cardona
- Mount Sinai Hospital, Department of Critical Care Medicine, York, New York
| | - Uttam Bodanapally
- The R. Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, Baltimore, Maryland
| | - Gary Schwartzbauer
- The R. Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, Baltimore, Maryland; University of Maryland School of Medicine, Department of Neurosurgery, Baltimore, Maryland
| | - Jessica Downing
- The R. Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, Baltimore, Program in Trauma/Surgical Critical Care, Baltimore, Maryland
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Forssten MP, Bass GA, Scheufler KM, Mohammad Ismail A, Cao Y, Martin ND, Sarani B, Mohseni S. Mortality risk stratification in isolated severe traumatic brain injury using the revised cardiac risk index. Eur J Trauma Emerg Surg 2021; 48:4481-4488. [PMID: 34839374 DOI: 10.1007/s00068-021-01841-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2021] [Accepted: 11/10/2021] [Indexed: 12/01/2022]
Abstract
PURPOSE Traumatic brain injury (TBI) continues to be a significant cause of mortality and morbidity worldwide. As cardiovascular events are among the most common extracranial causes of death after a severe TBI, the Revised Cardiac Risk Index (RCRI) could potentially aid in the risk stratification of this patient population. This investigation aimed to determine the association between the RCRI and in-hospital deaths among isolated severe TBI patients. METHODS All adult patients registered in the TQIP database between 2013 and 2017 who suffered an isolated severe TBI, defined as a head AIS ≥ 3 with an AIS ≤ 1 in all other body regions, were included. Patients were excluded if they had a head AIS of 6. The association between different RCRI scores (0, 1, 2, 3, ≥ 4) and in-hospital mortality was analyzed using a Poisson regression model with robust standard errors while adjusting for potential confounders, with RCRI 0 as the reference. RESULTS 259,399 patients met the study's inclusion criteria. RCRI 2 was associated with a 6% increase in mortality risk [adjusted IRR (95% CI) 1.06 (1.01-1.12), p = 0.027], RCRI 3 was associated with a 17% increased risk of mortality [adjusted IRR (95% CI) 1.17 (1.05-1.31), p = 0.004], and RCRI ≥ 4 was associated with a 46% increased risk of in-hospital mortality [adjusted IRR(95% CI) 1.46 (1.11-1.90), p = 0.006], compared to RCRI 0. CONCLUSION An elevated RCRI ≥ 2 is significantly associated with an increased risk of in-hospital mortality among patients with an isolated severe traumatic brain injury. The simplicity and bedside applicability of the index makes it an attractive choice for risk stratification in this patient population.
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Affiliation(s)
- Maximilian Peter Forssten
- School of Medical Sciences, Orebro University, 702 81, Örebro, Sweden.,Division of Trauma and Emergency Surgery, Orebro University Hospital, 70185, Örebro, Sweden
| | - Gary Alan Bass
- School of Medical Sciences, Orebro University, 702 81, Örebro, Sweden.,Division of Traumatology, Surgical Critical Care and Emergency Surgery, University of Pennsylvania, Philadelphia, PA, 19104, USA
| | - Kai-Michael Scheufler
- Department of Neurosurgery, Orebro University Hospital, 70185, Örebro, Sweden.,Medical School, Heinrich-Heine University Dusseldorf, Düsseldorf, Germany
| | - Ahmad Mohammad Ismail
- School of Medical Sciences, Orebro University, 702 81, Örebro, Sweden.,Division of Trauma and Emergency Surgery, Orebro University Hospital, 70185, Örebro, Sweden
| | - Yang Cao
- Clinical Epidemiology and Biostatistics, School of Medical Sciences, Orebro University, Örebro, Sweden
| | - Niels Douglas Martin
- Division of Traumatology, Surgical Critical Care and Emergency Surgery, University of Pennsylvania, Philadelphia, PA, 19104, USA
| | - Babak Sarani
- Division of Trauma and Acute Care Surgery, George Washington University School of Medicine & Health Sciences, Washington, DC, USA
| | - Shahin Mohseni
- School of Medical Sciences, Orebro University, 702 81, Örebro, Sweden. .,Division of Trauma and Emergency Surgery, Orebro University Hospital, 70185, Örebro, Sweden.
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Karr JE, Iverson GL, Isokuortti H, Kataja A, Brander A, Öhman J, Luoto TM. Preexisting conditions in older adults with mild traumatic brain injuries. Brain Inj 2021; 35:1607-1615. [PMID: 34546830 DOI: 10.1080/02699052.2021.1976419] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
OBJECTIVE This study examined the prevalence of preexisting conditions that could affect premorbid brain health, cognition, and functional independence among older adults with mild traumatic brain injury (MTBI), and the relationship between preexisting conditions, injury characteristics, and emergency department (ED) discharge location (home versus continued care). METHODS Older adults (N = 1,427; 55-104 years-old; 47.4% men) who underwent head computed tomography (CT) after acute head trauma were recruited from the ED. Researchers documented preexisting medical conditions retrospectively from hospital records. RESULTS Multiple preexisting conditions increased in frequency with greater age, including circulatory and nervous system diseases and preexisting abnormalities on head CT. Psychiatric and substance use disorders (SUDs) decreased in frequency with greater age. Among participants with uncomplicated MTBI and GCS = 15, preexisting nervous system diseases and preexisting CT abnormalities were associated with higher odds of continued care for all participants, whereas psychiatric disorders and SUDs were only associated with higher odds of continued care among participants <70 years-old. Preexisting circulatory diseases, loss of consciousness, and amnesia were unassociated with discharge location. CONCLUSIONS Preexisting medical conditions that could affect brain and cognitive health occur commonly among older adults who sustain MTBIs. These conditions can confound research examining post-injury outcomes within this age group.
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Affiliation(s)
- Justin E Karr
- Department of Psychology, University of Kentucky, Lexington, Kentucky, USA
| | - Grant L Iverson
- Department of Physical Medicine and Rehabilitation, Harvard Medical School; Spaulding Rehabilitation Hospital and Spaulding Research Institute; and Home Base, a Red Sox Foundation and Massachusetts General Hospital Program, Boston, Massachusetts, USA
| | - Harri Isokuortti
- Helsinki University Central Hospital, Neurocenter, Department of Neurology, Helsinki, Finland
| | - Anneli Kataja
- Medical Imaging Centre, Department of Radiology, Tampere University Hospital, Tampere, Finland
| | - Antti Brander
- Medical Imaging Centre, Department of Radiology, Tampere University Hospital, Tampere, Finland
| | - Juha Öhman
- Department of Neurosurgery, Tampere University, Tampere, Finland
| | - Teemu M Luoto
- Department of Neurosurgery, Tampere University Hospital and Tampere University, Tampere, Finland
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Cui W, Ge S, Shi Y, Wu X, Luo J, Lui H, Zhu G, Guo H, Feng D, Qu Y. Death after discharge: prognostic model of 1-year mortality in traumatic brain injury patients undergoing decompressive craniectomy. Chin Neurosurg J 2021; 7:24. [PMID: 33879254 PMCID: PMC8058982 DOI: 10.1186/s41016-021-00242-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2020] [Accepted: 03/31/2021] [Indexed: 11/21/2022] Open
Abstract
Background Despite advances in decompressive craniectomy (DC) for the treatment of traumatic brain injury (TBI), these patients are at risk of having a poor long-term prognosis. The aim of this study was to predict 1-year mortality in TBI patients undergoing DC using logistic regression and random tree models. Methods This was a retrospective analysis of TBI patients undergoing DC from January 1, 2015, to April 25, 2019. Patient demographic characteristics, biochemical tests, and intraoperative factors were collected. One-year mortality prognostic models were developed using multivariate logistic regression and random tree algorithms. The overall accuracy, sensitivity, specificity, and area under the receiver operating characteristic curves (AUCs) were used to evaluate model performance. Results Of the 230 patients, 70 (30.4%) died within 1 year. Older age (OR, 1.066; 95% CI, 1.045–1.087; P < 0.001), higher Glasgow Coma Score (GCS) (OR, 0.737; 95% CI, 0.660–0.824; P < 0.001), higher d-dimer (OR, 1.005; 95% CI, 1.001–1.009; P = 0.015), coagulopathy (OR, 2.965; 95% CI, 1.808–4.864; P < 0.001), hypotension (OR, 3.862; 95% CI, 2.176–6.855; P < 0.001), and completely effaced basal cisterns (OR, 3.766; 95% CI, 2.255–6.290; P < 0.001) were independent predictors of 1-year mortality. Random forest demonstrated better performance for 1-year mortality prediction, which achieved an overall accuracy of 0.810, sensitivity of 0.833, specificity of 0.800, and AUC of 0.830 on the testing data compared to the logistic regression model. Conclusions The random forest model showed relatively good predictive performance for 1-year mortality in TBI patients undergoing DC. Further external tests are required to verify our prognostic model.
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Affiliation(s)
- Wenxing Cui
- Department of Neurosurgery, Tangdu Hospital, No. 569 Xin Si Road, Xi'an, 710038, Shaanxi Province, China
| | - Shunnan Ge
- Department of Neurosurgery, Tangdu Hospital, No. 569 Xin Si Road, Xi'an, 710038, Shaanxi Province, China
| | - Yingwu Shi
- Department of Neurosurgery, Tangdu Hospital, No. 569 Xin Si Road, Xi'an, 710038, Shaanxi Province, China
| | - Xun Wu
- Department of Neurosurgery, Tangdu Hospital, No. 569 Xin Si Road, Xi'an, 710038, Shaanxi Province, China
| | - Jianing Luo
- Department of Neurosurgery, Tangdu Hospital, No. 569 Xin Si Road, Xi'an, 710038, Shaanxi Province, China
| | - Haixiao Lui
- Department of Neurosurgery, Tangdu Hospital, No. 569 Xin Si Road, Xi'an, 710038, Shaanxi Province, China
| | - Gang Zhu
- Department of Neurosurgery, Tangdu Hospital, No. 569 Xin Si Road, Xi'an, 710038, Shaanxi Province, China
| | - Hao Guo
- Department of Neurosurgery, Tangdu Hospital, No. 569 Xin Si Road, Xi'an, 710038, Shaanxi Province, China
| | - Dayun Feng
- Department of Neurosurgery, Tangdu Hospital, No. 569 Xin Si Road, Xi'an, 710038, Shaanxi Province, China
| | - Yan Qu
- Department of Neurosurgery, Tangdu Hospital, No. 569 Xin Si Road, Xi'an, 710038, Shaanxi Province, China.
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Excess Mortality Among Adults Hospitalized With Traumatic Brain Injury in Australia: A Population-Based Matched Cohort Study. J Head Trauma Rehabil 2020; 34:E1-E9. [PMID: 30418322 DOI: 10.1097/htr.0000000000000445] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To quantify and describe excess mortality attributable to traumatic brain injury (TBI) during the 12 months after hospitalization. DESIGN Population-based matched cohort study using linked hospital and mortality data. SETTING Australia. PARTICIPANTS Individuals 18 years and older who were hospitalized with a principal diagnosis of TBI in 2009 (n = 6929) and matched noninjured individuals randomly selected from the electoral roll (n = 6929). MAIN MEASURES Survival distributions were compared using a Kaplan-Meier plot with a log-rank test. Mortality rate ratios (MRRs) were computed using Cox proportional hazard regression with and without controlling for demographic characteristics and preexisting health status. RESULTS Individuals with TBI experienced significantly worse survival during the 12 months after hospitalization (χ = 640.9, df = 1, P < .001), and were more than 7.5 times more likely to die compared with their noninjured counterparts (adjusted MRR, 7.76; 95% confidence interval, 6.07-9.93). TBI was likely to be a contributory factor in 87% of deaths in the TBI cohort. Excess mortality was higher among males, younger age groups, and those with more severe TBI. CONCLUSION Excess mortality is high among individuals hospitalized with TBI and most deaths are attributable to the TBI. Increased primary and secondary preventive efforts are warranted to reduce the mortality burden of TBI.
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Xiong C, Hanafy S, Chan V, Hu ZJ, Sutton M, Escobar M, Colantonio A, Mollayeva T. Comorbidity in adults with traumatic brain injury and all-cause mortality: a systematic review. BMJ Open 2019; 9:e029072. [PMID: 31699721 PMCID: PMC6858248 DOI: 10.1136/bmjopen-2019-029072] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/12/2023] Open
Abstract
OBJECTIVES Comorbidity in traumatic brain injury (TBI) has been recognised to alter the clinical course of patients and influence short-term and long-term outcomes. We synthesised the evidence on the effects of different comorbid conditions on early and late mortality post-TBI in order to (1) examine the relationship between comorbid condition(s) and all-cause mortality in TBI and (2) determine the influence of sociodemographic and clinical characteristics of patients with a TBI at baseline on all-cause mortality. DESIGN Systematic review. DATA SOURCES Medline, Central, Embase, PsycINFO and bibliographies of identified articles were searched from May 1997 to January 2019. ELIGIBILITY CRITERIA FOR SELECTING STUDIES Included studies met the following criteria: (1) focused on comorbidity as it related to our outcome of interest in adults (ie, ≥18 years of age) diagnosed with a TBI; (2) comorbidity was detected by any means excluding self-report; (3) reported the proportion of participants without comorbidity and (4) followed participants for any period of time. DATA EXTRACTION AND SYNTHESIS Two independent reviewers extracted the data and assessed risk of bias using the Quality in Prognosis Studies tool. Data were synthesised through tabulation and qualitative description. RESULTS A total of 27 cohort studies were included. Among the wide range of individual comorbid conditions studied, only low blood pressure was a consistent predictors of post-TBI mortality. Other consistent predictors were traditional sociodemographic risk factors. Higher comorbidity scale, scores and the number of comorbid conditions were not consistently associated with post-TBI mortality. CONCLUSIONS Given the high number of comorbid conditions that were examined by the single studies, research is required to further substantiate the evidence and address conflicting findings. Finally, an enhanced set of comorbidity measures that are suited for the TBI population will allow for better risk stratification to guide TBI management and treatment. PROSPERO REGISTRATION NUMBER CRD42017070033.
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Affiliation(s)
- Chen Xiong
- Rehabilitation Sciences Institute, Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
- KITE-Toronto Rehab-University Health Network, Toronto, Ontario, Canada
- Acquired Brain Injury Research Lab, University of Toronto, Toronto, Ontario, Canada
| | - Sara Hanafy
- Rehabilitation Sciences Institute, Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
- KITE-Toronto Rehab-University Health Network, Toronto, Ontario, Canada
- Acquired Brain Injury Research Lab, University of Toronto, Toronto, Ontario, Canada
| | - Vincy Chan
- KITE-Toronto Rehab-University Health Network, Toronto, Ontario, Canada
- Acquired Brain Injury Research Lab, University of Toronto, Toronto, Ontario, Canada
| | - Zheng Jing Hu
- KITE-Toronto Rehab-University Health Network, Toronto, Ontario, Canada
- Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
| | - Mitchell Sutton
- KITE-Toronto Rehab-University Health Network, Toronto, Ontario, Canada
| | - Michael Escobar
- Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
| | - Angela Colantonio
- Rehabilitation Sciences Institute, Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
- KITE-Toronto Rehab-University Health Network, Toronto, Ontario, Canada
- Acquired Brain Injury Research Lab, University of Toronto, Toronto, Ontario, Canada
- Department of Occupational Science and Occupational Therapy, University of Toronto, Toronto, Ontario, Canada
| | - Tatyana Mollayeva
- KITE-Toronto Rehab-University Health Network, Toronto, Ontario, Canada
- Acquired Brain Injury Research Lab, University of Toronto, Toronto, Ontario, Canada
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Spahn DR, Bouillon B, Cerny V, Duranteau J, Filipescu D, Hunt BJ, Komadina R, Maegele M, Nardi G, Riddez L, Samama CM, Vincent JL, Rossaint R. The European guideline on management of major bleeding and coagulopathy following trauma: fifth edition. Crit Care 2019; 23:98. [PMID: 30917843 PMCID: PMC6436241 DOI: 10.1186/s13054-019-2347-3] [Citation(s) in RCA: 695] [Impact Index Per Article: 139.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2018] [Accepted: 02/06/2019] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND Severe traumatic injury continues to present challenges to healthcare systems around the world, and post-traumatic bleeding remains a leading cause of potentially preventable death among injured patients. Now in its fifth edition, this document aims to provide guidance on the management of major bleeding and coagulopathy following traumatic injury and encourages adaptation of the guiding principles described here to individual institutional circumstances and resources. METHODS The pan-European, multidisciplinary Task Force for Advanced Bleeding Care in Trauma was founded in 2004, and the current author group included representatives of six relevant European professional societies. The group applied a structured, evidence-based consensus approach to address scientific queries that served as the basis for each recommendation and supporting rationale. Expert opinion and current clinical practice were also considered, particularly in areas in which randomised clinical trials have not or cannot be performed. Existing recommendations were re-examined and revised based on scientific evidence that has emerged since the previous edition and observed shifts in clinical practice. New recommendations were formulated to reflect current clinical concerns and areas in which new research data have been generated. RESULTS Advances in our understanding of the pathophysiology of post-traumatic coagulopathy have supported improved management strategies, including evidence that early, individualised goal-directed treatment improves the outcome of severely injured patients. The overall organisation of the current guideline has been designed to reflect the clinical decision-making process along the patient pathway in an approximate temporal sequence. Recommendations are grouped behind the rationale for key decision points, which are patient- or problem-oriented rather than related to specific treatment modalities. While these recommendations provide guidance for the diagnosis and treatment of major bleeding and coagulopathy, emerging evidence supports the author group's belief that the greatest outcome improvement can be achieved through education and the establishment of and adherence to local clinical management algorithms. CONCLUSIONS A multidisciplinary approach and adherence to evidence-based guidance are key to improving patient outcomes. If incorporated into local practice, these clinical practice guidelines have the potential to ensure a uniform standard of care across Europe and beyond and better outcomes for the severely bleeding trauma patient.
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Affiliation(s)
- Donat R. Spahn
- Institute of Anaesthesiology, University of Zurich and University Hospital Zurich, Raemistrasse 100, CH-8091 Zurich, Switzerland
| | - Bertil Bouillon
- Department of Trauma and Orthopaedic Surgery, Cologne-Merheim Medical Centre (CMMC), University of Witten/Herdecke, Ostmerheimer Strasse 200, D-51109 Cologne, Germany
| | - Vladimir Cerny
- Department of Anaesthesiology, Perioperative Medicine and Intensive Care, J.E. Purkinje University, Masaryk Hospital, Usti nad Labem, Socialni pece 3316/12A, CZ-40113 Usti nad Labem, Czech Republic
- Centre for Research and Development, University Hospital Hradec Kralove, Hradec Kralove, Czech Republic, Sokolska 581, CZ-50005 Hradec Kralove, Czech Republic
- Department of Anaesthesiology and Intensive Care Medicine, Faculty of Medicine in Hradec Kralove, Charles University, Simkova 870, CZ-50003 Hradec Kralove, Czech Republic
- Department of Anaesthesia, Pain Management and Perioperative Medicine, QE II Health Sciences Centre, Dalhousie University, Halifax, 10 West Victoria, 1276 South Park St, Halifax, NS B3H 2Y9 Canada
| | - Jacques Duranteau
- Department of Anaesthesia and Intensive Care, Hôpitaux Universitaires Paris Sud, University of Paris XI, Faculté de Médecine Paris-Sud, 78 rue du Général Leclerc, F-94275 Le Kremlin-Bicêtre Cedex, France
| | - Daniela Filipescu
- Department of Cardiac Anaesthesia and Intensive Care, C. C. Iliescu Emergency Institute of Cardiovascular Diseases, Sos Fundeni 256-258, RO-022328 Bucharest, Romania
| | - Beverley J. Hunt
- King’s College and Departments of Haematology and Pathology, Guy’s and St Thomas’ NHS Foundation Trust, Westminster Bridge Road, London, SE1 7EH UK
| | - Radko Komadina
- Department of Traumatology, General and Teaching Hospital Celje, Medical Faculty Ljubljana University, SI-3000 Celje, Slovenia
| | - Marc Maegele
- Department of Trauma and Orthopaedic Surgery, Cologne-Merheim Medical Centre (CMMC), Institute for Research in Operative Medicine (IFOM), University of Witten/Herdecke, Ostmerheimer Strasse 200, D-51109 Cologne, Germany
| | - Giuseppe Nardi
- Department of Anaesthesia and ICU, AUSL della Romagna, Infermi Hospital Rimini, Viale Settembrini, 2, I-47924 Rimini, Italy
| | - Louis Riddez
- Department of Surgery and Trauma, Karolinska University Hospital, S-171 76 Solna, Sweden
| | - Charles-Marc Samama
- Hotel-Dieu University Hospital, 1, place du Parvis de Notre-Dame, F-75181 Paris Cedex 04, France
| | - Jean-Louis Vincent
- Department of Intensive Care, Erasme University Hospital, Université Libre de Bruxelles, Route de Lennik 808, B-1070 Brussels, Belgium
| | - Rolf Rossaint
- Department of Anaesthesiology, University Hospital Aachen, RWTH Aachen University, Pauwelsstrasse 30, D-52074 Aachen, Germany
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Krishnan A, Suarez-Pierre A, Zhou X, Lin CT, Fraser CD, Crawford TC, Hsu J, Hasan RK, Resar J, Chacko M, Baumgartner WA, Conte JV, Mandal K. Comparing Frailty Markers in Predicting Poor Outcomes after Transcatheter Aortic Valve Replacement. INNOVATIONS-TECHNOLOGY AND TECHNIQUES IN CARDIOTHORACIC AND VASCULAR SURGERY 2019; 14:43-54. [PMID: 30848712 DOI: 10.1177/1556984519827698] [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: 12/21/2022]
Abstract
INTRODUCTION Frailty is an important component of risk prognostication in transcatheter aortic valve replacement (TAVR). Objective markers of frailty, including sarcopenia, the modified Frailty Index (mFI), and albumin levels, have emerged, but little is known how such markers compare to each other in predicting outcomes after TAVR. We sought to define and compare these markers in predicting long-term outcomes after TAVR. METHODS Patients who underwent TAVR at our institution from 2011 to 2016 were included. Indexed cross-sectional areas of the lumbosacral muscles on preoperative computed tomography scans were used to assess sarcopenia. Optimal cutoffs for sarcopenia were defined using a statistically validated method. mFI was calculated using an 11-point scale of clinical characteristics. The primary outcome was 2-year all-cause mortality. Adjusted survival analysis was used to analyze outcomes. RESULTS A total of 381 patients were included in this study. Sarcopenia of the psoas muscles was associated with an increased risk of mortality on univariate (HR: 2.3, P = 0.01) and multivariate (HR: 2.5, P = 0.01) analysis. Sarcopenia of the paravertebral muscles was associated with increased risk of mortality only on univariate analysis (HR: 2.1, P = 0.03). Increased preoperative albumin levels were associated with decreased risk of mortality on univariate (HR: 0.3, P < 0.01) and multivariate analysis (HR: 0.3, P < 0.01). The (mFI) was not associated with mortality on univariate or multivariate analysis. DISCUSSION Novel cutoffs for sarcopenia of the psoas muscles were determined and associated with decreased survival after TAVR. Sarcopenia and albumin levels may be better tools for risk prediction than mFI in TAVR.
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Affiliation(s)
- Aravind Krishnan
- 1 Division of Cardiac Surgery, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Alejandro Suarez-Pierre
- 1 Division of Cardiac Surgery, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Xun Zhou
- 1 Division of Cardiac Surgery, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Cheng T Lin
- 2 Department of Radiology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Charles D Fraser
- 1 Division of Cardiac Surgery, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Todd C Crawford
- 1 Division of Cardiac Surgery, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Joshua Hsu
- 1 Division of Cardiac Surgery, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Rani K Hasan
- 3 Department of Medicine, Division of Cardiology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Jon Resar
- 3 Department of Medicine, Division of Cardiology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Matthews Chacko
- 3 Department of Medicine, Division of Cardiology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - William A Baumgartner
- 1 Division of Cardiac Surgery, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - John V Conte
- 4 Division of Cardiac Surgery, Department of Surgery, Penn State College of Medicine, Hershey, PA, USA
| | - Kaushik Mandal
- 4 Division of Cardiac Surgery, Department of Surgery, Penn State College of Medicine, Hershey, PA, USA
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Ali Ali B, Brinck T, Handolin L, Belzunegui Otano T. Severe head injury in elderly: 6-year comparison of treatment and outcome between southern Finland and Navarra (Spain). Eur J Trauma Emerg Surg 2019; 47:1429-1436. [PMID: 30747276 DOI: 10.1007/s00068-019-01091-8] [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] [Received: 09/13/2018] [Accepted: 02/07/2019] [Indexed: 11/30/2022]
Abstract
PURPOSE To compare the profile, treatment and outcome of elderly patients with severe traumatic brain injuries (TBI) between southern Finland and Navarra (Spain). METHODS Data collected from, 2010 to 2015, in the Major Trauma Registry of Navarra (MTR-N) and the Helsinki Trauma Registry (HTR) were compared. Patients with New Injury Severity Score (NISS) ≥ 16 and age ≥ 65 with isolated severe TBI were considered. Patients who had been admitted to the hospital ≥ 24 h after the trauma, had been pronounced dead before hospital arrival, or had been injured by hanging, drowning or burns, were excluded. Outcome was defined by 30-day hospital mortality. The expected mortality was calculated using the Revised Injury Severity Classification score II (RISC II). Other compared data included demographics, injury mechanism, pre-hospital and hospital treatment, and time intervals. RESULTS A total of 305 (MTR-N) and 137 (HTR) patients were included in the outcome analysis. The standardized mortality ratio with 95% confidence interval was for MTR-N 1.4 (1.1-1.6) and for HTR 0.8 (0.6-1.1). Patients in Navarra were older (average 79.7 vs. 75.0) while in southern Finland the percentage of pre-hospital intubation in patients with GCS ≤ 8 (75.0% vs 50.0%) and ICU admission (72.2% vs 22.0%) were higher. CONCLUSION The better adjusted outcome of elderly patients with severe TBI in southern Finland in comparison to Navarra could be due to higher rate of pre-hospital intubation and/or higher rate of ICU admissions in southern Finland. Increasing number of elderly patients with severe TBI necessitate uniformly accepted protocols in pre- and in-hospital management.
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Affiliation(s)
- Bismil Ali Ali
- Accident and Emergency Department, Complejo Hospitalario de Navarra, Health service of Navarra-Osasunbidea, 31011, Pamplona, Spain.
| | - Tuomas Brinck
- Trauma Unit, Helsinki University Hospital, University of Helsinki, Helsinki, Finland
| | - Lauri Handolin
- Trauma Unit, Helsinki University Hospital, University of Helsinki, Helsinki, Finland
| | - Tomas Belzunegui Otano
- Accident and Emergency Department, Complejo Hospitalario de Navarra, Health service of Navarra-Osasunbidea, 31011, Pamplona, Spain.,Department of Health, Public University of Navarra, Pamplona, Spain
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Glass NE, Vadlamani A, Hwang F, Sifri ZC, Kunac A, Bonne S, Pentakota SR, Yonclas P, Mosenthal AC, Livingston DH, Albrecht JS. Bleeding and Thromboembolism After Traumatic Brain Injury in the Elderly: A Real Conundrum. J Surg Res 2018; 235:615-620. [PMID: 30691850 DOI: 10.1016/j.jss.2018.10.021] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2018] [Revised: 08/22/2018] [Accepted: 10/16/2018] [Indexed: 12/23/2022]
Abstract
BACKGROUND Elderly patients presenting with a traumatic brain injury (TBI) often have comorbidities that increase risk of thromboembolic (TE) disease and recurrent TBI. A significant number are on anticoagulant therapy at the time of injury and studies suggest that continuing anticoagulation can prevent TE events. Understanding bleeding, recurrent TBI, and TE risk after TBI can help to guide therapy. Our objectives were to 1) evaluate the incidence of bleeding, recurrent TBI, and TE events after an initial TBI in older adults and 2) identify which factors contribute to this risk. METHODS Retrospective analysis of Medicare claims between May 30, 2006 and December 31, 2009 for patients hospitalized with TBI was performed. We defined TBI for the index admission, and hemorrhage (gastrointestinal bleeding or hemorrhagic stroke), recurrent TBI, and TE events (stroke, myocardial infarction, deep venous thrombosis, or pulmonary embolism) over the following year using ICD-9 codes. Unadjusted incidence rates and 95% confidence intervals (CIs) were calculated. Risk factors of these events were identified using logistic regression. RESULTS Among beneficiaries hospitalized with TBI, incidence of TE events (58.6 events/1000 person-years; 95% CI 56.2, 60.8) was significantly higher than bleeding (23.6 events/1000 person-years; 95% CI 22.2, 25.1) and recurrent TBI events (26.0 events/1000 person-years; 95% CI 24.5, 27.6). Several common factors predisposed to bleeding, recurrent TBI, and TE outcomes. CONCLUSIONS Among Medicare patients hospitalized with TBI, the incidence of TE was significantly higher than that of bleeding or recurrent TBI. Specific risk factors of bleeding and TE events were identified which may guide care of older adults after TBI.
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Affiliation(s)
- Nina E Glass
- Division of Trauma and Critical Care, Department of Surgery, Rutgers-New Jersey Medical School, Newark, New Jersey.
| | - Aparna Vadlamani
- Department of Epidemiology and Public Health, University of Maryland School of Medicine, Baltimore, Maryland
| | - Franchesca Hwang
- Division of Trauma and Critical Care, Department of Surgery, Rutgers-New Jersey Medical School, Newark, New Jersey
| | - Ziad C Sifri
- Division of Trauma and Critical Care, Department of Surgery, Rutgers-New Jersey Medical School, Newark, New Jersey
| | - Anastasia Kunac
- Division of Trauma and Critical Care, Department of Surgery, Rutgers-New Jersey Medical School, Newark, New Jersey
| | - Stephanie Bonne
- Division of Trauma and Critical Care, Department of Surgery, Rutgers-New Jersey Medical School, Newark, New Jersey
| | - Sri Ram Pentakota
- Division of Trauma and Critical Care, Department of Surgery, Rutgers-New Jersey Medical School, Newark, New Jersey
| | - Peter Yonclas
- Division of Trauma and Critical Care, Department of Surgery, Rutgers-New Jersey Medical School, Newark, New Jersey
| | - Anne C Mosenthal
- Division of Trauma and Critical Care, Department of Surgery, Rutgers-New Jersey Medical School, Newark, New Jersey
| | - David H Livingston
- Division of Trauma and Critical Care, Department of Surgery, Rutgers-New Jersey Medical School, Newark, New Jersey
| | - Jennifer S Albrecht
- Department of Epidemiology and Public Health, University of Maryland School of Medicine, Baltimore, Maryland
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Gardner RC, Dams-O'Connor K, Morrissey MR, Manley GT. Geriatric Traumatic Brain Injury: Epidemiology, Outcomes, Knowledge Gaps, and Future Directions. J Neurotrauma 2018; 35:889-906. [PMID: 29212411 PMCID: PMC5865621 DOI: 10.1089/neu.2017.5371] [Citation(s) in RCA: 244] [Impact Index Per Article: 40.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
This review of the literature on traumatic brain injury (TBI) in older adults focuses on incident TBI sustained in older adulthood ("geriatric TBI") rather than on the separate, but related, topic of older adults with a history of earlier-life TBI. We describe the epidemiology of geriatric TBI, the impact of comorbidities and pre-injury function on TBI risk and outcomes, diagnostic testing, management issues, outcomes, and critical directions for future research. The highest incidence of TBI-related emergency department visits, hospitalizations, and deaths occur in older adults. Higher morbidity and mortality rates among older versus younger individuals with TBI may contribute to an assumption of futility about aggressive management of geriatric TBI. However, many older adults with TBI respond well to aggressive management and rehabilitation, suggesting that chronological age and TBI severity alone are inadequate prognostic markers. Yet there are few geriatric-specific TBI guidelines to assist with complex management decisions, and TBI prognostic models do not perform optimally in this population. Major barriers in management of geriatric TBI include under-representation of older adults in TBI research, lack of systematic measurement of pre-injury health that may be a better predictor of outcome and response to treatment than age and TBI severity alone, and lack of geriatric-specific TBI common data elements (CDEs). This review highlights the urgent need to develop more age-inclusive TBI research protocols, geriatric TBI CDEs, geriatric TBI prognostic models, and evidence-based geriatric TBI consensus management guidelines aimed at improving short- and long-term outcomes for the large and growing geriatric TBI population.
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Affiliation(s)
- Raquel C. Gardner
- Department of Neurology, University of California San Francisco, and San Francisco VA Medical Center, San Francisco, California
- University of California San Francisco Weill Institute for Neurosciences, San Francisco, California
| | - Kristen Dams-O'Connor
- Department of Rehabilitation Medicine, Icahn School of Medicine at Mt. Sinai, New York, New York
| | - Molly Rose Morrissey
- Department of Neurosurgery, Brain and Spinal Injury Center, University of California San Francisco and Zuckerberg San Francisco General Hospital, San Francisco, California
| | - Geoffrey T. Manley
- University of California San Francisco Weill Institute for Neurosciences, San Francisco, California
- Department of Neurosurgery, Brain and Spinal Injury Center, University of California San Francisco and Zuckerberg San Francisco General Hospital, San Francisco, California
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Zarshenas S, Tam L, Colantonio A, Alavinia SM, Cullen N. Predictors of discharge destination from acute care in patients with traumatic brain injury. BMJ Open 2017; 7:e016694. [PMID: 28860230 PMCID: PMC5589015 DOI: 10.1136/bmjopen-2017-016694] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Abstract
INTRODUCTION Many studies have assessed the predictors of morbidity/mortality of patients with traumatic brain injury (TBI) in acute care. However, with the increasing rate of survival after TBI, more attention has been given to discharge destinations from acute care as an important measure of clinical priorities. This study describes the design of a systematic review compiling and synthesising studies on the prognostic factors of discharge settings from acute care in patients with TBI. METHODS AND ANALYSIS This systematic review will be conducted on peer-reviewed studies using seven databases including Medline/Medline in-Process, Embase, Cochrane Database of Systematic Reviews, Cochrane CENTRAL, PsycINFO, CINAHL and Supplemental PubMed. The reference list of selected articles and Google Scholar will also be reviewed to determine other relevant articles. This study will include all English language observational studies that focus on adult patients with TBI in acute care settings. The quality of articles will be assessed by the Quality in Prognostic Studies tool. ETHICS AND DISSEMINATION The results of this review will provide evidence that may guide healthcare providers in making more informed and timely discharge decisions to the next level of care for patient with TBI. Also, this study will provide valuable information to address the gaps in knowledge for future research. TRIAL REGISTRATION NUMBER Trial registration number (PROSPERO) is CRD42016033046.
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Affiliation(s)
- Sareh Zarshenas
- Rehabilitation Sciences Institute, University of Toronto, Toronto, Canada
- University Health Network-Toronto Rehabilitation Institute-University Centre, Toronto, Canada
| | - Laetitia Tam
- University Health Network-Toronto Rehabilitation Institute-University Centre, Toronto, Canada
| | - Angela Colantonio
- Rehabilitation Sciences Institute, University of Toronto, Toronto, Canada
- University Health Network-Toronto Rehabilitation Institute-University Centre, Toronto, Canada
| | - Seyed Mohammad Alavinia
- University Health Network-Toronto Rehabilitation Institute-Lyndhurst Centre, Toronto, Canada
| | - Nora Cullen
- Rehabilitation Sciences Institute, University of Toronto, Toronto, Canada
- University Health Network-Toronto Rehabilitation Institute-University Centre, Toronto, Canada
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Peeters W, Majdan M, Brazinova A, Nieboer D, Maas AIR. Changing Epidemiological Patterns in Traumatic Brain Injury: A Longitudinal Hospital-Based Study in Belgium. Neuroepidemiology 2017; 48:63-70. [PMID: 28448968 DOI: 10.1159/000471877] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2016] [Accepted: 03/19/2017] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Various reports have suggested that epidemiological patterns of Traumatic Brain Injury (TBI) are changing in high-income countries, but the evidence to support this is often indirect and only a few longitudinal studies exist. We aimed to explore epidemiological patterns of TBI in Belgium over a 10-year period. METHODS A retrospective analysis of Minimum Hospital Data provided by Statistics Belgium was performed for the period 2003-2012. ICD-9 classification was used to identify TBI and to differentiate subtypes. The annual incidence of hospital admissions and in-hospital mortality rates were calculated and further differentiated for age, gender and cause of injury. RESULTS The age-adjusted incidence of hospital admissions decreased by 3.6% per year. An increase in the number of elderly patients with TBI and a decrease in the younger age groups were found. Falls now represent the main cause of TBI. A mortality rate of 6.5 per 100,000 population per year was found and did not change significantly over time. CONCLUSIONS This longitudinal study confirms that epidemiological patterns in TBI are changing: overall incidence is steadily decreasing, but in elderly patients, the incidence is increasing. Falls are the leading cause, occurring most frequently in elderly patients. These changes are relevant for prevention.
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Computed tomography abbreviated assessment of sarcopenia following trauma: The CAAST measurement predicts 6-month mortality in older adult trauma patients. J Trauma Acute Care Surg 2016; 80:805-11. [PMID: 26885997 DOI: 10.1097/ta.0000000000000989] [Citation(s) in RCA: 45] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
BACKGROUND Older adult trauma patients are at increased risk of poor outcome, both immediately after injury and beyond hospital discharge. Identifying patients early in the hospital stay who are at increased risk of death after discharge can be challenging. METHODS Retrospective analysis was performed using our trauma registry linked with the social security death index from 2010 to 2014. Age was categorized as 18 to 64 and 65 years or older. We calculated mortality rates by age category then selected elderly patients with mechanism of injury being a fall for further analysis. Computed Tomography Abbreviated Assessment of Sarcopenia for Trauma (CAAST) was obtained by measuring psoas muscle cross-sectional area adjusted for height and weight. Kaplan-Meier survival analysis was performed, and proportional hazards regression modeling was used to determine independent risk factors for in-hospital and out-of-hospital mortality. RESULTS A total of 23,622 patients were analyzed (16,748, aged 18-64 years; and 6,874, aged 65 or older). In-hospital mortality was 1.96% for ages 18 to 64 and 7.19% for age 65 or older (p < 0.001); postdischarge 6-month mortality was 1.1% for ages 18 to 64 and 12.86% for age 65 or older (p < 0.001). Predictors of in-hospital and postdischarge mortality for ages 18 to 64 and in-hospital mortality for ages 65 or older group included injury characteristics such as ISS, admission vitals, and head injury. Predictors of postdischarge mortality for age 65or older included skilled nursing before admission, disposition, and mechanism of injury being a fall. A total of 57.5% (n = 256) of older patients who sustained a fall met criteria for sarcopenia. Sarcopenia was the strongest predictor of out-of-hospital mortality in this cohort with a hazard ratio of 4.77 (95% confidence interval, 2.71-8.40; p < 0.001). CONCLUSION Out of hospital does not assure out of danger for the elderly. Sarcopenia is a strong predictor of 6-month postdischarge mortality for older adults. The CAAST measurement is an efficient and inexpensive measure that can allow clinicians to target older trauma patients at risk of poor outcome for early intervention and/or palliative care services. LEVEL OF EVIDENCE Prognostic and epidemiologic study, level III.
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