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Zhuo M, Deng Z, Yuan L, Mai Z, Zhong M, Ye JM. Association of systemic inflammatory response index and clinical outcome in acute traumatic spinal cord injury patients. Sci Rep 2024; 14:19085. [PMID: 39154138 PMCID: PMC11330529 DOI: 10.1038/s41598-024-69699-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2024] [Accepted: 08/06/2024] [Indexed: 08/19/2024] Open
Abstract
Systemic inflammatory response index (SIRI) has been proven to be associated with the prognosis of coronary artery disease and many other diseases. However, the relationship between SIRI and acute traumatic spinal cord injury (tSCI) has rarely been evaluated. The study aims to assess the prognostic value of SIRI for clinical outcomes in individuals with acute tSCI. A total of 190 patients admitted within eight hours after tSCI between January 2021 and April 2023 were enrolled in our study. Logistic regression analysis was used to analyze the association between SIRI and American Spinal Injury Association Impairment Scale (AIS) grade at admission and discharge, as well as neurological improvement in tSCI patients, and receiver operating characteristic (ROC) analysis was performed to assess the discriminative ability of SIRI in predicting AIS grade at discharge. After adjusting for confounding factors, SIRI positively correlated with the AIS grade (A to C) at admission and discharge, and negatively correlated with neurological improvement. The area under the curve values in ROC analysis was 0.725 (95% CI 0.647, 0.803). The study suggests that SIRI is significantly associated with an increased risk of poor clinical outcome at discharge in tSCI patients and has a certain discriminative value.
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Affiliation(s)
- Ming Zhuo
- Medical College of Soochow University, Suzhou, 215123, Jiangsu, China
- Department of Anesthesiology, The First Affiliated Hospital of Gannan Medical University, Ganzhou, 341000, China
| | - Zihao Deng
- Department of Anesthesiology, The First Affiliated Hospital of Gannan Medical University, Ganzhou, 341000, China
| | - Lin Yuan
- Gannan Medical University, Ganzhou, 341000, China
| | - Zifeng Mai
- Gannan Medical University, Ganzhou, 341000, China
| | - Maolin Zhong
- Department of Anesthesiology, The First Affiliated Hospital of Gannan Medical University, Ganzhou, 341000, China
| | - Jun-Ming Ye
- Medical College of Soochow University, Suzhou, 215123, Jiangsu, China.
- Department of Anesthesiology, The First Affiliated Hospital of Gannan Medical University, Ganzhou, 341000, China.
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Gabbe BJ, Keeves J, McKimmie A, Gadowski AM, Holland AJ, Semple BD, Young JT, Crowe L, Ownsworth T, Bagg MK, Antonic-Baker A, Hicks AJ, Hill R, Curtis K, Romero L, Ponsford JL, Lannin NA, O'Brien TJ, Cameron PA, Cooper DJ, Rushworth N, Fitzgerald M. The Australian Traumatic Brain Injury Initiative: Systematic Review and Consensus Process to Determine the Predictive Value of Demographic, Injury Event, and Social Characteristics on Outcomes for People With Moderate-Severe Traumatic Brain Injury. J Neurotrauma 2024. [PMID: 38115598 DOI: 10.1089/neu.2023.0461] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2023] Open
Abstract
The objective of the Australian Traumatic Brain Injury (AUS-TBI) Initiative is to develop a data dictionary to inform data collection and facilitate prediction of outcomes of people who experience moderate-severe TBI in Australia. The aim of this systematic review was to summarize the evidence of the association between demographic, injury event, and social characteristics with outcomes, in people with moderate-severe TBI, to identify potentially predictive indicators. Standardized searches were implemented across bibliographic databases to March 31, 2022. English-language reports, excluding case series, which evaluated the association between demographic, injury event, and social characteristics, and any clinical outcome in at least 10 patients with moderate-severe TBI were included. Abstracts and full text records were independently screened by at least two reviewers in Covidence. A pre-defined algorithm was used to assign a judgement of predictive value to each observed association. The review findings were discussed with an expert panel to determine the feasibility of incorporation of routine measurement into standard care. The search strategy retrieved 16,685 records; 867 full-length records were screened, and 111 studies included. Twenty-two predictors of 32 different outcomes were identified; 7 were classified as high-level (age, sex, ethnicity, employment, insurance, education, and living situation at the time of injury). After discussion with an expert consensus group, 15 were recommended for inclusion in the data dictionary. This review identified numerous predictors capable of enabling early identification of those at risk for poor outcomes and improved personalization of care through inclusion in routine data collection.
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Affiliation(s)
- Belinda J Gabbe
- School of Public Health and Preventive Medicine, Monash University, Melbourne, VIC, Australia
- Health Data Research UK, Swansea University Medical School, Swansea University, Singleton Park, United Kingdom
| | - Jemma Keeves
- School of Public Health and Preventive Medicine, Monash University, Melbourne, VIC, Australia
- Perron Institute for Neurological and Translational Science, Nedlands, WA, Australia
- Curtin Health Innovation Research Institute, Faculty of Health Sciences, Curtin School of Population Health, Curtin University, Bentley, WA, Australia
| | - Ancelin McKimmie
- School of Public Health and Preventive Medicine, Monash University, Melbourne, VIC, Australia
| | - Adelle M Gadowski
- School of Public Health and Preventive Medicine, Monash University, Melbourne, VIC, Australia
| | - Andrew J Holland
- The Children's Hospital at Westmead Clinical School, Faculty of Medicine and Health, University of Sydney School of Medicine, Westmead, Australia
| | - Bridgette D Semple
- Department of Neuroscience, School of Translational Medicine, Monash University, Melbourne, VIC, Australia
| | - Jesse T Young
- Institute for Mental Health Policy Research, Centre for Addiction and Mental Health, Toronto, Ontario, Canada
- Centre for Epidemiology and Biostatistics, Melbourne School of Population and Global Health, The University of Melbourne, Parkville, VIC, Australia
- Clinical Sciences Murdoch Children's Research Institute, Parkville, VIC, Australia
- School of Population and Global Health, The University of Western Australia, Perth, WA, Australia
- Justice Health Group, Curtin School of Population Health, Curtin University, Bentley, WA, Australia
- Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
| | - Louise Crowe
- Clinical Sciences Murdoch Children's Research Institute, Parkville, VIC, Australia
| | - Tamara Ownsworth
- School of Applied Psychology and the Hopkins Centre, Griffith University, Brisbane, Australia
| | - Matthew K Bagg
- Perron Institute for Neurological and Translational Science, Nedlands, WA, Australia
- Curtin Health Innovation Research Institute, Faculty of Health Sciences, Curtin School of Population Health, Curtin University, Bentley, WA, Australia
- Centre for Pain IMPACT, Neuroscience Research Australia, Sydney, NSW, Australia
- School of Health Sciences, University of Notre Dame Australia, Fremantle, WA, Australia
| | - Ana Antonic-Baker
- Department of Neuroscience, School of Translational Medicine, Monash University, Melbourne, VIC, Australia
| | - Amelia J Hicks
- Monash-Epworth Rehabilitation Research Centre, Epworth Healthcare, Melbourne, VIC, Australia
- School of Psychological Sciences, Monash University, Melbourne, VIC, Australia
| | - Regina Hill
- Regina Hill Effective Consulting Pty. Ltd., Melbourne, VIC, Australia
| | - Kate Curtis
- Susan Wakil School of Nursing and Midwifery, Faculty of Medicine and Health, The University of Sydney, Camperdown, NSW, Australia
- Illawarra Shoalhaven LHD, Wollongong, NSW, Australia
- George Institute for Global Health, Newtown, NSW, Australia
| | | | - Jennie L Ponsford
- Monash-Epworth Rehabilitation Research Centre, Epworth Healthcare, Melbourne, VIC, Australia
- School of Psychological Sciences, Monash University, Melbourne, VIC, Australia
| | - Natasha A Lannin
- Department of Neuroscience, School of Translational Medicine, Monash University, Melbourne, VIC, Australia
- Alfred Health, Melbourne, VIC, Australia
| | - Terence J O'Brien
- Department of Neuroscience, School of Translational Medicine, Monash University, Melbourne, VIC, Australia
| | - Peter A Cameron
- School of Public Health and Preventive Medicine, Monash University, Melbourne, VIC, Australia
- National Trauma Research Institute, Melbourne, VIC, Australia
- Emergency and Trauma Centre, The Alfred Hospital, Melbourne, VIC, Australia
| | - D Jamie Cooper
- School of Public Health and Preventive Medicine, Monash University, Melbourne, VIC, Australia
- Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine, Monash University, Melbourne, VIC, Australia
- Department of Intensive Care and Hyperbaric Medicine, The Alfred, Melbourne, VIC, Australia
| | | | - Melinda Fitzgerald
- Perron Institute for Neurological and Translational Science, Nedlands, WA, Australia
- Curtin Health Innovation Research Institute, Faculty of Health Sciences, Curtin School of Population Health, Curtin University, Bentley, WA, Australia
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Chen X, Wang X, Liu Y, Guo X, Wu F, Yang Y, Hu W, Zheng F, He H. Plasma D-dimer levels are a biomarker for in-hospital complications and long-term mortality in patients with traumatic brain injury. Front Mol Neurosci 2023; 16:1276726. [PMID: 37965038 PMCID: PMC10641409 DOI: 10.3389/fnmol.2023.1276726] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2023] [Accepted: 10/11/2023] [Indexed: 11/16/2023] Open
Abstract
Introduction Traumatic brain injury (TBI) is a major health concern worldwide. D-dimer levels, commonly used in the diagnosis and treatment of neurological diseases, may be associated with adverse events in patients with TBI. However, the relationship between D-dimer levels, TBI-related in-hospital complications, and long-term mortality in patients with TBI has not been investigated. Here, examined whether elevated D-dimer levels facilitate the prediction of in-hospital complications and mortality in patients with TBI. Methods Overall, 1,338 patients with TBI admitted to our institute between January 2016 and June 2022 were retrospectively examined. D-dimer levels were assessed within 24 h of admission, and propensity score matching was used to adjust for baseline characteristics. Results Among the in-hospital complications, high D-dimer levels were associated with electrolyte metabolism disorders, pulmonary infections, and intensive care unit admission (p < 0.05). Compared with patients with low (0.00-1.54 mg/L) D-dimer levels, the odds of long-term mortality were significantly higher in all other patients, including those with D-dimer levels between 1.55 mg/L and 6.35 mg/L (adjusted hazard ratio [aHR] 1.655, 95% CI 0.9632.843), 6.36 mg/L and 19.99 mg/L (aHR 2.38, 95% CI 1.416-4.000), and >20 mg/L (aHR 3.635, 95% CI 2.195-6.018; p < 0.001). D-dimer levels were positively correlated with the risk of death when the D-dimer level reached 6.82 mg/L. Conclusion Overall, elevated D-dimer levels at admission were associated with adverse outcomes and may predict poor prognosis in patients with TBI. Our findings will aid in the acute diagnosis, classification, and management of TBI.
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Affiliation(s)
- Xinli Chen
- Department of Anesthesiology, The Second Affiliated Hospital of Fujian Medical University, Quanzhou, China
| | - Xiaohua Wang
- Department of Anesthesiology, The Second Affiliated Hospital of Fujian Medical University, Quanzhou, China
| | - Yingchao Liu
- Department of Anesthesiology, The Second Affiliated Hospital of Fujian Medical University, Quanzhou, China
| | - Xiumei Guo
- Department of Neurosurgery, The Second Affiliated Hospital of Fujian Medical University, Quanzhou, China
| | - Fan Wu
- Department of Anesthesiology, The Second Affiliated Hospital of Fujian Medical University, Quanzhou, China
| | - Yushen Yang
- Department of Anesthesiology, The Second Affiliated Hospital of Fujian Medical University, Quanzhou, China
| | - Weipeng Hu
- Department of Neurosurgery, The Second Affiliated Hospital of Fujian Medical University, Quanzhou, China
| | - Feng Zheng
- Department of Neurosurgery, The Second Affiliated Hospital of Fujian Medical University, Quanzhou, China
| | - Hefan He
- Department of Anesthesiology, The Second Affiliated Hospital of Fujian Medical University, Quanzhou, China
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Habibzadeh A, Andishgar A, Kardeh S, Keshavarzian O, Taheri R, Tabrizi R, Keshavarz P. Prediction of Mortality and Morbidity After Severe Traumatic Brain Injury: A Comparison Between Rotterdam and Richmond Computed Tomography Scan Scoring System. World Neurosurg 2023; 178:e371-e381. [PMID: 37482083 DOI: 10.1016/j.wneu.2023.07.076] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2023] [Accepted: 07/16/2023] [Indexed: 07/25/2023]
Abstract
OBJECTIVE Accurate prediction of the morbidity and mortality outcomes of traumatic brain injury patients is still challenging. In the present study, we aimed to compare the predictive value of the Richmond and Rotterdam scoring systems as two novel computed tomography-based predictive models. METHODS We retrospectively analyzed 1400 subjects who suffered from severe traumatic brain injury and were admitted to Emtiaz Hospital, a tertiary referral trauma center in Shiraz, south of Iran, from January 2018 to December 2019. We evaluated the 1-month results; considering two primary factors: mortality and morbidity. The patients' condition was the basis for this assessment. We conducted a logistic regression analysis to determine the association between scoring systems and outcomes. To determine the optimal threshold value, we utilized the receiver operating characteristic curve model. RESULTS The mean age of participants was 36.61 ± 17.58 years, respectively. Concerning predicting the mortality rate, the area under the curve (AUC) for the Rotterdam score was relatively low 0.64 (95% confidence interval: 0.60, 0.67), while the Richmond score had a higher AUC 0.74 (0.71-0.77), which demonstrated the superiority of this scoring system. Moreover, the Richmond score was more accurate for predicting 1-month morbidity with AUC: 0.71 (0.69, 0.74) versus 0.62 (0.59, 0.65). CONCLUSIONS The Richmond scoring system demonstrated more accurate predictions for the present outcomes. The simplicity and predictive value of the Richmond score make this system an ideal option for use in emergency settings and centers with high patient loads.
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Affiliation(s)
- Adrina Habibzadeh
- Student Research Committee, Fasa University of Medical Sciences, Fasa, Iran; USERN Office, Fasa University of Medical Sciences, Fasa, Iran
| | - Aref Andishgar
- Student Research Committee, Fasa University of Medical Sciences, Fasa, Iran
| | - Sina Kardeh
- Central Clinical School, Monash University, Melbourne, Australia
| | - Omid Keshavarzian
- School of Medicine, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Reza Taheri
- Clinical Research Development Unit, Valiasr Hospital, Fasa University of Medical Sciences, Fasa, Iran; Department of Neurosurgery, School of Medicine, Shiraz University of Medical Sciences, Shiraz, Iran.
| | - Reza Tabrizi
- USERN Office, Fasa University of Medical Sciences, Fasa, Iran; Clinical Research Development Unit, Valiasr Hospital, Fasa University of Medical Sciences, Fasa, Iran; Noncommunicable Diseases Research Center, Fasa University of Medical Science, Fasa, Iran.
| | - Pedram Keshavarz
- Department of Radiological Sciences, David Geffen School of Medicine, University of California, Los Angeles (UCLA), Los Angeles, California, USA
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Lang L, Wang T, Xie L, Yang C, Skudder-Hill L, Jiang J, Gao G, Feng J. An independently validated nomogram for individualised estimation of short-term mortality risk among patients with severe traumatic brain injury: a modelling analysis of the CENTER-TBI China Registry Study. EClinicalMedicine 2023; 59:101975. [PMID: 37180469 PMCID: PMC10173159 DOI: 10.1016/j.eclinm.2023.101975] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/27/2023] [Revised: 04/02/2023] [Accepted: 04/05/2023] [Indexed: 05/16/2023] Open
Abstract
Background Severe traumatic brain injury (sTBI) is extremely disabling and associated with high mortality. Early detection of patients at risk of short-term (≤14 days after injury) death and provision of timely treatment is critical. This study aimed to establish and independently validate a nomogram to estimate individualised short-term mortality for sTBI based on large-scale data from China. Methods The data were from the Collaborative European NeuroTrauma Effectiveness Research in TBI (CENTER-TBI) China registry (between Dec 22, 2014, and Aug 1, 2017; registered at ClinicalTrials.gov, NCT02210221). This analysis included information of eligible patients with diagnosed sTBI from 52 centres (2631 cases). 1808 cases from 36 centres were enrolled in the training group (used to construct the nomogram) and 823 cases from 16 centres were enrolled in the validation group. Multivariate logistic regression was used to identify independent predictors of short-term mortality and establish the nomogram. The discrimination of the nomogram was evaluated using area under the receiver operating characteristic curves (AUC) and concordance indexes (C-index), the calibration was evaluated using calibration curves and Hosmer-Lemeshow tests (H-L tests). Decision curve analysis (DCA) was used to evaluate the net benefit of the model for patients. Findings In the training group, multivariate logistic regression demonstrated that age (odds ratio [OR] 1.013, 95% confidence interval [CI] 1.003-1.022), Glasgow Coma Scale score (OR 33.997, 95% CI 14.657-78.856), Injury Severity Score (OR 1.020, 95% CI 1.009-1.032), abnormal pupil status (OR 1.738, 95% CI 1.178-2.565), midline shift (OR 2.266, 95% CI 1.378-3.727), and pre-hospital intubation (OR 2.059, 95% CI 1.472-2.879) were independent predictors for short-term death in patients with sTBI. A nomogram was built using the logistic regression prediction model. The AUC and C-index were 0.859 (95% CI 0.837-0.880). The calibration curve of the nomogram was close to the ideal reference line, and the H-L test p value was 0.504. DCA curve demonstrated significantly better net benefit with the model. Application of the nomogram in external validation group still showed good discrimination (AUC and C-index were 0.856, 95% CI 0.827-0.886), calibration, and clinical usefulness. Interpretation A nomogram was developed for predicting the occurrence of short-term (≤14 days after injury) death in patients with sTBI. This can provide clinicians with an effective and accurate tool for the early prediction and timely management of sTBI, as well as support clinical decision-making around the withdrawal of life-sustaining therapy. This nomogram is based on Chinese large-scale data and is especially relevant to low- and middle-income countries. Funding Shanghai Academic Research Leader (21XD1422400), Shanghai Medical and Health Development Foundation (20224Z0012).
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Affiliation(s)
- Lijian Lang
- Brain Injury Centre, Renji Hospital, Shanghai Jiao Tong University School of Medicine, 160 Pujian Road, Shanghai, 200127, China
- Shanghai Institute of Head Trauma, 160 Pujian Road, Shanghai, 200127, China
| | - Tianwei Wang
- Department of Neurosurgery, Zhujiang Hospital, Southern Medical University, 253 Gongye Dadao, Haizhu District, Guangzhou, 510282, China
| | - Li Xie
- Clinical Research Institute, Shanghai Jiao Tong University School of Medicine, 227 Chongqing Road, Shanghai, China
| | - Chun Yang
- Shanghai Institute of Head Trauma, 160 Pujian Road, Shanghai, 200127, China
| | - Loren Skudder-Hill
- Department of Neurosurgery, Yuquan Hospital Affiliated to Tsinghua University School of Clinical Medicine, 5 Shijingshan Road, Shijingshan, Beijing, 100049, China
| | - Jiyao Jiang
- Brain Injury Centre, Renji Hospital, Shanghai Jiao Tong University School of Medicine, 160 Pujian Road, Shanghai, 200127, China
- Shanghai Institute of Head Trauma, 160 Pujian Road, Shanghai, 200127, China
| | - Guoyi Gao
- Shanghai Institute of Head Trauma, 160 Pujian Road, Shanghai, 200127, China
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, 100070, China
- Corresponding author. Shanghai Institute of Head Trauma, 160 Pujian Road, Shanghai, 200127, China.
| | - Junfeng Feng
- Brain Injury Centre, Renji Hospital, Shanghai Jiao Tong University School of Medicine, 160 Pujian Road, Shanghai, 200127, China
- Shanghai Institute of Head Trauma, 160 Pujian Road, Shanghai, 200127, China
- Corresponding author. Brain Injury Centre, Renji Hospital, Shanghai Jiao Tong University School of Medicine, 160 Pujian Road, Shanghai, China.
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Longitudinal D-Dimer Trajectories and the Risk of Mortality in Abdominal Trauma Patients: A Group-Based Trajectory Modeling Analysis. J Clin Med 2023; 12:jcm12031091. [PMID: 36769738 PMCID: PMC9917395 DOI: 10.3390/jcm12031091] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2022] [Revised: 01/03/2023] [Accepted: 01/28/2023] [Indexed: 01/31/2023] Open
Abstract
This study aimed to identify the long-term D-dimer trajectory patterns and their associations with in-hospital all-cause mortality in abdominal trauma patients. This is a retrospective cohort study of general adult abdominal trauma patients admitted to Jinling Hospital (Nanjing, China) between January 2010 and April 2020. Group-based trajectory modeling was applied to model D-dimer trajectories over the first 50 days post-trauma. A multivariable logistic regression was performed to estimate the associations between D-dimer trajectories and in-hospital all-cause mortality. A total of 309 patients were included. We identified four distinct D-dimer trajectories: group 1 (57.61%; "stable low"), group 2 (28.16%; "moderate-decline"), group 3 (8.41%; "high-rapid decline"), and group 4 (5.83%; "high-gradual decline"). The SOFA score (p = 0.005) and ISS (p = 0.001) were statistically higher in groups 3 and 4 than in groups 1 and 2. The LMWH and UFH did not differ between groups 3 and 4. Compared with the patients in group 1, only the patients in group 4 were at a higher risk of in-hospital all-cause mortality (OR = 6.94, 95% CI: 1.20-40.25). The long-term D-dimer trajectories post-trauma were heterogeneous and associated with mortality. An initially high and slowly-resolved D-dimer might function as the marker of disease deterioration, and specific interventions are needed.
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Helmrich IRAR, Mikolić A, Kent DM, Lingsma HF, Wynants L, Steyerberg EW, van Klaveren D. Does poor methodological quality of prediction modeling studies translate to poor model performance? An illustration in traumatic brain injury. Diagn Progn Res 2022; 6:8. [PMID: 35509061 PMCID: PMC9068255 DOI: 10.1186/s41512-022-00122-0] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/01/2021] [Accepted: 02/09/2022] [Indexed: 12/01/2022] Open
Abstract
BACKGROUND Prediction modeling studies often have methodological limitations, which may compromise model performance in new patients and settings. We aimed to examine the relation between methodological quality of model development studies and their performance at external validation. METHODS We systematically searched for externally validated multivariable prediction models that predict functional outcome following moderate or severe traumatic brain injury. Risk of bias and applicability of development studies was assessed with the Prediction model Risk Of Bias Assessment Tool (PROBAST). Each model was rated for its presentation with sufficient detail to be used in practice. Model performance was described in terms of discrimination (AUC), and calibration. Delta AUC (dAUC) was calculated to quantify the percentage change in discrimination between development and validation for all models. Generalized estimation equations (GEE) were used to examine the relation between methodological quality and dAUC while controlling for clustering. RESULTS We included 54 publications, presenting ten development studies of 18 prediction models, and 52 external validation studies, including 245 unique validations. Two development studies (four models) were found to have low risk of bias (RoB). The other eight publications (14 models) showed high or unclear RoB. The median dAUC was positive in low RoB models (dAUC 8%, [IQR - 4% to 21%]) and negative in high RoB models (dAUC - 18%, [IQR - 43% to 2%]). The GEE showed a larger average negative change in discrimination for high RoB models (- 32% (95% CI: - 48 to - 15) and unclear RoB models (- 13% (95% CI: - 16 to - 10)) compared to that seen in low RoB models. CONCLUSION Lower methodological quality at model development associates with poorer model performance at external validation. Our findings emphasize the importance of adherence to methodological principles and reporting guidelines in prediction modeling studies.
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Affiliation(s)
- Isabel R A Retel Helmrich
- Department of Public Health, Center for Medical Decision Making, Erasmus MC-University Medical Center, Rotterdam, the Netherlands.
| | - Ana Mikolić
- Department of Public Health, Center for Medical Decision Making, Erasmus MC-University Medical Center, Rotterdam, the Netherlands
| | - David M Kent
- Predictive Analytics and Comparative Effectiveness Center, Institute for Clinical Research and Health Policy Studies/Tufts Medical Center, Boston, USA
| | - Hester F Lingsma
- Department of Public Health, Center for Medical Decision Making, Erasmus MC-University Medical Center, Rotterdam, the Netherlands
| | - Laure Wynants
- Department of Epidemiology, School for Public Health and Primary Care, Faculty of Health, Medicine and Life Sciences, Maastricht University, Maastricht, The Netherlands
| | - Ewout W Steyerberg
- Department of Public Health, Center for Medical Decision Making, Erasmus MC-University Medical Center, Rotterdam, the Netherlands
- Department of Biomedical Data Sciences, Leiden University Medical Center, Leiden, The Netherlands
| | - David van Klaveren
- Department of Public Health, Center for Medical Decision Making, Erasmus MC-University Medical Center, Rotterdam, the Netherlands
- Predictive Analytics and Comparative Effectiveness Center, Institute for Clinical Research and Health Policy Studies/Tufts Medical Center, Boston, USA
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Cerebral Pulsatility Index and In-Hospital Mortality in Chinese Patients with Traumatic Brain Injury: A Retrospective Cohort Study. J Clin Med 2022; 11:jcm11061559. [PMID: 35329885 PMCID: PMC8950001 DOI: 10.3390/jcm11061559] [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: 01/15/2022] [Revised: 03/08/2022] [Accepted: 03/09/2022] [Indexed: 02/04/2023] Open
Abstract
There are limited studies on the relationship between the vascular transcranial Doppler (TCD) pulsatility index (PI) and in-hospital mortality in patients with traumatic brain injury (TBI). To address this issue, we conducted this study to explore whether, in newly diagnosed Chinese TBI patients, the PI is an independent predictor of the in-hospital mortality rate after adjusting for other covariates. This study is a retrospective cohort study. From 24 March 2019 to 24 January 2020, we recruited 144 Chinese patients with newly diagnosed TBI from a Chinese hospital. The independent variable was the PI, and the dependent variable was in-hospital mortality in TBI patients. The relationship between the PI and in-hospital mortality in TBI patients was nonlinear and had an inflection point of 1.11. In the multivariate analysis, after adjusting for potential confounders, the effect sizes and confidence intervals per additional 0.1 units on the left and right sides of the inflection point were 4.09 (1.30–12.83) and 1.42 (0.93–2.17). The relationship between the PI and in-hospital mortality was nonlinear. The PI was positively related with in-hospital mortality when the PI was less than 1.11.
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The Association Between D-dimer Levels and Long-Term Neurological Outcomes of Patients with Traumatic Brain Injury: An Analysis of a Nationwide Observational Neurotrauma Database in Japan. Neurocrit Care 2021; 36:483-491. [PMID: 34462882 DOI: 10.1007/s12028-021-01329-7] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2021] [Accepted: 08/09/2021] [Indexed: 10/20/2022]
Abstract
BACKGROUND We evaluated the association between D-dimer (DD) levels and long-term neurological prognoses among patients with isolated traumatic brain injury. METHODS Using data from multiple centers in the Japanese Neurotrauma Data Bank, we conducted an observational retrospective cohort study. Patients with isolated traumatic brain injury (head Abbreviated Injury Scale score > 2; any other Abbreviated Injury Scale score < 3) who were registered in the Japanese Neurotrauma Data Bank from 2015 to 2017 were recruited. We excluded patients younger than age 16 years and those who developed cardiac arrest at hospital admission. We also excluded patients with unknown Glasgow Outcome Scale (GOS) scores at 6 months after injury and those with unknown DD levels. The primary outcome was the association of DD levels with GOS scores at 6 months. We defined GOS scores 1 to 3 as poor and GOS scores 4 and 5 as good. The secondary outcome was the association of DD levels with mortality at 6 months after injury. We conducted multivariate logistic regression analyses to calculate the adjusted odds ratios of DD levels at hospital admission and GOS scores at 6 months as tertiles with 95% confidence intervals (CIs). A total of 293 patients were enrolled (median age 67 years; interquartile range 51-79 years). The median DD level was 27.1 mg/L (interquartile range 9.7-70.8 mg/L), and 58.0% (n = 170) had poor GOS scores at 6 months. RESULTS The multivariable logistic regression analysis indicated that the adjusted odds ratios were 2.52 (95% CI 1.10-5.77) for middle DD levels with poor GOS scores at 6 months and 5.81 (95% CI 2.37-14.2) for high DD levels with poor GOS scores at 6 months. CONCLUSIONS We revealed an association between DD levels and poor long-term neurological outcomes among patients with isolated traumatic brain injury.
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Tunthanathip T, Oearsakul T, Tanvejsilp P, Sae-Heng S, Kaewborisutsakul A, Madteng S, Inkate S. Predicting the Health-related Quality of Life in Patients Following Traumatic Brain Injury. Surg J (N Y) 2021; 7:e100-e110. [PMID: 34159258 PMCID: PMC8211484 DOI: 10.1055/s-0041-1726426] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2020] [Accepted: 11/12/2020] [Indexed: 01/09/2023] Open
Abstract
Background Traumatic brain injury (TBI) commonly causes death and disability that can result in productivity loss and economic burden. The health-related quality of life (HRQoL) has been measured in patients suffering from TBI, both in clinical and socioeconomic perspectives. The study aimed to assess the HRQoL in patients following TBI using the European quality of life measure-5 domain-5 level (EQ-5D-5L) questionnaire and develop models for predicting the EQ-5D-5L index score in patients with TBI. Method A cross-sectional study was performed with 193 TBI patients who had completed the EQ-5D-5L questionnaire. The clinical characteristics, Glasgow coma scale (GCS) score, treatment, and Glasgow outcome scale (GOS) were collected. The total data was divided into training data (80%) and testing data (20%); hence, the factors affecting the EQ-5D-5L index scores were used to develop the predictive model with linear and nonlinear regression. The performances of the predictive models were estimated with the adjusted coefficient of determination (R 2 ) and the root mean square error (RMSE). Results A good recovery was found at 96.4%, while 2.1% displayed an unfavorable outcome. Moreover, the mean EQ-5D-5L index scores were 0.91558 (standard deviation [SD] 1.09639). GCS score, pupillary light reflex, surgery, and GOS score significantly correlated with the HRQoL scores. The multiple linear regression model had a high adjusted R 2 of 0.6971 and a low RMSE of 0.06701, while the polynomial regression developed a nonlinear model that had the highest adjusted R 2 of 0.6843 and the lowest RMSE of 0.06748. Conclusions A strong positive correlation between the physician-based outcome as GOS and HRQoL was observed. Furthermore, both the linear and nonlinear regression models were acceptable approaches to predict the HRQoL of patients after TBI. There would be limitations for estimating the HRQoL in unconscious or intubated patients. The HRQoL obtained from the predictive models would be an alternative method to resolve this problem.
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Affiliation(s)
- Thara Tunthanathip
- Division of Neurosurgery, Department of Surgery, Faculty of Medicine, Prince of Songkla University, HatYai, Songkhla, Thailand
| | - Thakul Oearsakul
- Division of Neurosurgery, Department of Surgery, Faculty of Medicine, Prince of Songkla University, HatYai, Songkhla, Thailand
| | - Pimwara Tanvejsilp
- Department of Pharmacy Administration, Faculty of Pharmaceutical Sciences, Prince of Songkla University, HatYai, Songkhla, Thailand
| | - Sakchai Sae-Heng
- Division of Neurosurgery, Department of Surgery, Faculty of Medicine, Prince of Songkla University, HatYai, Songkhla, Thailand
| | - Anukoon Kaewborisutsakul
- Division of Neurosurgery, Department of Surgery, Faculty of Medicine, Prince of Songkla University, HatYai, Songkhla, Thailand
| | - Suphavadee Madteng
- Division of Neurosurgery, Department of Surgery, Faculty of Medicine, Prince of Songkla University, HatYai, Songkhla, Thailand
| | - Srirat Inkate
- Division of Neurosurgery, Department of Surgery, Faculty of Medicine, Prince of Songkla University, HatYai, Songkhla, Thailand
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11
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Kamal VK, Pandey RM, Agrawal D. Development and temporal external validation of a simple risk score tool for prediction of outcomes after severe head injury based on admission characteristics from level-1 trauma centre of India using retrospectively collected data. BMJ Open 2021; 11:e040778. [PMID: 33455929 PMCID: PMC7813344 DOI: 10.1136/bmjopen-2020-040778] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
OBJECTIVE To develop and validate a simple risk scores chart to estimate the probability of poor outcomes in patients with severe head injury (HI). DESIGN Retrospective. SETTING Level-1, government-funded trauma centre, India. PARTICIPANTS Patients with severe HI admitted to the neurosurgery intensive care unit during 19 May 2010-31 December 2011 (n=946) for the model development and further, data from same centre with same inclusion criteria from 1 January 2012 to 31 July 2012 (n=284) for the external validation of the model. OUTCOMES In-hospital mortality and unfavourable outcome at 6 months. RESULTS A total of 39.5% and 70.7% had in-hospital mortality and unfavourable outcome, respectively, in the development data set. The multivariable logistic regression analysis of routinely collected admission characteristics revealed that for in-hospital mortality, age (51-60, >60 years), motor score (1, 2, 4), pupillary reactivity (none), presence of hypotension, basal cistern effaced, traumatic subarachnoid haemorrhage/intraventricular haematoma and for unfavourable outcome, age (41-50, 51-60, >60 years), motor score (1-4), pupillary reactivity (none, one), unequal limb movement, presence of hypotension were the independent predictors as its 95% confidence interval (CI) of odds ratio (OR)_did not contain one. The discriminative ability (area under the receiver operating characteristic curve (95% CI)) of the score chart for in-hospital mortality and 6 months outcome was excellent in the development data set (0.890 (0.867 to 912) and 0.894 (0.869 to 0.918), respectively), internal validation data set using bootstrap resampling method (0.889 (0.867 to 909) and 0.893 (0.867 to 0.915), respectively) and external validation data set (0.871 (0.825 to 916) and 0.887 (0.842 to 0.932), respectively). Calibration showed good agreement between observed outcome rates and predicted risks in development and external validation data set (p>0.05). CONCLUSION For clinical decision making, we can use of these score charts in predicting outcomes in new patients with severe HI in India and similar settings.
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Affiliation(s)
- Vineet Kumar Kamal
- Division of Epidemiology & Biostatistics, National Institute of Epidemiology, Indian Council of Medial Research (ICMR), Chennai, Tamil Nadu, India
| | - Ravindra Mohan Pandey
- Department of Biostatistics, All India Institute of Medical Sciences (AIIMS), New Delhi, India
| | - Deepak Agrawal
- Department of Neurosurgery, Jai Prakash Naryan Apex Trauma Centre, All India Institute of Medical Sciences (AIIMS), New Delhi, India
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12
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Kim NY, Lim J, Lee S, Kim K, Hong JH, Chun DH. Hematological factors predicting mortality in patients with traumatic epidural or subdural hematoma undergoing emergency surgical evacuation: A retrospective cohort study. Medicine (Baltimore) 2020; 99:e22074. [PMID: 32925745 PMCID: PMC7489590 DOI: 10.1097/md.0000000000022074] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/20/2023] Open
Abstract
Hematological abnormalities at admission are common after traumatic brain injuries and are associated with poor outcomes. The objective of this study was to identify the predictive factors of mortality among patients who underwent emergency surgery for the evacuation of epidural hematoma (EDH) or subdural hematoma (SDH).This was a single-center retrospective cohort study of 200 patients who underwent emergency surgical evacuation of EDH or SDH between September 2010 and December 2018. Data on hematological parameters and clinical and intraoperative features were collected. The primary end-point was 1-year mortality after surgery. Univariate and multivariate analysis were performed, and the receiver operating characteristic (ROC) curves were assessed.Of the 200 patients included in this study, 102 (51%) patients died within 1 year of emergency surgery. Lymphocyte count at admission, creatinine levels, activated partial thromboplastin time (aPTT), age, intraoperative epinephrine use, and Glasgow Coma Scale (GCS) score were significantly associated with mortality in the multivariate analysis. The areas under the ROC curve for the GCS score, aPTT, and lymphocyte counts were 0.677 (95% confidence interval [CI] 0.602-0.753), 0.644 (95% CI 0.567-0.721), and 0.576 (95% CI 0.496-0.656), respectively.Patients with elevated lymphocyte counts on admission showed a higher rate of 1-year mortality following emergency craniectomy for EDH or SDH. In addition, prolonged aPTT and a lower GCS score were also related to poor survival.
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MESH Headings
- Adult
- Aged
- Biomarkers/blood
- Craniotomy
- Creatinine/blood
- Emergency Service, Hospital
- Epinephrine/therapeutic use
- Female
- Glasgow Coma Scale
- Hematoma, Epidural, Cranial/blood
- Hematoma, Epidural, Cranial/mortality
- Hematoma, Epidural, Cranial/surgery
- Hematoma, Subdural, Intracranial/blood
- Hematoma, Subdural, Intracranial/mortality
- Hematoma, Subdural, Intracranial/surgery
- Humans
- Intraoperative Period
- Lymphocyte Count
- Male
- Middle Aged
- Partial Thromboplastin Time
- Prognosis
- Retrospective Studies
- Vasoconstrictor Agents/therapeutic use
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Affiliation(s)
- Na Young Kim
- Department of Anesthesiology and Pain Medicine, Anesthesia and Pain Research Institute, Yonsei University College of Medicine, 50-1 Yonsei-ro, Seodaemun-gu, Seoul
| | | | - Seunghoon Lee
- Department of Anesthesiology and Pain Medicine, CHA Bundang Medical Center, CHA University School of Medicine, 59 Yatap-ro, Bundang-gu, Seongnam
| | - Koeun Kim
- Department of Anesthesiology and Pain Medicine, CHA Bundang Medical Center, CHA University School of Medicine, 59 Yatap-ro, Bundang-gu, Seongnam
| | - Jung Hwa Hong
- Department of Policy Research Affairs National Health Insurance Service Ilsan Hospital, 100 Ilsan-ro, Ilsandong-gu, Goyang, Gyeonggi-do, Republic of Korea
| | - Duk-Hee Chun
- Department of Anesthesiology and Pain Medicine, CHA Bundang Medical Center, CHA University School of Medicine, 59 Yatap-ro, Bundang-gu, Seongnam
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13
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Zhao JL, Lai ST, Du ZY, Xu J, Sun YR, Yuan Q, Wu X, Li ZQ, Hu J, Xie R. Circulating neutrophil-to-lymphocyte ratio at admission predicts the long-term outcome in acute traumatic cervical spinal cord injury patients. BMC Musculoskelet Disord 2020; 21:548. [PMID: 32799840 PMCID: PMC7429795 DOI: 10.1186/s12891-020-03556-z] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/09/2019] [Accepted: 08/03/2020] [Indexed: 01/11/2023] Open
Abstract
Background The prognostic value of Neutrophil-to-Lymphocyte Ratio (NLR) for the outcome of acute cervical traumatic spinal cord injury (tSCI) patients has rarely been studied by now throughout the world. Methods We performed a single-center retrospective cohort study to evaluate the prognostic value of NLR from peripheral whole blood count in patients with acute cervical tSCI. Patients within 6 h of acute cervical tSCI treated between Dec 2008 and May 2018 in Huashan Hospital of Fudan University were enrolled. Outcomes of patients with tSCI were assessed using American spinal injury association Impairment Scale (AIS). 6-month outcomes were dichotomized into poor outcome group (AIS A to C) and good outcome group (AIS D and E). Uni- and multivariate analyses were performed to assess the independent predictors of 6-month outcome. Two prediction models based on admission characteristics were built to evaluate the prognostic value of NLR. The discriminative ability of predictive models was evaluated using the area under the curve (AUC). Results A total of 377 patients were identified from our single center in China PR. Multivariate analysis showed that age, AIS grade at admission, NLR (p < 0.001) and coagulopathy (p = 0.003) were independent predictors of the 6-months outcome for acute cervical tSCI patients. The model combing NLR and standard variables (AUC = 0.944; 95% CI, 0.923–0.964) showed a more favorable prognostic value than that without NLR (AUC = 0.841; 95% CI, 0.798–0.885) in terms of 6-month outcome. Conclusions NLR is firstly identified as an independent predictor of the 6-month outcome in acute cervical tSCI patients worldwide. The prognostic value of NLR is favorable, and a high NLR is associated with poor outcome in patients with acute cervical tSCI.
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Affiliation(s)
- Jian-Lan Zhao
- Department of Neurosurgery, Huashan Hospital, Shanghai Medical College, Fudan University, 12 Wulumuqi Road (M), Shanghai, 200040, P.R. China.,Neurosurgical Institute of Fudan University, 12 Wulumuqi Road (M), Shanghai, 200040, P.R. China.,Shanghai Clinical Medical Center of Neurosurgery, 12 Wulumuqi Road (M), Shanghai, 200040, P.R. China.,Shanghai Key laboratory of Brain Function and Restoration and Neural Regeneration, 12 Wulumuqi Road (M), Shanghai, 200040, P.R. China
| | - Song-Tao Lai
- Department of Radiation Oncology, Fudan University Shanghai Cancer Center, Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, 200032, China
| | - Zhuo-Ying Du
- Department of Neurosurgery, Huashan Hospital, Shanghai Medical College, Fudan University, 12 Wulumuqi Road (M), Shanghai, 200040, P.R. China.,Neurosurgical Institute of Fudan University, 12 Wulumuqi Road (M), Shanghai, 200040, P.R. China.,Shanghai Clinical Medical Center of Neurosurgery, 12 Wulumuqi Road (M), Shanghai, 200040, P.R. China.,Shanghai Key laboratory of Brain Function and Restoration and Neural Regeneration, 12 Wulumuqi Road (M), Shanghai, 200040, P.R. China
| | - Jian Xu
- Department of General Surgery, the Seventh Affiliated Hospital, SUN Yat-sen University, Shenzhen, 518000, China
| | - Yi-Rui Sun
- Department of Neurosurgery, Huashan Hospital, Shanghai Medical College, Fudan University, 12 Wulumuqi Road (M), Shanghai, 200040, P.R. China.,Neurosurgical Institute of Fudan University, 12 Wulumuqi Road (M), Shanghai, 200040, P.R. China.,Shanghai Clinical Medical Center of Neurosurgery, 12 Wulumuqi Road (M), Shanghai, 200040, P.R. China.,Shanghai Key laboratory of Brain Function and Restoration and Neural Regeneration, 12 Wulumuqi Road (M), Shanghai, 200040, P.R. China
| | - Qiang Yuan
- Department of Neurosurgery, Huashan Hospital, Shanghai Medical College, Fudan University, 12 Wulumuqi Road (M), Shanghai, 200040, P.R. China.,Neurosurgical Institute of Fudan University, 12 Wulumuqi Road (M), Shanghai, 200040, P.R. China.,Shanghai Clinical Medical Center of Neurosurgery, 12 Wulumuqi Road (M), Shanghai, 200040, P.R. China.,Shanghai Key laboratory of Brain Function and Restoration and Neural Regeneration, 12 Wulumuqi Road (M), Shanghai, 200040, P.R. China
| | - Xing Wu
- Department of Neurosurgery, Huashan Hospital, Shanghai Medical College, Fudan University, 12 Wulumuqi Road (M), Shanghai, 200040, P.R. China.,Neurosurgical Institute of Fudan University, 12 Wulumuqi Road (M), Shanghai, 200040, P.R. China.,Shanghai Clinical Medical Center of Neurosurgery, 12 Wulumuqi Road (M), Shanghai, 200040, P.R. China.,Shanghai Key laboratory of Brain Function and Restoration and Neural Regeneration, 12 Wulumuqi Road (M), Shanghai, 200040, P.R. China
| | - Zhi-Qi Li
- Department of Neurosurgery, Huashan Hospital, Shanghai Medical College, Fudan University, 12 Wulumuqi Road (M), Shanghai, 200040, P.R. China.,Neurosurgical Institute of Fudan University, 12 Wulumuqi Road (M), Shanghai, 200040, P.R. China.,Shanghai Clinical Medical Center of Neurosurgery, 12 Wulumuqi Road (M), Shanghai, 200040, P.R. China.,Shanghai Key laboratory of Brain Function and Restoration and Neural Regeneration, 12 Wulumuqi Road (M), Shanghai, 200040, P.R. China
| | - Jin Hu
- Department of Neurosurgery, Huashan Hospital, Shanghai Medical College, Fudan University, 12 Wulumuqi Road (M), Shanghai, 200040, P.R. China. .,Neurosurgical Institute of Fudan University, 12 Wulumuqi Road (M), Shanghai, 200040, P.R. China. .,Shanghai Clinical Medical Center of Neurosurgery, 12 Wulumuqi Road (M), Shanghai, 200040, P.R. China. .,Shanghai Key laboratory of Brain Function and Restoration and Neural Regeneration, 12 Wulumuqi Road (M), Shanghai, 200040, P.R. China.
| | - Rong Xie
- Department of Neurosurgery, Huashan Hospital, Shanghai Medical College, Fudan University, 12 Wulumuqi Road (M), Shanghai, 200040, P.R. China. .,Neurosurgical Institute of Fudan University, 12 Wulumuqi Road (M), Shanghai, 200040, P.R. China. .,Shanghai Clinical Medical Center of Neurosurgery, 12 Wulumuqi Road (M), Shanghai, 200040, P.R. China. .,Shanghai Key laboratory of Brain Function and Restoration and Neural Regeneration, 12 Wulumuqi Road (M), Shanghai, 200040, P.R. China.
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14
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Karsy M, Kim R, Azab M, Harper J, Guan J, Eli I, Couldwell W. Higher Admission D-Dimer Values Are Associated With an Increased Risk of Nonroutine Discharge in Neurosurgery Patients. Cureus 2020; 12:e9425. [PMID: 32864251 PMCID: PMC7450899 DOI: 10.7759/cureus.9425] [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] [Subscribe] [Scholar Register] [Indexed: 12/02/2022] Open
Abstract
Background D-dimers are serum acute-phase proteins with a role in mediating inflammation that may be used as biomarkers for the prediction of deep vein thrombosis. Recent studies have shown that D-dimers can be used to predict prognosis and stratify risk in neurosurgical patients; however, a comparative analysis across diagnostic subtypes has yet to be performed. Methods A bioinformatics analysis evaluated neurosurgical patients with admission D-dimer levels between 2008 and 2017. Nonroutine disposition (e.g., skilled nursing facility, rehabilitation, other hospital, mortality) was primarily evaluated. Results A total of 1,854 patients (mean age 55.1±18.2 years, 55.4% male; mean admission D-dimer 4.83±7.78 μg/ml) were identified. Patient diagnoses included vascular (27.1%), trauma (16.4%), multiple diagnoses (15.7%), spine (15.6%), tumor (13.0%), and other (12.2%) causes. Univariate analysis showed that older age (p=0.0001), higher American Society of Anesthesiologists (ASA) score (p=0.0001), lower Glasgow Coma Scale (GCS) score (p=0.0001), diagnosis type (p=0.0001), longer length of stay (LOS) (p=0.0001), higher infection rate (p=0.0001), surgery in the past year (p=0.02), and higher D-dimer levels (3.4±4.9 vs. 5.4±8.7 μg/ml, p=0.0001) were associated with nonroutine disposition. Multivariate logistic regression showed that elevated D-dimers were independently associated with a greater relative risk of nonroutine disposition (relative risk [RR] 1.026, 95% CI 1.02-1.033, p=0.0001). Conclusions Elevated admission D-dimer values were independently associated with a 3% increased risk of nonroutine disposition per D-dimer unit after accounting for other factors. These results suggest that D-dimer values may help in stratifying patient risk models despite clinical heterogeneity. Further refinement of neurosurgical patient risk models using clinical variables and biomarkers may aid in resource allocation and early warning.
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Affiliation(s)
- Michael Karsy
- Neurosurgery, University of Utah, Salt Lake City, USA
| | - Robert Kim
- Neurosurgery, University of Utah, Salt Lake City, USA
| | - Mohammed Azab
- Neurosurgery, University of Utah, Salt Lake City, USA
| | | | - Jian Guan
- Neurosurgery, University of Utah, Salt Lake City, USA
| | - Ilyas Eli
- Neurosurgery, University of Utah, Salt Lake City, USA
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15
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Algethamy H. Baseline Predictors of Survival, Neurological Recovery, Cognitive Function, Neuropsychiatric Outcomes, and Return to Work in Patients after a Severe Traumatic Brain Injury: an Updated Review. Mater Sociomed 2020; 32:148-157. [PMID: 32843865 PMCID: PMC7428895 DOI: 10.5455/msm.2020.32.148-157] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
Introduction Severe traumatic brain injury (sTBI) is a common cause of death and disability worldwide, with long-term squeal among survivors that include cognitive deficits, psychosocial and neuropsychiatric dysfunction, failure to return to pre-injury levels of work, school and inter-personal relationships, and overall reduced quality of and satisfaction with life. Aim The aim of this work is to review the current literature on baseline predictors of outcomes in adults post sTBI. Method Most of available literature on baseline predictors of outcomes in adults post sTBI were reviewed and summarized in this work. Results Currently, a sizeable number of composite predictors of mortality and overall function exists; however, these instruments tend to over-estimate poor outcomes and fail to address issues like cognition, psychosocial/ neuropsychiatric dysfunction, and return to work or school. Conclusion This article reviews currently-identified predictors of all these outcomes.
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Affiliation(s)
- Haifa Algethamy
- Department of Anaesthesia and Critical Care, King Abdulaziz University Hospital, Jeddah, Saudi Arabia
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16
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The behavioural and pathophysiological effects of the ketogenic diet on mild traumatic brain injury in adolescent rats. Behav Brain Res 2019; 376:112225. [DOI: 10.1016/j.bbr.2019.112225] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2019] [Revised: 08/16/2019] [Accepted: 09/09/2019] [Indexed: 02/07/2023]
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17
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The Clinical Application of Nerve Injury Unit Mode in Patients with Moderate or Severe Traumatic Brain Injury. J Craniofac Surg 2019; 30:2102-2105. [DOI: 10.1097/scs.0000000000005995] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022] Open
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18
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Dijkland SA, Foks KA, Polinder S, Dippel DWJ, Maas AIR, Lingsma HF, Steyerberg EW. Prognosis in Moderate and Severe Traumatic Brain Injury: A Systematic Review of Contemporary Models and Validation Studies. J Neurotrauma 2019; 37:1-13. [PMID: 31099301 DOI: 10.1089/neu.2019.6401] [Citation(s) in RCA: 83] [Impact Index Per Article: 16.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
Outcome prognostication in traumatic brain injury (TBI) is important but challenging due to heterogeneity of the disease. The aim of this systematic review is to present the current state-of-the-art on prognostic models for outcome after moderate and severe TBI and evidence on their validity. We searched for studies reporting on the development, validation or extension of prognostic models for functional outcome after TBI with Glasgow Coma Scale (GCS) ≤12 published between 2006-2018. Studies with patients age ≥14 years and evaluating a multi-variable prognostic model based on admission characteristics were included. Model discrimination was expressed with the area under the receiver operating characteristic curve (AUC), and model calibration with calibration slope and intercept. We included 58 studies describing 67 different prognostic models, comprising the development of 42 models, 149 external validations of 31 models, and 12 model extensions. The most common predictors were GCS (motor) score (n = 55), age (n = 54), and pupillary reactivity (n = 48). Model discrimination varied substantially between studies. The International Mission for Prognosis and Analysis of Clinical Trials (IMPACT) and Corticoid Randomisation After Significant Head injury (CRASH) models were developed on the largest cohorts (8509 and 10,008 patients, respectively) and were most often externally validated (n = 91), yielding AUCs ranging between 0.65-0.90 and 0.66-1.00, respectively. Model calibration was reported with a calibration intercept and slope for seven models in 53 validations, and was highly variable. In conclusion, the discriminatory validity of the IMPACT and CRASH prognostic models is supported across a range of settings. The variation in calibration, reflecting heterogeneity in reliability of predictions, motivates continuous validation and updating if clinical implementation is pursued.
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Affiliation(s)
- Simone A Dijkland
- Department of Public Health, Center for Medical Decision Making, Erasmus MC-University Medical Center Rotterdam, the Netherlands
| | - Kelly A Foks
- Department of Public Health, Center for Medical Decision Making, Erasmus MC-University Medical Center Rotterdam, the Netherlands.,Department of Neurology, Erasmus MC-University Medical Center Rotterdam, the Netherlands
| | - Suzanne Polinder
- Department of Public Health, Center for Medical Decision Making, Erasmus MC-University Medical Center Rotterdam, the Netherlands
| | - Diederik W J Dippel
- Department of Neurology, Erasmus MC-University Medical Center Rotterdam, the Netherlands
| | - Andrew I R Maas
- Department of Neurosurgery, Antwerp University Hospital, University of Antwerp, Edegem, Belgium
| | - Hester F Lingsma
- Department of Public Health, Center for Medical Decision Making, Erasmus MC-University Medical Center Rotterdam, the Netherlands
| | - Ewout W Steyerberg
- Department of Public Health, Center for Medical Decision Making, Erasmus MC-University Medical Center Rotterdam, the Netherlands.,Department of Biomedical Data Sciences, Leiden University Medical Center, Leiden, the Netherlands
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19
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Gan ZS, Stein SC, Swanson R, Guan S, Garcia L, Mehta D, Smith DH. Blood Biomarkers for Traumatic Brain Injury: A Quantitative Assessment of Diagnostic and Prognostic Accuracy. Front Neurol 2019; 10:446. [PMID: 31105646 PMCID: PMC6498532 DOI: 10.3389/fneur.2019.00446] [Citation(s) in RCA: 105] [Impact Index Per Article: 21.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2019] [Accepted: 04/12/2019] [Indexed: 12/18/2022] Open
Abstract
Blood biomarkers have been explored for their potential to provide objective measures in the assessment of traumatic brain injury (TBI). However, it is not clear which biomarkers are best for diagnosis and prognosis in different severities of TBI. Here, we compare existing studies on the discriminative abilities of serum biomarkers for four commonly studied clinical situations: detecting concussion, predicting intracranial damage after mild TBI (mTBI), predicting delayed recovery after mTBI, and predicting adverse outcome after severe TBI (sTBI). We conducted a literature search of publications on biomarkers in TBI published up until July 2018. Operating characteristics were pooled for each biomarker for comparison. For detecting concussion, 4 biomarker panels and creatine kinase B type had excellent discriminative ability. For detecting intracranial injury and the need for a head CT scan after mTBI, 2 biomarker panels, and hyperphosphorylated tau had excellent operating characteristics. For predicting delayed recovery after mTBI, top candidates included calpain-derived αII-spectrin N-terminal fragment, tau A, neurofilament light, and ghrelin. For predicting adverse outcome following sTBI, no biomarker had excellent performance, but several had good performance, including markers of coagulation and inflammation, structural proteins in the brain, and proteins involved in homeostasis. The highest-performing biomarkers in each of these categories may provide insight into the pathophysiologies underlying mild and severe TBI. With further study, these biomarkers have the potential to be used alongside clinical and radiological data to improve TBI diagnostics, prognostics, and evidence-based medical management.
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Affiliation(s)
- Zoe S Gan
- University of North Carolina School of Medicine, Chapel Hill, NC, United States
| | - Sherman C Stein
- Department of Neurosurgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, United States
| | - Randel Swanson
- Department of Physical Medicine and Rehabilitation, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, United States.,Rehabilitation Medicine Service, Corporal Michael J. Crescenz VA Medical Center, Philadelphia, PA, United States.,Center for Neurotrauma, Neurodegeneration and Restoration, Corporal Michael J. Crescenz VA Medical Center, Philadelphia, PA, United States.,Department of Neurosurgery, Perelman School of Medicine, Center for Brain Injury and Repair, University of Pennsylvania, Philadelphia, PA, United States
| | - Shaobo Guan
- Department of Neurosurgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, United States
| | - Lizette Garcia
- Department of Neurosurgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, United States
| | - Devanshi Mehta
- Department of Neurosurgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, United States
| | - Douglas H Smith
- Department of Neurosurgery, Perelman School of Medicine, Center for Brain Injury and Repair, University of Pennsylvania, Philadelphia, PA, United States
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20
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Bae IS, Chun HJ, Yi HJ, Bak KH, Choi KS, Kim DW. Modified Glasgow Coma Scale Using Serum Factors as a Prognostic Model in Traumatic Brain Injury. World Neurosurg 2019; 126:e959-e964. [PMID: 30876987 DOI: 10.1016/j.wneu.2019.02.197] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2018] [Revised: 02/19/2019] [Accepted: 02/20/2019] [Indexed: 11/26/2022]
Abstract
BACKGROUND Traumatic brain injury (TBI) is a major cause of death and disability. This study evaluated a possible relationship between serum factors at admission and the outcome of TBI. We propose a statistically validated scale for patients with TBI that combines serum factors and the Glasgow Coma Scale (GCS). METHODS Between May 2011 and July 2016, 219 patients underwent decompressive craniectomy for TBI. We assessed laboratory data on admission, and correlations with GSC and Glasgow Outcome Scale were investigated. The modified GCS was developed from a multivariable logistic regression model, which was validated with the backward stepwise method. RESULTS Of 219 patients with TBI enrolled in our study, 175 were men (79.9%) and 44 were women (20.1%) with a mean age of 49.1 ± 11.5 years. Initial serum values of hemoglobin, platelets, prothrombin time, and lactate dehydrogenase were associated with in-hospital mortality. The factor score was derived by adding the following points: hemoglobin (≥13.0 g/dL = 0, <13.0 g/dL = 1), platelets (≥150 × 103/mm3 = 0, <150 × 103/mm3 = 1), prothrombin time (<13.2 seconds = 0, ≥13.2 seconds = 1), and lactate dehydrogenase (<271 U/L = 0, ≥271 U/L = 1). The modified GCS score (GCS score [range, 6-15] - FS [range, 0-4]) was calculated. CONCLUSIONS The modified GCS score using serum factors extended the information provided about patient outcomes to be comparable to more complex methods. The modified GCS score may be useful to predict in-hospital mortality in patients with TBI.
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Affiliation(s)
- In-Suk Bae
- Department of Neurosurgery, Hanyang University Medical Center, Seoul, South Korea
| | - Hyoung-Joon Chun
- Department of Neurosurgery, Hanyang University Medical Center, Seoul, South Korea.
| | - Hyeong-Joong Yi
- Department of Neurosurgery, Hanyang University Medical Center, Seoul, South Korea
| | - Koang-Hum Bak
- Department of Neurosurgery, Hanyang University Medical Center, Seoul, South Korea
| | - Kyu-Sun Choi
- Department of Neurosurgery, Hanyang University Medical Center, Seoul, South Korea
| | - Dong-Won Kim
- Department of Anesthesiology and Pain Medicine, Hanyang University Medical Center, Seoul, South Korea
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Zhao JL, Du ZY, Yuan Q, Yu J, Sun YR, Wu X, Li ZQ, Wu XH, Hu J. Prognostic Value of Neutrophil-to-Lymphocyte Ratio in Predicting the 6-Month Outcome of Patients with Traumatic Brain Injury: A Retrospective Study. World Neurosurg 2019; 124:e411-e416. [PMID: 30610986 DOI: 10.1016/j.wneu.2018.12.107] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2018] [Revised: 12/14/2018] [Accepted: 12/17/2018] [Indexed: 01/26/2023]
Abstract
BACKGROUND Peripheral white blood cells are regularly analyzed on admission for patients with traumatic brain injury (TBI). The prognostic value of the neutrophil-to-lymphocyte ratio (NLR) in predicting the 6-month outcome of patients with TBI is unclear. METHODS We designed a single-center retrospective cohort study. Patients admitted to Fudan University Huashan Hospital within 6 hours after TBI were identified between December 2004 and December 2017. The primary outcome was 6-month Glasgow Outcome Scale score. Independent predictors of 6-month outcome were assessed using uni- and multivariate analyses. Three models based on admission characteristics were built to evaluate the prognostic value of the NLR in predicting the outcome of patients with TBI. The discriminative ability of predictive models was evaluated by the area under the curve (AUC). RESULTS A total of 1291 patients with TBI were included. Multivariate analysis showed age, Glasgow Coma Scale scores at admission, subdural hematoma, intraparenchymal hemorrhage, traumatic subarachnoid hemorrhage, NLR (P < 0.001), and coagulopathy (P = 0.028) were independent predictors of 6-month outcome. The model combining the NLR and standard variables (AUC = 0.936; 95% confidence interval [CI], 0.923-0.949) was more favorable in predicting 6-month outcome of patients with TBI than the model without the NLR (AUC = 0.901; 95% CI, 0.883-0.919) and the model based only on the NLR (AUC = 0.827; 95% CI, 0.802-0.852). CONCLUSIONS NLR is an independent prognostic factor of predicting 6-month outcome of patients with TBI. A high NLR in patients with TBI is associated with poor outcome. The prognostic value of the NLR in predicting 6-month outcome of patients with TBI is favorable.
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Affiliation(s)
- Jian-Lan Zhao
- Department of Neurosurgery, Huashan Hospital, Fudan University, Shanghai, P.R. China
| | - Zhuo-Ying Du
- Department of Neurosurgery, Huashan Hospital, Fudan University, Shanghai, P.R. China
| | - Qiang Yuan
- Department of Neurosurgery, Huashan Hospital, Fudan University, Shanghai, P.R. China
| | - Jian Yu
- Department of Neurosurgery, Huashan Hospital, Fudan University, Shanghai, P.R. China; Department of Neurosurgery, Shigatse People's Hospital, Shigatse, Tibet Autonomous Region, P.R. China
| | - Yi-Rui Sun
- Department of Neurosurgery, Huashan Hospital, Fudan University, Shanghai, P.R. China; Department of Neurosurgery, Minhang Branch, Zhongshan Hospital, Fudan University, Shanghai, P.R. China
| | - Xing Wu
- Department of Neurosurgery, Huashan Hospital, Fudan University, Shanghai, P.R. China
| | - Zhi-Qi Li
- Department of Neurosurgery, Huashan Hospital, Fudan University, Shanghai, P.R. China
| | - Xue-Hai Wu
- Department of Neurosurgery, Huashan Hospital, Fudan University, Shanghai, P.R. China
| | - Jin Hu
- Department of Neurosurgery, Huashan Hospital, Fudan University, Shanghai, P.R. China.
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Di G, Zhang Y, Liu H, Jiang X, Liu Y, Yang K, Chen J, Liu H. Postoperative complications influencing the long-term outcome of head-injured patients after decompressive craniectomy. Brain Behav 2019; 9:e01179. [PMID: 30511376 PMCID: PMC6346640 DOI: 10.1002/brb3.1179] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/28/2018] [Revised: 11/03/2018] [Accepted: 11/06/2018] [Indexed: 11/29/2022] Open
Abstract
OBJECTIVE Postoperative complications are common in patients who underwent decompressive craniectomy (DC) after traumatic brain injury (TBI). However, little is known about the degree of association between the postoperative complications and the long-term outcome of adult TBI patients after DC. The aim of this study was to evaluate the risk of postoperative complications that influenced the long-term outcome of DC in TBI patients. METHOD A total of 121 patients were studied up to 6 months after DC in TBI. The collected data included demographic, clinical and radiological information, postoperative complications, and Glasgow Outcome Scale-Extended (GOSE) scores at follow-up 6 months after DC. Based on their GOSE scores, they were divided into two functional groups: favorable (GOSE = 5-8) or unfavorable outcome (GOSE = 2-4) group. The characteristics of the two groups were compared using statistical analysis. Finally, a regression model was established and a receiver operating characteristic (ROC) curve was applied to analyze its performance power. RESULTS Of 121 admitted patients, 31 (25.62%) sustained an unfavorable outcome. A logistic regression analysis showed that the presence of Glasgow Coma Scale (GCS) scores on admission (odds ratio [OR] 0.285, p = 0.001), posttraumatic hydrocephalus (PTH) (OR 8.688, p = 0.003), craniectomy site (OR 8.068, p = 0.033), and postoperative progressive hemorrhagic injury (PHI) (OR 6.196, p = 0.026) were independent risk factors that correlated with an unfavorable outcome. Analysis using ROC curves demonstrated that these factors had different accuracies in predicting an unfavorable outcome (AUC = 0.852 for GCS scores on admission; AUC = 0.826 for PTH, AUC = 0.617 for craniectomy site; AUC = 0.616 for postoperative PHI). The performance power of the GCS scores on admission and PTH influenced the patient's outcomes to a similar degree (p = 0.623), and either predicted the outcome better than the craniectomy site or the postoperative PHI (p < 0.05, respectively). CONCLUSION These findings suggest that the occurrence of PTH and postoperative PHI were independently associated with an unfavorable long-term outcome after DC in patients with TBI. Early prevention and treatment of PTH and postoperative PHI may be beneficial to improve the long-term outcome, especially in patients with lower admission GCS scores or bilateral DC.
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Affiliation(s)
- Guangfu Di
- Department of Neurosurgery, The Affiliated Brain Hospital with Nanjing Medical University, Fourth Clinical College of Nanjing Medical University, Nanjing, China.,Department of Neurosurgery, First Affiliated Hospital of Wannan Medical College, Wuhu, China
| | - Yuhai Zhang
- Department of Neurosurgery, The Affiliated Brain Hospital with Nanjing Medical University, Fourth Clinical College of Nanjing Medical University, Nanjing, China
| | - Hua Liu
- Department of Neurosurgery, The Affiliated Brain Hospital with Nanjing Medical University, Fourth Clinical College of Nanjing Medical University, Nanjing, China
| | - Xiaochun Jiang
- Department of Neurosurgery, First Affiliated Hospital of Wannan Medical College, Wuhu, China
| | - Yong Liu
- Department of Neurosurgery, The Affiliated Brain Hospital with Nanjing Medical University, Fourth Clinical College of Nanjing Medical University, Nanjing, China
| | - Kun Yang
- Department of Neurosurgery, The Affiliated Brain Hospital with Nanjing Medical University, Fourth Clinical College of Nanjing Medical University, Nanjing, China
| | - Jiu Chen
- Institute of Neuropsychiatry, The Affiliated Brain Hospital with Nanjing Medical University, Fourth Clinical College of Nanjing Medical University, Nanjing, China.,Institute of Brain Functional Imaging, Nanjing Medical University, Nanjing, China
| | - Hongyi Liu
- Department of Neurosurgery, The Affiliated Brain Hospital with Nanjing Medical University, Fourth Clinical College of Nanjing Medical University, Nanjing, China
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Salehpour F, Bazzazi AM, Aghazadeh J, Hasanloei AV, Pasban K, Mirzaei F, Naseri Alavi SA. What do You Expect from Patients with Severe Head Trauma? Asian J Neurosurg 2018; 13:660-663. [PMID: 30283522 PMCID: PMC6159042 DOI: 10.4103/ajns.ajns_260_16] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Background: Head trauma is one of the most common mortality and morbidity causes in adolescent. Numerous studies have been conducted on changes in laboratory results and mortality and morbidity prognostic factors; however, the obtained results have been varied and controversial. The aim of this study is to evaluate changes in laboratory findings and arterial blood gas (ABG) analyses test at admission and investigation of the relation between these changes with outcomes in patients with traumatic brain injury. Materials and Methods: In this study, laboratory and metabolic variables were compared in patients with severe brain trauma and normal subjects. Laboratory and metabolic variables and ABG were measured on admission in patients with severe brain trauma and then compared with normal values. At last, the correlation between these variables with the prognosis in the patients was studied. Results: Of 93 studied patients, 82 were male and 11 were female with the mean age of 30.54 years. Among the studied variables, prothrombin time (PT), partial thromboplastin time, international normalized ratio (INR), creatinine (Cr), blood sugar, sodium (Na+), potassium, white blood cell, and blood urea nitrogen increased while hemoglobin and platelet decreased significantly. Regarding the ABG results, the difference in PaCO2, HCO3, and SO2 at values was significant; whereas there were no statistical significant difference between the discharged and expired patients. In contrast, PT, INR, Cr, and Na had significant difference comparing the discharged and expired patients. Conclusion: Laboratory variables do change in patients with severe brain trauma; these changes are influential on patient prognosis, especially in case of PT, INR, Cr, and Na.
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Affiliation(s)
- Firooz Salehpour
- Department of Neurosurgery, Faculty of Medicine, Tabriz University of Medical Sciences, Tabriz, Iran
| | | | - Javad Aghazadeh
- Department of Neurosurgery, Faculty of Medicine, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Amin Valizadeh Hasanloei
- Department of Neurosurgery, Faculty of Medicine, Urmia University of Medical Sciences, Urmia, Iran
| | - Khatere Pasban
- Department of Neurosurgery, Faculty of Medicine, Urmia University of Medical Sciences, Urmia, Iran
| | - Farhad Mirzaei
- Department of Neurosurgery, Faculty of Medicine, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Seyed Ahmad Naseri Alavi
- Department of Neurosurgery, Faculty of Medicine, Tabriz University of Medical Sciences, Tabriz, Iran
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Abstract
BACKGROUND The aim of this study was to evaluate the prognostic role of D-dimer level upon admission in patients with traumatic brain injury (TBI) through performing a meta-analysis. METHODS PubMed, Web of Science, Cochrane Library, and EMBASE were searched for potential eligible literature. The study characteristics and relevant data were extracted. Poor functional outcome was defined according to the Glasgow Outcome Scale (GOS ≤3). Odds ratios (ORs) with 95% confidence intervals (CIs) were pooled to estimate the predictive value of D-dimer for progressive hemorrhagic injury (PHI) and poor functional outcome at 3 months (3M GOS ≤3) in patients with TBI. RESULTS Eleven studies with 2761 patients were included. Eight studies examined the predictive role of higher D-dimer level for the risk of PHI, and the pooled OR was 1.72 (95% CI, 1.23-2.42). Three studies examined the predictive role of higher D-dimer level for the risk of 3M GOS ≤3, and the pooled OR was 2.00 (95% CI, 0.87-4.59). Significant between-study heterogeneities were observed, and sensitivity analyses and subgroup analyses were performed. No significant publication bias was found. CONCLUSIONS In conclusion, in patients with TBI, higher D-dimer level upon admission was associated with higher risk of PHI, yet no significant relationship was found between D-dimer level and the risk of 3M GOS ≤3. In the future, this readily available marker could help identify patients at risk and tailor management of these patients, thus reducing PHI and improving outcome.
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Affiliation(s)
| | - Min He
- Intensive Care Unit, West China Hospital, Sichuan University, Chengdu, P.R. China
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25
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Späni CB, Braun DJ, Van Eldik LJ. Sex-related responses after traumatic brain injury: Considerations for preclinical modeling. Front Neuroendocrinol 2018; 50:52-66. [PMID: 29753798 PMCID: PMC6139061 DOI: 10.1016/j.yfrne.2018.03.006] [Citation(s) in RCA: 108] [Impact Index Per Article: 18.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/30/2018] [Revised: 03/26/2018] [Accepted: 03/29/2018] [Indexed: 12/18/2022]
Abstract
Traumatic brain injury (TBI) has historically been viewed as a primarily male problem, since men are more likely to experience a TBI because of more frequent participation in activities that increase risk of head injuries. This male bias is also reflected in preclinical research where mostly male animals have been used in basic and translational science. However, with an aging population in which TBI incidence is increasingly sex-independent due to falls, and increasing female participation in high-risk activities, the attention to potential sex differences in TBI responses and outcomes will become more important. These considerations are especially relevant in designing preclinical animal models of TBI that are more predictive of human responses and outcomes. This review characterizes sex differences following TBI with a special emphasis on the contribution of the female sex hormones, progesterone and estrogen, to these differences. This information is potentially important in developing and customizing TBI treatments.
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Affiliation(s)
- Claudia B Späni
- Sanders-Brown Center on Aging, University of Kentucky, 101 Sanders-Brown Bldg., 800 S. Limestone Street, Lexington, KY 40536, USA.
| | - David J Braun
- Sanders-Brown Center on Aging, University of Kentucky, 101 Sanders-Brown Bldg., 800 S. Limestone Street, Lexington, KY 40536, USA.
| | - Linda J Van Eldik
- Sanders-Brown Center on Aging, University of Kentucky, 101 Sanders-Brown Bldg., 800 S. Limestone Street, Lexington, KY 40536, USA; Spinal Cord and Brain Injury Research Center (SCoBIRC), University of Kentucky, B481, BBSRB, 741 S. Limestone Street, Lexington, KY 40536, USA; Department of Neuroscience, College of Medicine, University of Kentucky, UK Medical Center MN 150, Lexington, KY 40536, USA.
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Stein P, Studt JD, Albrecht R, Müller S, von Ow D, Fischer S, Seifert B, Mariotti S, Spahn DR, Theusinger OM. The Impact of Prehospital Tranexamic Acid on Blood Coagulation in Trauma Patients. Anesth Analg 2018; 126:522-529. [DOI: 10.1213/ane.0000000000002708] [Citation(s) in RCA: 30] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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28
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Yamamoto S, DeWitt DS, Prough DS. Impact & Blast Traumatic Brain Injury: Implications for Therapy. Molecules 2018; 23:E245. [PMID: 29373501 PMCID: PMC6017013 DOI: 10.3390/molecules23020245] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2017] [Revised: 01/22/2018] [Accepted: 01/24/2018] [Indexed: 12/23/2022] Open
Abstract
Traumatic brain injury (TBI) is one of the most frequent causes of combat casualties in Operations Iraqi Freedom (OIF), Enduring Freedom (OEF), and New Dawn (OND). Although less common than combat-related blast exposure, there have been significant numbers of blast injuries in civilian populations in the United States. Current United States Department of Defense (DoD) ICD-9 derived diagnoses of TBI in the DoD Health Care System show that, for 2016, severe and moderate TBIs accounted for just 0.7% and 12.9%, respectively, of the total of 13,634 brain injuries, while mild TBIs (mTBIs) accounted for 86% of the total. Although there is a report that there are differences in the frequency of long-term complications in mTBI between blast and non-blast TBIs, clinical presentation is classified by severity score rather than mechanism because severity scoring is associated with prognosis in clinical practice. Blast TBI (bTBI) is unique in its pathology and mechanism, but there is no treatment specific for bTBIs-these patients are treated similarly to TBIs in general and therapy is tailored on an individual basis. Currently there is no neuroprotective drug recommended by the clinical guidelines based on evidence.
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Affiliation(s)
- Satoshi Yamamoto
- Department of Anesthesiology, University of Texas Medical Branch, Galveston, TX 77555, USA.
| | - Douglas S DeWitt
- Department of Anesthesiology, University of Texas Medical Branch, Galveston, TX 77555, USA.
| | - Donald S Prough
- Department of Anesthesiology, University of Texas Medical Branch, Galveston, TX 77555, USA.
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Yuan Q, Yu J, Wu X, Sun YR, Li ZQ, Du ZY, Wu XH, Hu J. Prognostic value of coagulation tests for in-hospital mortality in patients with traumatic brain injury. Scand J Trauma Resusc Emerg Med 2018; 26:3. [PMID: 29304855 PMCID: PMC5756421 DOI: 10.1186/s13049-017-0471-0] [Citation(s) in RCA: 42] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2017] [Accepted: 12/27/2017] [Indexed: 01/01/2023] Open
Abstract
BACKGROUND Coagulopathy is commonly observed after traumatic brain injury (TBI). However, it is not known whether using the standard independent predictors in conjunction with coagulation tests would improve their prognostic value. We determined the incidence of TBI-associated coagulopathy in patients with isolated TBI (iTBI), evaluated the prognostic value of coagulation tests for in-hospital mortality, and tested their predictive power for in-hospital mortality in patients with iTBI. METHODS We conducted a retrospective, observational database study on 2319 consecutive patients with iTBI who attended the Huashan Hospital Department of the Neurosurgery Neurotrauma Center at Fudan University in China between December 2004 and June 2015. Two models based on the admission characteristics were developed: model A included predictors such as age, Glasgow Coma Scale (GCS) score, pupil reactivity, type of injury, and hemoglobin and glucose levels, while model B included the predictors from model A as well as coagulation test results. A total of 1643 patients enrolled between December 2004 and December 2011 were used to derive the prognostic models, and 676 patients enrolled between January 2012 and June 2015 were used to validate the models. RESULTS Overall, 18.6% (n = 432) of the patients developed coagulopathy after iTBI. The prevalence of acute traumatic coagulopathy is associated with the severity of brain injury. The percentage of platelet count <100 × 109/L, international normalized ratio (INR) > 1.25, the prothrombin time (PT) > 14 s, activated partial thromboplastin time (APTT) > 36 s, D-dimer >5 mg/L and fibrinogen (FIB) < 1.5 g/L was also closely related to the severity of brain injury, significance being found among three groups. Age, pupillary reactivity, GCS score, epidural hematoma (EDH), and glucose levels were independent prognostic factors for in-hospital mortality in model A, whereas age, pupillary reactivity, GCS score, EDH, glucose levels, INR >1.25, and APTT >36 s exhibited strong prognostic effects in model B. Discrimination and calibration were good for the development group in both prediction models. However, the external validation test showed that calibration was better in model B than in model A for patients from the validation population (Hosmer-Lemeshow test, p = 0.152 vs. p = 0.046, respectively). CONCLUSIONS Coagulation tests can improve the predictive power of the standard model for in-hospital mortality after TBI.
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Affiliation(s)
- Qiang Yuan
- Department of Neurosurgery, Huashan Hospital, Fudan University, 12 Wulumuqi Zhong Road, Shanghai, 200040, People's Republic of China
| | - Jian Yu
- Department of Neurosurgery, Huashan Hospital, Fudan University, 12 Wulumuqi Zhong Road, Shanghai, 200040, People's Republic of China
| | - Xing Wu
- Department of Neurosurgery, Huashan Hospital, Fudan University, 12 Wulumuqi Zhong Road, Shanghai, 200040, People's Republic of China
| | - Yi-Rui Sun
- Department of Neurosurgery, Huashan Hospital, Fudan University, 12 Wulumuqi Zhong Road, Shanghai, 200040, People's Republic of China
| | - Zhi-Qi Li
- Department of Neurosurgery, Huashan Hospital, Fudan University, 12 Wulumuqi Zhong Road, Shanghai, 200040, People's Republic of China
| | - Zhuo-Ying Du
- Department of Neurosurgery, Huashan Hospital, Fudan University, 12 Wulumuqi Zhong Road, Shanghai, 200040, People's Republic of China
| | - Xue-Hai Wu
- Department of Neurosurgery, Huashan Hospital, Fudan University, 12 Wulumuqi Zhong Road, Shanghai, 200040, People's Republic of China
| | - Jin Hu
- Department of Neurosurgery, Huashan Hospital, Fudan University, 12 Wulumuqi Zhong Road, Shanghai, 200040, People's Republic of China.
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Almeida Vieira RDC, Paiva WS, de Oliveira DV, de Paula Guirado VM, Caetano Lança EDF, de Sousa RMC. Recovery of Patients with Pure Diffuse Axonal Injury Who Remained in a Coma for 6 Hours or More. World Neurosurg 2018; 109:140-146. [DOI: 10.1016/j.wneu.2017.09.101] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2017] [Revised: 09/14/2017] [Accepted: 09/15/2017] [Indexed: 02/06/2023]
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Fu YQ, Chong SL, Lee JH, Liu CJ, Fu S, Loh TF, Ng KC, Xu F. The impact of early hyperglycaemia on children with traumatic brain injury. Brain Inj 2017; 31:396-400. [PMID: 28296528 DOI: 10.1080/02699052.2016.1264629] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
OBJECTIVE Hyperglycaemia is common amongst children with traumatic brain injury (TBI). We aim to investigate the association between early hyperglycaemia and poor clinical outcomes in children with moderate to severe TBI. METHODS We performed a retrospective study in a tertiary paediatric hospital between May 2012 and October 2014 of all patients with TBI who were aged <16 years with a Glasgow Coma Scale (GCS) of ≤13. The primary outcome was death. Secondary outcomes were 14 ventilation-free, 14 paediatric intensive care unit (PICU)-free and 28 hospital-free days. We defined hyperglycaemia as glucose >11.1 mmol/L (200 mg/dL). RESULTS There were 109 patients with a median age of 54 months [inter-quartile range (IQR): 17-82]. Median glucose on arrival was 6.1 mmol/L (IQR: 5.2-9.8). Median GCS in our cohort was 8 (IQR: 6-12). Multivariate logistic regression demonstrated that initial hyperglycaemia [odds ratio (OR): 15.23; 95% confidence interval (CI): 3.74-62.00; P < 0.001], and GCS <8 (OR: 13.02; 95% CI: 2.31-73.33; P = 0.004) were risk factors for mortality. Multivariate linear regression showed that initial hyperglycaemia was a risk factor for reduced ventilation-free, PICU-free and hospital-free days. CONCLUSIONS Early hyperglycaemia predicts for in-hospital mortality, reduced ventilation-free, PICU-free and hospital-free days in children with moderate to severe TBI.
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Affiliation(s)
- Yue-Qiang Fu
- a Department of Critical Care Medicine, Children's Hospital , Chongqing Medical University , Chongqing , China
| | - Shu-Ling Chong
- b Department of Children's Emergency , KK Women's and Children's Hospital , Singapore , Singapore.,c Duke-NUS Medical School , Singapore , Singapore
| | - Jan Hau Lee
- c Duke-NUS Medical School , Singapore , Singapore.,d Children's Intensive Care Unit , KK Women's and Children's Hospital , Singapore , Singapore
| | - Cheng-Jun Liu
- a Department of Critical Care Medicine, Children's Hospital , Chongqing Medical University , Chongqing , China
| | - Sheng Fu
- e Department of Paediatrics , KK Women's and Children's Hospital , Singapore , Singapore
| | - Tsee Foong Loh
- c Duke-NUS Medical School , Singapore , Singapore.,d Children's Intensive Care Unit , KK Women's and Children's Hospital , Singapore , Singapore
| | - Kee Chong Ng
- b Department of Children's Emergency , KK Women's and Children's Hospital , Singapore , Singapore.,c Duke-NUS Medical School , Singapore , Singapore
| | - Feng Xu
- a Department of Critical Care Medicine, Children's Hospital , Chongqing Medical University , Chongqing , China
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Kupas DF, Melnychuk EM, Young AJ. Glasgow Coma Scale Motor Component (“Patient Does Not Follow Commands”) Performs Similarly to Total Glasgow Coma Scale in Predicting Severe Injury in Trauma Patients. Ann Emerg Med 2016; 68:744-750.e3. [DOI: 10.1016/j.annemergmed.2016.06.017] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2015] [Revised: 06/03/2016] [Accepted: 06/13/2016] [Indexed: 11/28/2022]
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Kamal VK, Agrawal D, Pandey RM. Prognostic models for prediction of outcomes after traumatic brain injury based on patients admission characteristics. Brain Inj 2016; 30:393-406. [DOI: 10.3109/02699052.2015.1113568] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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Chen H, Cao HL, Chen SW, Guo Y, Gao WW, Tian HL, Xue LX. Neuroglobin and Nogo-a as biomarkers for the severity and prognosis of traumatic brain injury. Biomarkers 2015; 20:495-501. [PMID: 26472601 DOI: 10.3109/1354750x.2015.1094138] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
OBJECTIVE To identify the early changes of serum neuroglobin and Nogo-A concentrations and the relations to traumatic brain injury (TBI) severity and prognosis. METHODS Serum samples were obtained and analyzed from 34 patients with TBI within the first 96 h after injury. Comparative analysis combined with Glasgow Coma Scale (GCS) scores and the 6-month prognosis of these patients was performed. RESULTS Significant correlations were found between peak serum neuroglobin and Nogo-A concentrations and a patient's GCS score on admission (p < 0.001). The mean peak serum neuroglobin and Nogo-A concentrations were both significantly higher in patients with an unfavorable outcome at 6 months after injury (p < 0.05). CONCLUSIONS Serum neuroglobin and Nogo-A levels could be suggested as biomarkers for predicting TBI severity and prognosis.
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Affiliation(s)
- Hao Chen
- a Department of Neurosurgery and
| | | | | | - Yan Guo
- a Department of Neurosurgery and
| | | | | | - Li-Xia Xue
- b Department of Neurology , Shanghai Jiao Tong University Affiliated Sixth People's Hospital , Shanghai , P.R. China
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Kim DS, Choi HJ, Yang JS, Cho YJ, Kang SH. Radiologic Determination of Corpus Callosum Injury in Patients with Mild Traumatic Brain Injury and Associated Clinical Characteristics. J Korean Neurosurg Soc 2015; 58:131-6. [PMID: 26361529 PMCID: PMC4564745 DOI: 10.3340/jkns.2015.58.2.131] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2014] [Revised: 06/08/2015] [Accepted: 06/10/2015] [Indexed: 12/01/2022] Open
Abstract
Objective To investigate the incidence of corpus callosum injury (CCI) in patients with mild traumatic brain injury (TBI) using brain MRI. We also performed a review of the clinical characteristics associated with this injury. Methods A total of 356 patients in the study were diagnosed with TBI, with 94 patients classified as having mild TBI. We included patients with mild TBI for further evaluation if they had normal findings via brain computed tomography (CT) scans and also underwent brain MRI in the acute phase following trauma. As assessed by brain MRI, CCI was defined as a high-signal lesion in T2 sagittal images and a corresponding low-signal lesion as determined by axial gradient echo (GRE) imaging. Based on these criteria, we divided patients into two groups for further analysis : Group I (TBI patients with CCI) and Group II (TBI patients without CCI). Results A total of 56 patients were enrolled in this study (including 16 patients in Group I and 40 patients in Group II). Analysis of clinical symptoms revealed a significant difference in headache severity between groups. Over 50% of patients in Group I experienced prolonged neurological symptoms including dizziness and gait disturbance and were more common in Group I than Group II (dizziness : 37 and 12% in Groups I and II, respectively; gait disturbance : 12 and 0% in Groups I and II, respectively). Conclusion The incidence of CCI in patients with mild TBI was approximately 29%. We suggest that brain MRI is a useful method to reveal the cause of persistent symptoms and predict clinical prognosis.
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Affiliation(s)
- Dong Shin Kim
- Department of Neurosurgery, Chuncheon Sacred Heart Hospital, College of Medicine, Hallym University, Chuncheon, Korea
| | - Hyuk Jai Choi
- Department of Neurosurgery, Chuncheon Sacred Heart Hospital, College of Medicine, Hallym University, Chuncheon, Korea
| | - Jin Seo Yang
- Department of Neurosurgery, Chuncheon Sacred Heart Hospital, College of Medicine, Hallym University, Chuncheon, Korea
| | - Yong Jun Cho
- Department of Neurosurgery, Chuncheon Sacred Heart Hospital, College of Medicine, Hallym University, Chuncheon, Korea
| | - Suk Hyung Kang
- Department of Neurosurgery, Chuncheon Sacred Heart Hospital, College of Medicine, Hallym University, Chuncheon, Korea
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Yuan L, Wei X, Xu C, Jin Y, Wang G, Li Y, Tian H, Chen S. Use of multisequence 3.0-T MRI to detect severe traumatic brain injury and predict the outcome. Br J Radiol 2015; 88:20150129. [PMID: 26067919 DOI: 10.1259/bjr.20150129] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
OBJECTIVE The aim of this study was to evaluate multisequence 3.0-T MRI in the detection of severe traumatic brain injury (sTBI) and in predicting the outcome. METHODS 32 patients with sTBI were prospectively enrolled, and multisequence 3.0-T MRI was performed 4-8 weeks post injury. Quantitative data were recorded on each sequence. The ability to display the parenchymal lesions was compared with that of 64-slice spiral CT. The clinical and radiological results were correlated with the Glasgow Outcome Scale Extended scores 6 months after injury. RESULTS 3.0-T MRI could display more lesions than CT, especially when the lesion was deeply located. The lesion volumes and diffuse axonal injury (DAI) scores were different between good and poor outcome groups on fluid attenuated inversion recovery (p < 0.05). The apparent diffusion coefficient (ADC) values of the splenium of the corpus callosum and brain stem were also different (p < 0.05). Patients with unfavourable outcome showed a significantly higher volume of haemorrhage on susceptibility-weighted imaging than those with favourable outcomes and had haemorrhages generally located more deeply. Logistic regression analysis revealed that the location of haemorrhage and the ADC values of the splenium of the corpus callosum were independent risk factors for poor outcome, with an overall predictive accuracy of 91.4%. CONCLUSION The joint use of conventional and advanced sequences of 3.0-T MRI can comprehensively detect the pathological changes occurring after sTBI. Haemorrhagic and non-haemorrhagic DAIs in deep structures strongly suggest poor outcome. ADVANCES IN KNOWLEDGE This article improves the understanding of advanced MRI sequences in the detection of patients with sTBI and prediction of prognosis.
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Affiliation(s)
- L Yuan
- 1 Department of Neurosurgery, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai, China
| | - X Wei
- 2 Department of Diagnostic Radiology, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai, China
| | - C Xu
- 1 Department of Neurosurgery, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai, China
| | - Y Jin
- 1 Department of Neurosurgery, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai, China
| | - G Wang
- 1 Department of Neurosurgery, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai, China
| | - Y Li
- 2 Department of Diagnostic Radiology, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai, China
| | - H Tian
- 1 Department of Neurosurgery, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai, China
| | - S Chen
- 1 Department of Neurosurgery, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai, China
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Revuelto-Rey J, Aldabó-Pallás T, Egea-Guerrero JJ, Vilches-Arenas Á, Lara EJ, Gordillo-Escobar E. Utilidad de la tomografía computarizada como herramienta para detectar potenciales donantes en muerte encefálica. Med Clin (Barc) 2015; 144:531-5. [DOI: 10.1016/j.medcli.2014.04.031] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2014] [Revised: 04/15/2014] [Accepted: 04/24/2014] [Indexed: 11/25/2022]
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Chong SL, Harjanto S, Testoni D, Ng ZM, Low CYD, Lee KP, Lee JH. Early Hyperglycemia in Pediatric Traumatic Brain Injury Predicts for Mortality, Prolonged Duration of Mechanical Ventilation, and Intensive Care Stay. Int J Endocrinol 2015; 2015:719476. [PMID: 26074963 PMCID: PMC4446478 DOI: 10.1155/2015/719476] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/25/2014] [Revised: 04/23/2015] [Accepted: 04/30/2015] [Indexed: 12/30/2022] Open
Abstract
We aim to study the association between hyperglycemia and in-hospital outcomes among children with moderate and severe traumatic brain injury (TBI). This retrospective cohort study was conducted in a tertiary pediatric hospital between 2003 and 2013. All patients < 16 years old who presented to the Emergency Department within 24 hours of head injury with a Glasgow Coma Scale (GCS) ≤ 13 were included. Our outcomes of interest were death, 14 ventilation-free, 14 pediatric intensive care unit- (PICU-) free, and 28 hospital-free days. Hyperglycemia was defined as glucose > 200 mg/dL (11.1 mmol/L). Among the 44 patients analyzed, the median age was 8.6 years (interquartile range (IQR) 5.0-11.0). Median GCS and pediatric trauma scores were 7 (IQR 4-10) and 4 (IQR 3-6), respectively. Initial hyperglycemia was associated with death (37% in the hyperglycemia group versus 8% in the normoglycemia group, p = 0.019), reduced median PICU-free days (6 days versus 11 days, p = 0.006), and reduced median ventilation-free days (8 days versus 12 days, p = 0.008). This association was however not significant in the stratified analysis of patients with GCS ≤ 8. Conclusion. Our findings demonstrate that early hyperglycemia is associated with increased mortality, prolonged duration of mechanical ventilation, and PICU stay in children with TBI.
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Affiliation(s)
- Shu-Ling Chong
- Department of Emergency Medicine, KK Women's and Children's Hospital, 100 Bukit Timah Road, Singapore 229899
- SingHealth Duke-NUS Paediatrics Academic Clinical Programme, 100 Bukit Timah Road, Singapore 229899
| | - Sumitro Harjanto
- Duke-NUS Graduate Medical School, 8 College Road, Singapore 169857
| | - Daniela Testoni
- Division of Neonatal Medicine, Escola Paulista de Medicina-Universidade Federal de Sao Paulo, Rua Marselhesa 630, Vila Clementino, 04020-060 São Paulo, SP, Brazil
| | - Zhi Min Ng
- SingHealth Duke-NUS Paediatrics Academic Clinical Programme, 100 Bukit Timah Road, Singapore 229899
- Department of Paediatric Medicine, KK Women's and Children's Hospital, 100 Bukit Timah Road, Singapore 229899
| | - Chyi Yeu David Low
- Department of Neurosurgery, KK Women's and Children's Hospital, 100 Bukit Timah Road, Singapore 229899
| | - Khai Pin Lee
- Department of Emergency Medicine, KK Women's and Children's Hospital, 100 Bukit Timah Road, Singapore 229899
- SingHealth Duke-NUS Paediatrics Academic Clinical Programme, 100 Bukit Timah Road, Singapore 229899
| | - Jan Hau Lee
- SingHealth Duke-NUS Paediatrics Academic Clinical Programme, 100 Bukit Timah Road, Singapore 229899
- Children's Intensive Care Unit, KK Women's and Children's Hospital, 100 Bukit Timah Road, Singapore 229899
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Krishna V, Andrews H, Varma A, Mintzer J, Kindy MS, Guest J. Spinal cord injury: how can we improve the classification and quantification of its severity and prognosis? J Neurotrauma 2014; 31:215-27. [PMID: 23895105 DOI: 10.1089/neu.2013.2982] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023] Open
Abstract
The preservation of functional neural tissue after spinal cord injury (SCI) is the basis for spontaneous neurological recovery. Some injured patients in the acute phase have more potential for recovery than others. This fact is problematic for the construction of clinical trials because enrollment of subjects with variable recovery potential makes it difficult to detect effects, requires large sample sizes, and risks Type II errors. In addition, the current methods to assess injury and recovery are non-quantitative and not sensitive. It is likely that therapeutic combinations will be necessary to cause substantially improved function after SCI, thus we need highly sensitive techniques to evaluate changes in motor, sensory, autonomic and other functions. We review several emerging neurophysiological techniques with high sensitivity. Quantitative methods to evaluate residual tissue sparing after severe acute SCI have not entered widespread clinical use. This reduces the ability to correlate structural preservation with clinical outcome following SCI resulting in enrollment of subjects with varying patterns of tissue preservation and injury into clinical trials. We propose that the inclusion of additional measures of injury severity, pattern, and individual genetic characteristics may enable stratification in clinical trials to make the testing of therapeutic interventions more effective and efficient. New imaging techniques to assess tract injury and demyelination and methods to quantify tissue injury, inflammatory markers, and neuroglial biochemical changes may improve the evaluation of injury severity, and the correlation with neurological outcome, and measure the effects of treatment more robustly than is currently possible. The ability to test such a multimodality approach will require a high degree of collaboration between clinical and research centers and government research support. When the most informative of these assessments is determined, it may be possible to identify patients with substantial recovery potential, improve selection criteria and conduct more efficient clinical trials.
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Affiliation(s)
- Vibhor Krishna
- 1 Department of Neurosciences, Medical University of South Carolina , Charleston, South Carolina
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Zelnick LR, Morrison LJ, Devlin SM, Bulger EM, Brasel KJ, Sheehan K, Minei JP, Kerby JD, Tisherman SA, Rizoli S, Karmy-Jones R, van Heest R, Newgard CD. Addressing the challenges of obtaining functional outcomes in traumatic brain injury research: missing data patterns, timing of follow-up, and three prognostic models. J Neurotrauma 2014; 31:1029-38. [PMID: 24552494 DOI: 10.1089/neu.2013.3122] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Traumatic brain injury (TBI) is common and debilitating. Randomized trials of interventions for TBI ideally assess effectiveness by using long-term functional neurological outcomes, but such outcomes are difficult to obtain and costly. If there is little change between functional status at hospital discharge versus 6 months, then shorter-term outcomes may be adequate for use in future clinical trials. Using data from a previously published multi-center, randomized, placebo-controlled TBI clinical trial, we evaluated patterns of missing outcome data, changes in functional status between hospital discharge and 6 months, and three prognostic models to predict long-term functional outcome from covariates available at hospital discharge (functional measures, demographics, and injury characteristics). The Resuscitation Outcomes Consortium Hypertonic Saline trial enrolled 1282 TBI patients, obtaining the primary outcome of 6-month Glasgow Outcome Score Extended (GOSE) for 85% of patients, but missing the primary outcome for the remaining 15%. Patients with missing outcomes had less-severe injuries, higher neurological function at discharge (GOSE), and shorter hospital stays than patients whose GOSE was obtained. Of 1066 (83%) patients whose GOSE was obtained both at hospital discharge and at 6-months, 71% of patients had the same dichotomized functional status (severe disability/death vs. moderate/no disability) after 6 months as at discharge, 28% had an improved functional status, and 1% had worsened. Performance was excellent (C-statistic between 0.88 and 0.91) for all three prognostic models and calibration adequate for two models (p values, 0.22 and 0.85). Our results suggest that multiple imputation of the standard 6-month GOSE may be reasonable in TBI research when the primary outcome cannot be obtained through other means.
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Affiliation(s)
- Leila R Zelnick
- 1 Department of Biostatistics, University of Washington ROC Clinical Trial Center , Seattle, Washington
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The role of serious concomitant injuries in the treatment and outcome of pediatric severe traumatic brain injury. J Trauma Acute Care Surg 2014; 75:836-42. [PMID: 24158203 DOI: 10.1097/ta.0b013e3182a685b0] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND The study objective was to describe the epidemiology of serious concomitant injuries and their effects on outcome in pediatric severe traumatic brain injury (sTBI). METHODS A retrospective cohort of all severely injured (Injury Severity Score [ISS] ≥ 12) pediatric patients (<18 years) admitted to our pediatric intensive care unit, between 2000 and 2011, after experiencing an sTBI (Glasgow Coma Scale [GCS] score ≤ 8 and head Abbreviated Injury Scale [AIS] ≥ 4) were included. Two groups were compared based on the presence of serious concomitant injuries (maximum AIS score ≥ 3). Multivariate logistic regression was undertaken to determine variable associations with mortality. RESULTS Of the 180 patients with sTBI, 113 (63%) sustained serious concomitant injuries. Chest was the most commonly injured extracranial body region (84%), with lung being the most often injured. Patients with serious concomitant injuries had increased age, weight, and injury severity (p < 0.001) and were more likely injured in a motor vehicle collision (91% vs. 48%, p < 0.001). Those with serious concomitant injuries had worse sTBI, based on lower presedation GCS (p = 0.031), higher frequency of fixed pupils (p = 0.006), and increased imaging abnormalities (SAH and DAI, p ≤ 0.01). Non-neurosurgical operations and blood transfusions were more frequent in the serious concomitant injury group (p < 0.01). The differences in mortality for the two groups failed to reach statistical significant (p = 0.053), but patients with serious concomitant injuries had higher rates of infection and acute central diabetes insipidus, fewer ventilator-free days, and greater length of stays (p < 0.05). Multivariate analyses revealed fixed pupillary response (odd ratio [OR], 63.58; p < 0.001), presedation motor GCS (OR, 0.23; p = 0.001), blood transfusion (OR, 5.80; p = 0.008), and hypotension (OR, 4.82; p = 0.025) were associated with mortality, but serious concomitant injuries was not (p = 0.283). CONCLUSION Head injury is the most important prognostic factor in mortality for sTBI pediatric patients, but the presence of serious concomitant injuries does contribute to greater morbidity, including longer stays, more infections, fewer ventilator-free days, and a higher level of care required on discharge from hospital. LEVEL OF EVIDENCE Prognostic and epidemiologic study, level III.
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Muehlschlegel S, Carandang R, Ouillette C, Hall W, Anderson F, Goldberg R. Frequency and impact of intensive care unit complications on moderate-severe traumatic brain injury: early results of the Outcome Prognostication in Traumatic Brain Injury (OPTIMISM) Study. Neurocrit Care 2014; 18:318-31. [PMID: 23377884 DOI: 10.1007/s12028-013-9817-2] [Citation(s) in RCA: 41] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
BACKGROUND Known predictors of adverse outcomes in patients with moderate-severe TBI (msTBI) explain only a relatively small proportion of patient-related outcomes. The frequency and impact of intensive care unit complications (ICU-COMPL) on msTBI-associated outcomes are poorly understood. METHODS In 213 consecutive msTBI patients admitted to a Level I Trauma Center neuro trauma ICU, twenty-eight ICU-COMPL (21 medical and 7 neurological) were prospectively collected and adjudicated by group consensus, using pre-defined criteria. We determined frequencies, and explored associations of ICU-COMPL and hospital discharge outcomes using multivariable logistic regression. RESULTS The average age of the study sample was 53 years, and the median presenting Glasgow Coma Scale and Injury Severity Scores were 5 and 27, respectively. Hyperglycemia (79%), fever (62%), systemic inflammatory response syndrome (60%), and hypotension requiring vasopressors (42%) were the four most common medical ICU-COMPL. Herniation (39%), intracranial rebleed (39%), and brain edema requiring osmotherapy (37%) were the three most common neurological ICU-COMPL. After adjusting for admission variables, duration of ventilation, and ICU length-of-stay, patients with brain edema (OR 5.8; 95% CI 2, 16.7) had a significantly increased odds for dying during hospitalization whereas patients with hospital-acquired urinary tract infection (UTI) had a decreased odds (OR 0.05; 95% CI 0.005, 0.6). Sensitivity analysis revealed that UTI occurred later, suggesting a non-causal association with survival. Brain herniation (OR 15.7; 95% CI 2.6, 95.4) was associated with an unfavorable functional status (GOS 1-3). CONCLUSION ICU-COMPL are very common after msTBI, have a considerable impact on short-term outcomes, and should be considered in the prognostication of these high risk patients. Survival associations of time-dependent complications warrant cautious interpretation.
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Affiliation(s)
- Susanne Muehlschlegel
- Division of Neurocritical Care, Department of Neurology, University of Massachusetts Medical School, Worcester, MA, USA.
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Dai D, Yuan Q, Sun Y, Yuan F, Su Z, Ding J, Tian H. Impact of thoracic injury on traumatic brain injury outcome. PLoS One 2013; 8:e74204. [PMID: 24019957 PMCID: PMC3760828 DOI: 10.1371/journal.pone.0074204] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2013] [Accepted: 07/28/2013] [Indexed: 11/18/2022] Open
Abstract
Background To assessed the significance of thoracic injury on the 30-day mortality and outcome of traumatic brain injury (TBI). Methods TBI patients admitted to our department were retrospectively evaluated. We developed two prognostic models based on admission predictors with logistic regression analysis to assess the significance of thoracic injuries in determining the 30-day mortality and outcome. The internal validity of the models was evaluated with the bootstrap re-sampling technique. We also validated the models in an external series of 165 patients that collected from our center. Discriminative ability was evaluated with C statistic. Calibrative ability was assessed with the Hosmer-Lemeshow test (H-L test). Results Among 505 TBI patients admitted, 102 (20.2%) had thoracic injuries. Patients with a PCS ≥6 had a 3.142 and 8.065 times higher odds of mortality and poor outcome compared with patients with a PCS <6, respectively. Any one-score increase of the TTS had a 1.193 times higher odds of a poor outcome (p = 0.017). The predictive model for mortality and 30-day functional outcome both had good accuracy (AUC: 0.875; 95% confidence interval [CI], 0.841–0.910 and AUC: 0.888; 95%CI, 0.860–0.916, respectively). Internal validation showed no over optimism in any of the two models’ predictive C statistics (C statistic 0.872 for 30-day mortality and C statistic 0.884 for the 30-day neurological outcome). The external validation confirmed the discriminatory ability of these models (C statistic 0.949 (95%CI: 0.919–0.980) for 30-day mortality and C statistic 0.915 (95%CI: 0.868–0.963) for the 30-day neurological outcome). The calibration was also good for patients from the validation population (H-L test p>0.05). Conclusion Thoracic injury diagnosed by CT has a negative impact on the 30-day mortality and functional outcome of TBI patients. The extent of PC and the TTS are the predictors for TBI outcome.
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Affiliation(s)
- Dawei Dai
- Department of Neurosurgery, Shanghai 6th People’s Hospital, Shanghai Jiao Tong University, Shanghai, China
| | - Qiang Yuan
- Department of Neurosurgery, Shanghai 6th People’s Hospital, Shanghai Jiao Tong University, Shanghai, China
| | - Yinfeng Sun
- Department of Hyperbaric Oxygen, Shanghai 6th People’s Hospital, Shanghai Jiao Tong University, Shanghai, China
| | - Fang Yuan
- Department of Neurosurgery, Shanghai 6th People’s Hospital, Shanghai Jiao Tong University, Shanghai, China
| | - Zuopeng Su
- Department of Neurosurgery, Shanghai 6th People’s Hospital, Shanghai Jiao Tong University, Shanghai, China
| | - Jun Ding
- Department of Neurosurgery, Shanghai 6th People’s Hospital, Shanghai Jiao Tong University, Shanghai, China
- * E-mail: (JD); (HT)
| | - Hengli Tian
- Department of Neurosurgery, Shanghai 6th People’s Hospital, Shanghai Jiao Tong University, Shanghai, China
- * E-mail: (JD); (HT)
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Klein AM, Howell K, Vogler J, Grill E, Straube A, Bender A. Rehabilitation outcome of unconscious traumatic brain injury patients. J Neurotrauma 2013; 30:1476-83. [PMID: 23477301 PMCID: PMC3751265 DOI: 10.1089/neu.2012.2735] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Outcome prediction of traumatic brain injury (TBI) patients with severe disorders of consciousness (DOC) at the end of their time in an intensive care setting is important for clinical decision making and counseling of relatives, and constitutes a major challenge. Even the question of what constitutes an improved outcome is controversially discussed. We have conducted a retrospective cohort study for the rehabilitation dynamics and outcome of TBI patients with DOC. Out of 188 patients, 37.2% emerged from a minimally conscious state (MCS) and 16.5% achieved at least partial functional independence after a mean observation period of 107 days (range 1-399 days). This reflects that emergence from MCS is much easier to achieve than functional independence. Logistic regression analysis identified age and level of consciousness upon admission to neurorehabilitation as independent prognostic factors for both outcomes. The group who reached at least partial functional independence started to improve significantly more than the corresponding outcome group by post-injury week 7, and the average time to reach this functional status was 18 weeks. In contrast, the group who emerged from MCS started to improve after 6 weeks. The longest delay between brain injury and the beginning of functional improvement (measured by biweekly Functional Independence Measure [FIM] scores) still compatible with reaching at least partial functional independence was 18 weeks. In conclusion, despite a strong negative selection, a substantial proportion of severe TBI patients with DOC achieve functional improvements or at least emerge from MCS within the inpatient rehabilitation phase. In order to avoid self-fulfilling prophecies in decision making, it is important to be aware of the fact that the beginning of clinical improvement may take several months after brain injury. In this study, separation of both of the functional outcome groups started by 7 weeks post-injury.
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Affiliation(s)
- Anke-Maria Klein
- Department of Neurology, Ludwig-Maximilians-University, Munich, Germany
| | - Kaitlen Howell
- Department of Neurology, Ludwig-Maximilians-University, Munich, Germany
| | - Jana Vogler
- Department of Neurology, Ludwig-Maximilians-University, Munich, Germany
| | - Eva Grill
- Institute of Medical Informatics, Biometry and Epidemiology, Ludwig-Maximilians-University, Munich, Germany
- Integrated Center for Research and Treatment of Vertigo, Balance and Ocular Motor Disorders, Ludwig-Maximilians-University, Munich, Germany
| | - Andreas Straube
- Department of Neurology, Ludwig-Maximilians-University, Munich, Germany
| | - Andreas Bender
- Department of Neurology, Ludwig-Maximilians-University, Munich, Germany
- Department of Neurology, Therapiezentrum Burgau, Burgau, Germany
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Ding J, Yuan F, Guo JY, Chen H, Tian HL. Influence of glibenclamide on outcome in patients with type 2 diabetes and traumatic brain injury. Clin Neurol Neurosurg 2013; 115:2166-9. [PMID: 23998719 DOI: 10.1016/j.clineuro.2013.08.010] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2013] [Revised: 08/06/2013] [Accepted: 08/11/2013] [Indexed: 10/26/2022]
Abstract
BACKGROUND AND PURPOSE The influence of sulfonylurea receptor 1 (SUR1) and its inhibitor glibenclamide on progressive secondary hemorrhage (PSH), progressive hemorrhagic necrosis (PHN), and brain edema has been studied in rat models of traumatic brain injury (TBI) and ischemia. These studies indicate that blocking SUR1 may exert protective effects in terms of outcome. METHODS We discuss the effects of glibenclamide on outcome in patients with type 2 diabetes mellitus and TBI. We collected demographic, clinical, and imaging data from the clinical records of TBI patients with type 2 diabetes who were admitted to the neurosurgery department at Shanghai 6th People's Hospital between 2001 and 2012. Data from patients who met the inclusion criteria were analyzed. Patients were divided into glibenclamide group and insulin group. RESULTS Of 70 patients fit criteria for inclusion, no significant difference was observed except for age and fasting plasma glucose between the two groups. Outcome indicators, including GCS discharge, GOS discharge, length of study in hospital (LOS-H), and the presence of PSH showed no significant difference too (p>0.05), except for length of stay in neuro-intensive care unit (LOS-NICU) (p<0.05). Age, hours between the initial CT scan and the injury (HCT1) and GCS at admission were observed as factors associated with PSH after logistic regression. CONCLUSIONS In general, the use of glibenclamide to control plasma glucose after TBI had no significant effect on patient outcome at discharge but it could reduce the LOS-NICU (p<0.05). Glibenclamide also had no apparent effect on the presence of PSH in TBI patients with type 2 diabetes mellitus.
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Affiliation(s)
- Jun Ding
- Department of Neurosurgery, Shanghai Sixth People Hospital, Shanghai Jiaotong University, Shanghai 200233, China
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Nakase-Richardson R, McNamee S, Howe LL, Massengale J, Peterson M, Barnett SD, Harris O, McCarthy M, Tran J, Scott S, Cifu DX. Descriptive characteristics and rehabilitation outcomes in active duty military personnel and veterans with disorders of consciousness with combat- and noncombat-related brain injury. Arch Phys Med Rehabil 2013; 94:1861-9. [PMID: 23810353 DOI: 10.1016/j.apmr.2013.05.027] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2013] [Revised: 04/24/2013] [Accepted: 05/23/2013] [Indexed: 11/17/2022]
Abstract
OBJECTIVE To report the injury and demographic characteristics, medical course, and rehabilitation outcome for a consecutive series of veterans and active duty military personnel with combat- and noncombat-related brain injury and disorder of consciousness (DOC) at the time of rehabilitation admission. DESIGN Retrospective study. SETTING Rehabilitation center. PARTICIPANTS From January 2004 to October 2009, persons (N=1654) were admitted to the Polytrauma Rehabilitation System of Care. This study focused on the N=122 persons admitted with a DOC. Participants with a DOC were primarily men (96%), on active duty (82%), ≥12 years of education, and a median age of 25. Brain injury etiologies included mixed blast trauma (24%), penetrating (8%), other trauma (56%), and nontrauma (13%). Median initial Glasgow Coma Scale score was 3, and rehabilitation admission Glasgow Coma Scale score was 8. Individuals were admitted for acute neurorehabilitation approximately 51 days postinjury with a median rehabilitation length of stay of 132 days. INTERVENTIONS None. MAIN OUTCOME MEASURES Recovery of consciousness and the FIM instrument. RESULTS Most participants emerged to regain consciousness during neurorehabilitation (64%). Average gains ± SD on the FIM cognitive and motor subscales were 19 ± 25 and 7 ± 8, respectively. Common medical complications included spasticity (70%), dysautonomia (34%), seizure occurrence (30%), and intracranial infection (22%). Differential outcomes were observed across etiologies, particularly for those with blast-related brain injury etiology. CONCLUSIONS Despite complex comorbidities, optimistic outcomes were observed. Individuals with severe head injury because of blast-related etiologies have different outcomes and comorbidities observed. Health-services research with a focus on prevention of comorbidities is needed to inform optimal models of care, particularly for combat injured soldiers with blast-related injuries.
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Affiliation(s)
- Risa Nakase-Richardson
- Mental Health and Behavioral Science Service, James A. Haley Veterans Hospital, Tampa, FL; Department of Psychology, University of South Florida, Tampa, FL; Center of Excellence for Maximizing Rehabilitation Outcomes, Tampa, FL.
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Lugeder A. Differences between groups. DEUTSCHES ARZTEBLATT INTERNATIONAL 2013; 110:288. [PMID: 23671474 PMCID: PMC3648897 DOI: 10.3238/arztebl.2013.0288a] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/02/2023]
Affiliation(s)
- Armin Lugeder
- *Klinik für Unfallchirurgie und Orthopädie, Johannes Wesling Klinikum Minden,
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