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Shad A, Rewell SSJ, Macowan M, Gandasasmita N, Wang J, Chen K, Marsland B, O'Brien TJ, Li J, Semple BD. Modelling lung infection with Klebsiella pneumoniae after murine traumatic brain injury. J Neuroinflammation 2024; 21:122. [PMID: 38720343 PMCID: PMC11080247 DOI: 10.1186/s12974-024-03093-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2024] [Accepted: 04/05/2024] [Indexed: 05/12/2024] Open
Abstract
Pneumonia is a common comorbidity in patients with severe traumatic brain injury (TBI), and is associated with increased morbidity and mortality. In this study, we established a model of intratracheal Klebsiella pneumoniae administration in young adult male and female mice, at 4 days following an experimental TBI, to investigate how K. pneumoniae infection influences acute post-TBI outcomes. A dose-response curve determined the optimal dose of K. pneumoniae for inoculation (1 x 10^6 colony forming units), and administration at 4 days post-TBI resulted in transient body weight loss and sickness behaviors (hypoactivity and acute dyspnea). K. pneumoniae infection led to an increase in pro-inflammatory cytokines in serum and bronchoalveolar lavage fluid at 24 h post-infection, in both TBI and sham (uninjured) mice. By 7 days, when myeloperoxidase + neutrophil numbers had returned to baseline in all groups, lung histopathology was observed with an increase in airspace size in TBI + K. pneumoniae mice compared to TBI + vehicle mice. In the brain, increased neuroinflammatory gene expression was observed acutely in response to TBI, with an exacerbated increase in Ccl2 and Hmox1 in TBI + K. pneumoniae mice compared to either TBI or K. pneumoniae alone. However, the presence of neuroinflammatory immune cells in the injured brain, and the extent of damage to cortical and hippocampal brain tissue, was comparable between K. pneumoniae and vehicle-treated mice by 7 days. Examination of the fecal microbiome across a time course did not reveal any pronounced effects of either injury or K. pneumoniae on bacterial diversity or abundance. Together, these findings demonstrate that K. pneumoniae lung infection after TBI induces an acute and transient inflammatory response, primarily localized to the lungs with some systemic effects. However, this infection had minimal impact on secondary injury processes in the brain following TBI. Future studies are needed to evaluate the potential longer-term consequences of this dual-hit insult.
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Affiliation(s)
- Ali Shad
- Department of Neuroscience, The School of Translational Medicine, Monash University, Level 6 Alfred Centre, 99 Commercial Rd, Melbourne, VIC, 3004 VIC, Australia
- Alfred Health, Prahran, VIC, Australia
| | - Sarah S J Rewell
- Department of Neuroscience, The School of Translational Medicine, Monash University, Level 6 Alfred Centre, 99 Commercial Rd, Melbourne, VIC, 3004 VIC, Australia
- Alfred Health, Prahran, VIC, Australia
| | - Matthew Macowan
- Department of Immunology, The School of Translational Medicine, Monash University, Melbourne, VIC, Australia
- GIN Discovery Program, The School of Translational Medicine, Monash University, Melbourne, VIC, Australia
| | - Natasha Gandasasmita
- Department of Neuroscience, The School of Translational Medicine, Monash University, Level 6 Alfred Centre, 99 Commercial Rd, Melbourne, VIC, 3004 VIC, Australia
| | - Jiping Wang
- Department of Microbiology, Monash Biomedical Discovery Institute, Monash University, Clayton, VIC, Australia
| | - Ke Chen
- Department of Microbiology, Monash Biomedical Discovery Institute, Monash University, Clayton, VIC, Australia
| | - Ben Marsland
- Department of Immunology, The School of Translational Medicine, Monash University, Melbourne, VIC, Australia
- GIN Discovery Program, The School of Translational Medicine, Monash University, Melbourne, VIC, Australia
| | - Terence J O'Brien
- Department of Neuroscience, The School of Translational Medicine, Monash University, Level 6 Alfred Centre, 99 Commercial Rd, Melbourne, VIC, 3004 VIC, Australia
- Alfred Health, Prahran, VIC, Australia
- GIN Discovery Program, The School of Translational Medicine, Monash University, Melbourne, VIC, Australia
- Department of Medicine (Royal Melbourne Hospital), University of Melbourne, Parkville, VIC, Australia
| | - Jian Li
- Department of Microbiology, Monash Biomedical Discovery Institute, Monash University, Clayton, VIC, Australia
| | - Bridgette D Semple
- Department of Neuroscience, The School of Translational Medicine, Monash University, Level 6 Alfred Centre, 99 Commercial Rd, Melbourne, VIC, 3004 VIC, Australia.
- Alfred Health, Prahran, VIC, Australia.
- Department of Medicine (Royal Melbourne Hospital), University of Melbourne, Parkville, VIC, Australia.
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2
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Castellani GB, Maietti E, Colombo V, Clemente S, Cassani I, Rucci P. Impact of Multidrug-Resistant Organisms on Severe Acquired Brain Injury Rehabilitation: An Observational Study. Microorganisms 2024; 12:830. [PMID: 38674774 PMCID: PMC11052286 DOI: 10.3390/microorganisms12040830] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2024] [Revised: 04/16/2024] [Accepted: 04/18/2024] [Indexed: 04/28/2024] Open
Abstract
Healthcare-associated infections (HAIa) and antimicrobial resistance are expected to be the next threat to human health and are most frequent in people with severe acquired brain injury (SABI), who can be more easily colonized by multidrug-resistant organisms (MDROs). The study's aim is to investigate the impact of MDRO colonizations and infections on SABI rehabilitation outcomes. This retrospective observational study was performed in a tertiary referral specialized rehabilitation hospital. The main outcomes were the presence of carbapenemase-producing Enterobacteriaceae (CPE) colonization, type and timing of HAI and MDRO HAI, and the number of CPE transmissions. We included 48 patients, 31% carrying CPE on admission and 33% colonized during the hospitalization. A total of 101 HAI were identified in 40 patients, with an overall incidence of 10.5/1000 patient days. Some 37% of patients had at least one MDRO infection, with a MDRO infection incidence of 2.8/1000 patient days. The number of HAIs was significantly correlated with the length of stay (LOS) (r = 0.453, p = 0.001). A significant correlation was found between colonization and type of hospital room (p = 0.013). Complications and HAI significantly affected LOS. We suggest that CPE carriers might be at risk of HAI and worse outcomes compared with non-CPE carriers.
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Affiliation(s)
| | - Elisa Maietti
- Department of Biomedical and Neuromotor Sciences, University of Bologna, 40126 Bologna, Italy;
| | - Valentina Colombo
- Montecatone Rehabilitation Institute, 40026 Imola, Italy; (V.C.); (S.C.); (I.C.)
| | - Stefano Clemente
- Montecatone Rehabilitation Institute, 40026 Imola, Italy; (V.C.); (S.C.); (I.C.)
| | - Ivo Cassani
- Montecatone Rehabilitation Institute, 40026 Imola, Italy; (V.C.); (S.C.); (I.C.)
| | - Paola Rucci
- Department of Biomedical and Neuromotor Sciences, University of Bologna, 40126 Bologna, Italy;
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3
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Ritzel RM, Li Y, Jiao Y, Doran SJ, Khan N, Henry RJ, Brunner K, Loane DJ, Faden AI, Szeto GL, Wu J. Bi-directional neuro-immune dysfunction after chronic experimental brain injury. J Neuroinflammation 2024; 21:83. [PMID: 38581043 PMCID: PMC10996305 DOI: 10.1186/s12974-024-03082-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2024] [Accepted: 03/30/2024] [Indexed: 04/07/2024] Open
Abstract
BACKGROUND It is well established that traumatic brain injury (TBI) causes acute and chronic alterations in systemic immune function and that systemic immune changes contribute to posttraumatic neuroinflammation and neurodegeneration. However, how TBI affects bone marrow (BM) hematopoietic stem/progenitor cells chronically and to what extent such changes may negatively impact innate immunity and neurological function has not been examined. METHODS To further understand the role of BM cell derivatives on TBI outcome, we generated BM chimeric mice by transplanting BM from chronically injured or sham (i.e., 90 days post-surgery) congenic donor mice into otherwise healthy, age-matched, irradiated CD45.2 C57BL/6 (WT) hosts. Immune changes were evaluated by flow cytometry, multiplex ELISA, and NanoString technology. Moderate-to-severe TBI was induced by controlled cortical impact injury and neurological function was measured using a battery of behavioral tests. RESULTS TBI induced chronic alterations in the transcriptome of BM lineage-c-Kit+Sca1+ (LSK+) cells in C57BL/6 mice, including modified epigenetic and senescence pathways. After 8 weeks of reconstitution, peripheral myeloid cells from TBI→WT mice showed significantly higher oxidative stress levels and reduced phagocytic activity. At eight months after reconstitution, TBI→WT chimeric mice were leukopenic, with continued alterations in phagocytosis and oxidative stress responses, as well as persistent neurological deficits. Gene expression analysis revealed BM-driven changes in neuroinflammation and neuropathology after 8 weeks and 8 months of reconstitution, respectively. Chimeric mice subjected to TBI at 8 weeks and 8 months post-reconstitution showed that longer reconstitution periods (i.e., time post-injury) were associated with increased microgliosis and leukocyte infiltration. Pre-treatment with a senolytic agent, ABT-263, significantly improved behavioral performance of aged C57BL/6 mice at baseline, although it did not attenuate neuroinflammation in the acutely injured brain. CONCLUSIONS TBI causes chronic activation and progressive dysfunction of the BM stem/progenitor cell pool, which drives long-term deficits in hematopoiesis, innate immunity, and neurological function, as well as altered sensitivity to subsequent brain injury.
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Affiliation(s)
- Rodney M Ritzel
- Department of Anesthesiology and Shock, Trauma and Anesthesiology Research (STAR) Center, University of Maryland School of Medicine, Baltimore, MD, 21201, USA.
- Department of Neurology, McGovern Medical School, The University of Texas Health Science Center at Houston, Houston, TX, 77030, USA.
| | - Yun Li
- Department of Anesthesiology and Shock, Trauma and Anesthesiology Research (STAR) Center, University of Maryland School of Medicine, Baltimore, MD, 21201, USA
| | - Yun Jiao
- Department of Chemical, Biochemical and Environmental Engineering, University of Maryland, Baltimore County, Baltimore, MD, 21250, USA
| | - Sarah J Doran
- Department of Anesthesiology and Shock, Trauma and Anesthesiology Research (STAR) Center, University of Maryland School of Medicine, Baltimore, MD, 21201, USA
| | - Niaz Khan
- Department of Anesthesiology and Shock, Trauma and Anesthesiology Research (STAR) Center, University of Maryland School of Medicine, Baltimore, MD, 21201, USA
| | - Rebecca J Henry
- Department of Anesthesiology and Shock, Trauma and Anesthesiology Research (STAR) Center, University of Maryland School of Medicine, Baltimore, MD, 21201, USA
| | - Kavitha Brunner
- Department of Anesthesiology and Shock, Trauma and Anesthesiology Research (STAR) Center, University of Maryland School of Medicine, Baltimore, MD, 21201, USA
| | - David J Loane
- Department of Anesthesiology and Shock, Trauma and Anesthesiology Research (STAR) Center, University of Maryland School of Medicine, Baltimore, MD, 21201, USA
| | - Alan I Faden
- Department of Anesthesiology and Shock, Trauma and Anesthesiology Research (STAR) Center, University of Maryland School of Medicine, Baltimore, MD, 21201, USA
| | - Gregory L Szeto
- Department of Chemical, Biochemical and Environmental Engineering, University of Maryland, Baltimore County, Baltimore, MD, 21250, USA
| | - Junfang Wu
- Department of Anesthesiology and Shock, Trauma and Anesthesiology Research (STAR) Center, University of Maryland School of Medicine, Baltimore, MD, 21201, USA.
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Gandasasmita N, Li J, Loane DJ, Semple BD. Experimental Models of Hospital-Acquired Infections After Traumatic Brain Injury: Challenges and Opportunities. J Neurotrauma 2024; 41:752-770. [PMID: 37885226 DOI: 10.1089/neu.2023.0453] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2023] Open
Abstract
Patients hospitalized after a moderate or severe traumatic brain injury (TBI) are at increased risk of nosocomial infections, including bacterial pneumonia and other upper respiratory tract infections. Infections represent a secondary immune challenge for vulnerable TBI patients that can lead to increased morbidity and poorer long-term prognosis. This review first describes the clinical significance of infections after TBI, delving into the known mechanisms by which a TBI can alter systemic immunological responses towards an immunosuppressive state, leading to promotion of increased vulnerability to infections. Pulmonary dysfunction resulting from respiratory tract infections is considered in the context of neurotrauma, including the bidirectional relationship between the brain and lungs. Turning to pre-clinical modeling, current laboratory approaches to study experimental TBI and lung infections are reviewed, to highlight findings from the limited key studies to date that have incorporated both insults. Then, practical decisions for the experimental design of animal studies of post-injury infections are discussed. Variables associated with the host animal, the infectious agent (e.g., species, strain, dose, and administration route), as well as the timing of the infection relative to the injury model are important considerations for model development. Together, the purpose of this review is to highlight the significant clinical need for increased pre-clinical research into the two-hit insult of a hospital-acquired infection after TBI to encourage further scientific enquiry in the field.
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Affiliation(s)
| | - Jian Li
- Biomedicine Discovery Institute, Monash University, Melbourne, Victoria, Australia
- Department of Microbiology, Monash University, Melbourne, Victoria, Australia
| | - David J Loane
- School of Biochemistry and Immunology, Trinity Biomedical Sciences Institute, Trinity College Dublin, Dublin, Ireland
- Department of Anesthesiology and Shock, Trauma and Anesthesiology Research (STAR) Center, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Bridgette D Semple
- Department of Neuroscience, Monash University, Melbourne, Victoria, Australia
- Department of Neurology, Alfred Health, Prahran, Victoria, Australia
- Department of Medicine (Royal Melbourne Hospital), The University of Melbourne, Parkville, Victoria, Australia
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5
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Chan WH, Huang SM, Chiu YL. Pulmonary Effects of Traumatic Brain Injury in Mice: A Gene Set Enrichment Analysis. Int J Mol Sci 2024; 25:3018. [PMID: 38474264 DOI: 10.3390/ijms25053018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2024] [Revised: 02/24/2024] [Accepted: 03/03/2024] [Indexed: 03/14/2024] Open
Abstract
Acute lung injury occurs in 20-25% of cases following traumatic brain injury (TBI). We investigated changes in lung transcriptome expression post-TBI using animal models and bioinformatics. Employing unilateral controlled cortical impact for TBI, we conducted microarray analysis after lung acquisition, followed by gene set enrichment analysis of differentially expressed genes. Our findings indicate significant upregulation of inflammation-related genes and downregulation of nervous system genes. There was enhanced infiltration of adaptive immune cells, evidenced by positive enrichment in Lung-Th1, CD4, and CD8 T cells. Analysis using the Tabula Sapiens database revealed enrichment in lung-adventitial cells, pericytes, myofibroblasts, and fibroblasts, indicating potential effects on lung vasculature and fibrosis. Gene set enrichment analysis linked TBI to lung diseases, notably idiopathic pulmonary hypertension. A Venn diagram overlap analysis identified a common set of 20 genes, with FOSL2 showing the most significant fold change. Additionally, we observed a significant increase in ADRA1A→IL6 production post-TBI using the L1000 library. Our study highlights the impact of brain trauma on lung injury, revealing crucial gene expression changes related to immune cell infiltration, cytokine production, and potential alterations in lung vasculature and fibrosis, along with a specific spectrum of disease influence.
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Affiliation(s)
- Wei-Hung Chan
- Department of Anesthesiology, Tri-Service General Hospital, National Defense Medical Center, Taipei City 114201, Taiwan
- Graduate Institute of Medical Sciences, National Defense Medical Center, Taipei City 114201, Taiwan
| | - Shih-Ming Huang
- Department of Biochemistry, National Defense Medical Center, Taipei City 114201, Taiwan
| | - Yi-Lin Chiu
- Department of Biochemistry, National Defense Medical Center, Taipei City 114201, Taiwan
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6
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Malik S, Lavania A, Shukla D, Shah J, Raj S, Murugan SS, Sathya TN, Goswami A, Kumaravel TS. Evaluating CAPO®: A biocompatibility, transparency, and fitment assessment for use with CEREBO® in traumatic intracranial injury detection. JOURNAL OF BIOPHOTONICS 2024; 17:e202300243. [PMID: 38176408 DOI: 10.1002/jbio.202300243] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/22/2023] [Revised: 12/05/2023] [Accepted: 12/06/2023] [Indexed: 01/06/2024]
Abstract
Healthcare-associated infections (HAIs) are a global concern affecting millions of patients, requiring robust infection prevention and control measures. In particular, patients with traumatic brain injury (TBI) are highly susceptible to nosocomial infections, emphasizing the importance of infection control. Non-invasive near infrared spectroscopy (NIRS) device, CEREBO® integrated with a disposable component CAPO® has emerged as a valuable tool for TBI patient triage and this study evaluated the safety and efficacy of this combination. Biocompatibility tests confirmed safety and transparency assessments demonstrated excellent light transmission. Clinical evaluation with 598 enrollments demonstrated high accuracy of CEREBO® in detecting traumatic intracranial hemorrhage. During these evaluations, the cap fitted well and moved smoothly with the probes demonstrating appropriate flexibility. These findings support the efficacy of the CAPO® and CEREBO® combination, potentially improving infection control and enhancing intracranial hemorrhage detection for TBI patient triage. Ultimately, this can lead to better healthcare outcomes and reduced global HAIs.
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Affiliation(s)
- Shilpa Malik
- Bioscan Research Pvt. Ltd., Ahmedabad, Gujarat, India
| | | | - Dhaval Shukla
- Department of Neurosurgery, National Institute of Mental Health and Neurosciences (NIMHANS), Bangalore, India
| | - Jaimin Shah
- Department of Neurosurgery, Civil Hospital, Ahmedabad, India
| | - Sumit Raj
- Department of Neurosurgery, All India Institute of Medical Sciences, Bhopal, India
| | - S S Murugan
- GLR Laboratories Pvt. Ltd., Chennai, Tamil Nadu, India
| | - T N Sathya
- GLR Laboratories Pvt. Ltd., Chennai, Tamil Nadu, India
| | | | - T S Kumaravel
- GLR Laboratories (Europe) Pvt. Ltd., Sharnbrook, United Kingdom
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7
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Ritter K, Somnuke P, Hu L, Griemert EV, Schäfer MKE. Current state of neuroprotective therapy using antibiotics in human traumatic brain injury and animal models. BMC Neurosci 2024; 25:10. [PMID: 38424488 PMCID: PMC10905838 DOI: 10.1186/s12868-024-00851-6] [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: 09/25/2023] [Accepted: 02/02/2024] [Indexed: 03/02/2024] Open
Abstract
TBI is a leading cause of death and disability in young people and older adults worldwide. There is no gold standard treatment for TBI besides surgical interventions and symptomatic relief. Post-injury infections, such as lower respiratory tract and surgical site infections or meningitis are frequent complications following TBI. Whether the use of preventive and/or symptomatic antibiotic therapy improves patient mortality and outcome is an ongoing matter of debate. In contrast, results from animal models of TBI suggest translational perspectives and support the hypothesis that antibiotics, independent of their anti-microbial activity, alleviate secondary injury and improve neurological outcomes. These beneficial effects were largely attributed to the inhibition of neuroinflammation and neuronal cell death. In this review, we briefly outline current treatment options, including antibiotic therapy, for patients with TBI. We then summarize the therapeutic effects of the most commonly tested antibiotics in TBI animal models, highlight studies identifying molecular targets of antibiotics, and discuss similarities and differences in their mechanistic modes of action.
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Affiliation(s)
- Katharina Ritter
- Department of Anesthesiology, University Medical Center, Johannes Gutenberg-University Mainz, Langenbeckstraße 1 (Bld. 505), Mainz, 55131, Germany
| | - Pawit Somnuke
- Department of Anesthesiology, University Medical Center, Johannes Gutenberg-University Mainz, Langenbeckstraße 1 (Bld. 505), Mainz, 55131, Germany
- Department of Anesthesiology, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, 10700, Thailand
| | - Lingjiao Hu
- Department of Anesthesiology, University Medical Center, Johannes Gutenberg-University Mainz, Langenbeckstraße 1 (Bld. 505), Mainz, 55131, Germany
- Department of Gastroenterology, Nanxishan Hospital of Guangxi Zhuang Autonomous Region, Guilin, China
| | - Eva-Verena Griemert
- Department of Anesthesiology, University Medical Center, Johannes Gutenberg-University Mainz, Langenbeckstraße 1 (Bld. 505), Mainz, 55131, Germany
| | - Michael K E Schäfer
- Department of Anesthesiology, University Medical Center, Johannes Gutenberg-University Mainz, Langenbeckstraße 1 (Bld. 505), Mainz, 55131, Germany.
- Focus Program Translational Neurosciences (FTN, Johannes Gutenberg-University Mainz, Mainz, Germany.
- Research Center for Immunotherapy, University Medical Center, Johannes Gutenberg- University Mainz, Mainz, Germany.
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8
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Dibera GB, Yizengaw MA, Yadeta GL, Iticha DD, Gamachu B, Legesse BT. Clinical characteristics and outcomes of traumatic brain injury in patients admitted to surgical ward of Jimma Medical Center, Southwest Ethiopia: a prospective observational follow-up study. BMJ Open 2024; 14:e080598. [PMID: 38307533 PMCID: PMC10836355 DOI: 10.1136/bmjopen-2023-080598] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/10/2023] [Accepted: 01/15/2024] [Indexed: 02/04/2024] Open
Abstract
OBJECTIVE To assess the Clinical Characteristics and Outcomes of Traumatic Brain Injury in Patients Admitted to the Surgical Ward of Jimma Medical Center, Southwest Ethiopia from January to July 2022. DESIGN AND SETTING A hospital-based prospective observational study was conducted among 175 patients admitted with Traumatic Brain Injury at Jimma Medical Center from January to July 2022. Data were collected by structured questionnaires and a convenient sampling technique was used. For data entry, Epidata V.4.6.0.5 software was used and exported to Stata V.14.0.2 for analysis. The Cox regression model was fitted to evaluate the predictors of mortality and variables with a p value <0.05 at 95% CI were taken as statistically significant predictors. RESULTS The incidence of in-hospital mortality was 22 (12.6%). The mean length of hospital stay was 6 days. In-hospital complications were recorded in 32.0% of patients. A Glasgow Coma Scale (GCS) score of <8 on admission (adjusted HR (AHR)=6.2, 95% CI 0.75 to 51), hyperthermia (AHR: 1.7, 95% CI 1.02 to 3.05) and lack of prehospital care (AHR: 3.2, 95% CI 2.2 to 8.07) were predictors of mortality in patients with traumatic brain injury. CONCLUSION In-hospital mortality was recorded in over one-tenth of patients with traumatic brain injury. The GCS score of <8 on admission, hyperthermia and lack of prehospital care positively affected the outcome of patients with traumatic brain injury. Screening of patients for hyperthermia and antipsychotics should be strengthened to reduce death. However, a multicentred study is needed for further evidence. Giving priority to the patients with those predictors will decrease the number of deaths.
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Affiliation(s)
| | | | | | | | - Busha Gamachu
- Department of Pharmacy, Wollega University, Nekemte, Ethiopia
| | - Bruck Tesfaye Legesse
- Department of Pediatrics and Neonatal Nursing, Wollega University, Nekemte, Ethiopia
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9
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Baker TL, Wright DK, Uboldi AD, Tonkin CJ, Vo A, Wilson T, McDonald SJ, Mychasiuk R, Semple BD, Sun M, Shultz SR. A pre-existing Toxoplasma gondii infection exacerbates the pathophysiological response and extent of brain damage after traumatic brain injury in mice. J Neuroinflammation 2024; 21:14. [PMID: 38195485 PMCID: PMC10775436 DOI: 10.1186/s12974-024-03014-w] [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: 10/21/2023] [Accepted: 01/04/2024] [Indexed: 01/11/2024] Open
Abstract
Traumatic brain injury (TBI) is a key contributor to global morbidity that lacks effective treatments. Microbial infections are common in TBI patients, and their presence could modify the physiological response to TBI. It is estimated that one-third of the human population is incurably infected with the feline-borne parasite, Toxoplasma gondii, which can invade the central nervous system and result in chronic low-grade neuroinflammation, oxidative stress, and excitotoxicity-all of which are also important pathophysiological processes in TBI. Considering the large number of TBI patients that have a pre-existing T. gondii infection prior to injury, and the potential mechanistic synergies between the conditions, this study investigated how a pre-existing T. gondii infection modified TBI outcomes across acute, sub-acute and chronic recovery in male and female mice. Gene expression analysis of brain tissue found that neuroinflammation and immune cell markers were amplified in the combined T. gondii + TBI setting in both males and females as early as 2-h post-injury. Glutamatergic, neurotoxic, and oxidative stress markers were altered in a sex-specific manner in T. gondii + TBI mice. Structural MRI found that male, but not female, T. gondii + TBI mice had a significantly larger lesion size compared to their uninfected counterparts at 18-weeks post-injury. Similarly, diffusion MRI revealed that T. gondii + TBI mice had exacerbated white matter tract abnormalities, particularly in male mice. These novel findings indicate that a pre-existing T. gondii infection affects the pathophysiological aftermath of TBI in a sex-dependent manner, and may be an important modifier to consider in the care and prognostication of TBI patients.
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Affiliation(s)
- Tamara L Baker
- Department of Neuroscience, Central Clinical School, Monash University, 6th Floor, The Alfred Centre, 99 Commercial Road, Melbourne, VIC, 3004, Australia
| | - David K Wright
- Department of Neuroscience, Central Clinical School, Monash University, 6th Floor, The Alfred Centre, 99 Commercial Road, Melbourne, VIC, 3004, Australia
| | - Alessandro D Uboldi
- Division of Infectious Disease and Immune Defense, , The Walter and Eliza Hall Institute of Medical Research, Parkville, VIC, Australia
- Department of Medical Biology, The University of Melbourne, Melbourne, VIC, 3010, Australia
| | - Christopher J Tonkin
- Division of Infectious Disease and Immune Defense, , The Walter and Eliza Hall Institute of Medical Research, Parkville, VIC, Australia
- Department of Medical Biology, The University of Melbourne, Melbourne, VIC, 3010, Australia
| | - Anh Vo
- Monash Health Translation Precinct, Monash University, Melbourne, VIC, Australia
| | - Trevor Wilson
- Monash Health Translation Precinct, Monash University, Melbourne, VIC, Australia
| | - Stuart J McDonald
- Department of Neuroscience, Central Clinical School, Monash University, 6th Floor, The Alfred Centre, 99 Commercial Road, Melbourne, VIC, 3004, Australia
| | - Richelle Mychasiuk
- Department of Neuroscience, Central Clinical School, Monash University, 6th Floor, The Alfred Centre, 99 Commercial Road, Melbourne, VIC, 3004, Australia
| | - Bridgette D Semple
- Department of Neuroscience, Central Clinical School, Monash University, 6th Floor, The Alfred Centre, 99 Commercial Road, Melbourne, VIC, 3004, Australia
| | - Mujun Sun
- Department of Neuroscience, Central Clinical School, Monash University, 6th Floor, The Alfred Centre, 99 Commercial Road, Melbourne, VIC, 3004, Australia
| | - Sandy R Shultz
- Department of Neuroscience, Central Clinical School, Monash University, 6th Floor, The Alfred Centre, 99 Commercial Road, Melbourne, VIC, 3004, Australia.
- Health Sciences, Vancouver Island University, Nanaimo, BC, Canada.
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10
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Poblete RA, Pena JE, Kuo G, Tarzi F, Nguyen PL, Cen SY, Yaceczko S, Louie SG, Lewis MR, Martin M, Amar AP, Sanossian N, Sung G, Lyden PD. Immunonutrition with Omega-3 Fatty Acid Supplementation in Severe TBI: Retrospective Analysis of Patient Characteristics and Outcomes. RESEARCH SQUARE 2023:rs.3.rs-3548036. [PMID: 37986931 PMCID: PMC10659558 DOI: 10.21203/rs.3.rs-3548036/v1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/22/2023]
Abstract
Background Early evidence-based medical interventions to improve patient outcomes after traumatic brain injury (TBI) are lacking. In patients admitted to the ICU after TBI, optimization of nutrition is an emerging field of interest. Specialized enteral nutrition (EN) formulas that include immunonutrition containing omega-3 polyunsaturated fatty acids (n-3 PUFAs) have been developed and are used for their proposed anti-inflammatory and pro-immune properties; however, their use has not been rigorously studied in human TBI populations. Methods A single-center, retrospective, descriptive observational study was conducted at LAC + USC Medical Center. Patients with severe TBI (sTBI, Glasgow Coma Scale score ≤ 8) who remained in the ICU for ≥ 2 weeks and received EN were identified between 2017 and 2022 using the institutional trauma registry. Those who received immunonutrition formulas containing n-3 PUFAs were compared to those who received standard, polymeric EN in regard to baseline characteristics, clinical markers of inflammation and immune function, and short-term clinical outcomes. Results A total of 151 patients with sTBI were analyzed. Those who received immunonutrition with n-3 PUFA supplementation were more likely to be male, younger, Hispanic/Latinx, and have polytrauma needing non-central nervous system surgery. No differences in clinical markers of inflammation or infection rate were found. In multivariate regression analysis, immunonutrition was associated with reduced hospital length of stay (LOS). ICU LOS was also reduced in the subgroup of patients with polytrauma and TBI. Conclusion This study identifies important differences in patient characteristics and outcomes associated with the EN formula prescribed. Study results can directly inform a prospective pragmatic study of immunonutrition with n-3 PUFA supplementation aimed to confirm the biomechanistic and clinical benefits of the intervention.
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Affiliation(s)
- Roy A Poblete
- University of Southern California Keck School of Medicine
| | - Jesus E Pena
- University of Southern California Keck School of Medicine
| | - Grace Kuo
- University of Southern California Keck School of Medicine
| | - Fawaz Tarzi
- University of Southern California Keck School of Medicine
| | - Peggy L Nguyen
- University of Southern California Keck School of Medicine
| | - Steven Y Cen
- University of Southern California Keck School of Medicine
| | - Shelby Yaceczko
- University of California Los Angeles Health System: UCLA Health
| | - Stan G Louie
- University of Southern California School of Pharmacy
| | - Meghan R Lewis
- University of Southern California Keck School of Medicine
| | - Matthew Martin
- University of Southern California Keck School of Medicine
| | - Arun P Amar
- University of Southern California Keck School of Medicine
| | | | - Gene Sung
- University of Southern California Keck School of Medicine
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11
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Khan TA, Kamm S. State of the Globe: Traumatic Brain Injury and Infections: The Two-Hit Insult. J Glob Infect Dis 2023; 15:135-136. [PMID: 38292696 PMCID: PMC10824226 DOI: 10.4103/jgid.jgid_197_23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2023] [Revised: 11/27/2023] [Accepted: 11/27/2023] [Indexed: 02/01/2024] Open
Affiliation(s)
- Tahir Ali Khan
- Department of Anesthesiology, GMC, Bhopal, Madhya Pradesh, India
| | - Steve Kamm
- Department of Emergency Medicine, Sarasota Memorial Healthcare System ECC, Florida, US
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12
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Kar M, Sahu C, Singh P, Bhaisora KS, Tejan N, Patel SS, Ghoshal U. Prevalence of Traumatic Brain Injury and Associated Infections in a Trauma Center in Northern India. J Glob Infect Dis 2023; 15:137-143. [PMID: 38292689 PMCID: PMC10824228 DOI: 10.4103/jgid.jgid_66_23] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2023] [Revised: 06/21/2023] [Accepted: 08/31/2023] [Indexed: 02/01/2024] Open
Abstract
Introduction One of the rapidly escalating public health problems worldwide is traumatic brain injury (TBI) due to road traffic accidents. In comparison to postneurosurgery patients and other patients inhabiting the intensive care units (ICUs), patients with TBI are more susceptible to nosocomially acquired infections from the hospital milieu. Methods This retrospective study was conducted at a university hospital in Northern India from December 2018 to September 2022. All patients presenting with TBI formed the cohort of our study population. Results A total of 72 patients with TBI were enrolled. The mean age of patients was 40.07 ± 18.31 years. The most common infections were ventilator-associated pneumonia (VAP) (44/72, 61.11%) and bloodstream infection (BSI) in 21 (21/72, 29.17%) patients. Concomitant infections were observed in 21 (21/72, 29.17%) patients. The common organism causing VAP was Acinetobacter spp. (29/58, 50.0%), BSI was Klebsiella pneumoniae (10/23, 43.48%), urinary tract infection was K. pneumoniae (5/16, 31.25%), and surgical site infection was Acinetobacter spp. (3/8, 37.5%) in TBI patients. An increased incidence of multidrug resistance was demonstrated in our patients. The increased length of hospital and ICU stay, ICU admission, intubation, diabetes mellitus, chronic kidney disease, and hypertension were statistically significant parameters that made TBI patients prone to develop an infection. Conclusion TBI patients suffering from underlying comorbidities are prone to develop infections with multidrug-resistant bacteria was observed among our study cohort which also mirrors the lack of adherence to infection control measures.
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Affiliation(s)
- Mitra Kar
- Department of Microbiology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
| | - Chinmoy Sahu
- Department of Microbiology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
| | - Pooja Singh
- Department of Microbiology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
| | - Kamlesh Singh Bhaisora
- Department of Microbiology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
| | - Nidhi Tejan
- Department of Microbiology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
| | - Sangram Singh Patel
- Department of Microbiology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
| | - Ujjala Ghoshal
- Department of Microbiology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
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13
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Hoadley ME, Galea J, Singh N, Hulme S, Ajao DO, Rothwell N, King A, Tyrrell P, Hopkins SJ. The role of cortisol in immunosuppression in subarachnoid haemorrhage. Eur J Med Res 2023; 28:303. [PMID: 37644600 PMCID: PMC10466816 DOI: 10.1186/s40001-023-01222-3] [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: 09/21/2022] [Accepted: 07/12/2023] [Indexed: 08/31/2023] Open
Abstract
BACKGROUND We sought to determine the extent to which cortisol suppressed innate and T cell-mediated cytokine production and whether it could be involved in reducing peripheral cytokine production following subarachnoid haemorrhage (SAH). METHODS Whole blood from healthy controls, patients with SAH and healthy volunteers was stimulated with lipopolysaccharide (LPS), to stimulate innate immunity, or phytohaemagglutinin (PHA), to stimulate T cell-mediated immunity. Varying concentrations of cortisol were included, with or without the cortisol antagonist RU486. Concentration of interleukin-6 (IL-6), IL-1β and tumour necrosis factor-alpha) TNFα were determined as a measure of innate immunity. IL-6, IL-17 (interferon gamma) IFNƔ and IL-17 were determined as an indicator of T cell-mediated immunity. RESULTS Suppression of innate responses to LPS was apparent in whole blood from SAH patients, relative to healthy controls, and TNFα production was inversely correlated with plasma cortisol concentration. Cytokine production in whole blood from healthy volunteers was inhibited by cortisol concentrations from 0.33 µM, or 1 µM and above, and these responses were effectively reversed by the cortisol antagonist RU-486. In SAH patients, RU-486 reversed suppression of innate TNF-α and IL-6 responses, but not IL-1ß or T cell-mediated responses. CONCLUSION These data suggest that cortisol may play a role in reducing innate, but not T cell-mediated immune responses in patients with injuries such as SAH and that cortisol antagonists could be effective in boosting early innate responses.
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Affiliation(s)
- Margaret E Hoadley
- Northern Care Alliance Research and Innovation, Salford Royal NHS Foundation Trust, Stott Lane, Salford, M6 8HD, UK.
- Division of Cardiovascular Sciences, Manchester Academic Health Sciences Centre, University of Manchester, Stott Lane, Salford, M13 9PT, UK.
| | - James Galea
- Ninewells Hospital and Medical School, University of Dundee, Ninewells, Dundee, DD1 9SY, UK
- Division of Cardiovascular Sciences, Manchester Academic Health Sciences Centre, University of Manchester, Stott Lane, Salford, M13 9PT, UK
| | - Navneet Singh
- Atkinson Morley, Dept of Neurosurgery, St Georges Hospital, Blackshaw Rd, London, Sw17 0QT, UK
| | - Sharon Hulme
- Division of Cardiovascular Sciences, Manchester Academic Health Sciences Centre, University of Manchester, Stott Lane, Salford, M13 9PT, UK
| | - David O Ajao
- Division of Cardiovascular Sciences, Manchester Academic Health Sciences Centre, University of Manchester, Stott Lane, Salford, M13 9PT, UK
- Stockport NHS Foundation Trust, Stepping Hill Hospital, Poplar Grove, Hazel Grove, Stockport, SK2 7JE, UK
| | - Nancy Rothwell
- Faculty of Life Sciences, University of Manchester, AV Hill Building, Oxford Road, Manchester, M13 9PL, UK
| | - Andrew King
- Division of Cardiovascular Sciences, Manchester Academic Health Sciences Centre, University of Manchester, Stott Lane, Salford, M13 9PT, UK
| | - Pippa Tyrrell
- Division of Cardiovascular Sciences, Manchester Academic Health Sciences Centre, University of Manchester, Stott Lane, Salford, M13 9PT, UK
| | - Stephen J Hopkins
- Northern Care Alliance Research and Innovation, Salford Royal NHS Foundation Trust, Stott Lane, Salford, M6 8HD, UK
- Division of Cardiovascular Sciences, Manchester Academic Health Sciences Centre, University of Manchester, Stott Lane, Salford, M13 9PT, UK
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14
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Castellani GB, Maietti E, Leonardi G, Bertoletti E, Trapani F, Battistini A, Tedeschi S, Piperno R, Viale P. Healthcare-associated infections and antimicrobial resistance in severe acquired brain injury: a retrospective multicenter study. Front Neurol 2023; 14:1219862. [PMID: 37662048 PMCID: PMC10469002 DOI: 10.3389/fneur.2023.1219862] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2023] [Accepted: 07/24/2023] [Indexed: 09/05/2023] Open
Abstract
Background Recent studies underscore that healthcare-associated infections (HAIs) and multidrug-resistant (MDR) HAIs affect rehabilitation outcomes and hospital length of stay (LOS) for severe acquired brain injury (sABI). Objective This study aimed to estimate HAI incidence in different sABI rehabilitation settings and determine risk factors and HAI impact on neuromotor and cognitive recovery. Methods We conducted a retrospective multicenter study in two semi-intensive units (SICUs), two high-specialty post-acute units (PAUs), and one long-term care (LTC) rehabilitation facility. Data extraction was performed by experienced clinicians, using a structured Excel file and they agreed upon criteria for case definitions of healthcare. The main outcome measures were the HAI and MDR HAI incidence and the LOS, the functional recovery was measured using the Level of Cognitive Functioning and Disability Rating Scale. Results There were 134 sABI participants. The calculation of the probability level was adjusted for three pairwise comparisons among settings (0.05/3 = 0.017). The HAI and MDR HAI incidences were significantly higher in SICU (3.7 and 1.3 per 100 person-days) than in other settings (LTC: 1.9, p = 0.034 and 0.5, p = 0.026; PAU: 1.2, p < 0.001 and 0.3, p < 0.001). HAI and MDR HAI risk variables included older age, an increased number of devices, and carbapenemase-producing Enterobacteriaceae (CPE) colonization, while a high prealbumin plasma value seemed to have a protective effect. Conclusion HAIs are related to longer LOS, and colonization is associated with poor prognosis and poor functional outcomes with reduced ability to achieve the cognitive capacity of self-care, employability, and independent living. The need to ensure the protection of non-colonized patients, especially those with severe disabilities on admission, is highlighted.
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Affiliation(s)
| | - Elisa Maietti
- Department of Biomedical and Neuromotor Sciences, University of Bologna, Bologna, Emilia-Romagna, Italy
| | - Gloria Leonardi
- Department of Long-Term Care Rehabilitation, Santa Viola Hospital Colibrì Consortium, Bologna, Italy
| | - Erik Bertoletti
- Department of Long-Term Care Rehabilitation, Santa Viola Hospital Colibrì Consortium, Bologna, Italy
| | - Filippo Trapani
- Infectious Disease Unit, Department of Integrated Management of Infectious Risk, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Alberto Battistini
- Rehabilitation Medicine and Neurorehabilitation Unit, IRCCS Istituto delle Scienze Neurologiche di Bologna, Bologna, Italy
| | - Sara Tedeschi
- Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy
| | - Roberto Piperno
- Rehabilitation Medicine and Neurorehabilitation Unit, IRCCS Istituto delle Scienze Neurologiche di Bologna, Bologna, Italy
| | - Pierluigi Viale
- Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy
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15
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Al Qasem MA, Algarni AM, Al Bshabshe A, Jiman-Fatani A. The microbiological profile of isolates recovered from ICU patients with traumatic brain injuries at a tertiary care center, Southern Region, Saudi Arabia. J Infect Public Health 2023; 16:1269-1275. [PMID: 37307641 DOI: 10.1016/j.jiph.2023.05.033] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2023] [Revised: 05/08/2023] [Accepted: 05/25/2023] [Indexed: 06/14/2023] Open
Abstract
INTRODUCTION Traumatic head injury THI is a Neurosurgical condition in which brain function is interrupted as a result of blunt (motor vehicle accidents MVA, falls, and assaults) or penetrating trauma. Nearly half of all injuries are caused by head trauma. Head traumas are a leading cause of death and organ loss in young people, where this population accounts for the vast majority of TBI patients. METHODOLOGY This retrospective cohort study was conducted at Asir Central Hospital, KSA with data from 2015 to 2019. Records of bacterial cultures and outcomes such as length of stay in the hospital were analyzed. In addition, treatment outcomes were also analyzed. RESULTS A total of 300 ICU patient samples (69 patients) were included. Patients' ages ranged from 13 to 87 years with a mean age of 32.4 ± 17.5 years old. The most frequently reported diagnosis was RTA (71 %), followed by SDH (11.6 %), The most isolated organisms from the recovered samples were Klebsiella pneumoniae (27 %), followed by Pseudomonas aeruginosa (14.7 %). Regarding susceptibility, Tigecycline was the most sensitive (44 %), followed by Gentamicin (43.3 %). A total of 36 (52.2 %) patients stayed for less than one month, 24 (34.8 %) stayed for 1-3 months, and 7 (10.1 %) stayed for 3-6 months. The mortality rate in our study population was (40.6 %) as 28 patients died. CONCLUSION The prevalence of pathogens in TBI needs to be determined in different institutions for the establishment of effective empiric antibiotic treatment following infections in traumatic brain injuries. This will ultimately help to improve treatment outcomes. In neurosurgical patients undergoing cranial procedures after trauma, a hospital-standardized antibiotic policy is effective in achieving low rates of bacterial infections especially MDR infections.
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Affiliation(s)
| | | | - Ali Al Bshabshe
- Department of Medicine, Division of Adult Critical Care, College of Medicine, King Khalid University, Abha, Saudi Arabia.
| | - Asif Jiman-Fatani
- Department of Clinical Microbiology and Immunology, Faculty of Medicine, King Abdulaziz University, Jeddah, Saudi Arabia; Clinical and Molecular Microbiology Laboratory, King Abdulaziz University Hospital, Jeddah, Saudi Arabia.
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16
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Varma S, Sharad N, Kiro V, Srivastava S, Ningombam A, Bindra A, Gupta D, Malhotra R, Mathur P. Microbiological Profile and the Resistance Pattern of Pathogens in Neurosurgical Patients from a New Delhi Trauma Center. World Neurosurg 2023; 173:e436-e441. [PMID: 36828276 DOI: 10.1016/j.wneu.2023.02.075] [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: 11/16/2022] [Revised: 02/14/2023] [Accepted: 02/15/2023] [Indexed: 02/24/2023]
Abstract
BACKGROUND Neurosurgical patients are considered to be at higher risk for infections including nosocomial infections compared with other critically ill individuals. Empirical antimicrobial therapy is of utmost importance for the survival of infected neurosurgical patients. METHODS The microbial distribution and antimicrobial resistance patients from January 2012 to December 2021 (10 years) were analyzed retrospectively. Identification was done using VITEK-2 and MALDI-TOF systems. Antimicrobial susceptibility testing was determined by the Kirby Bauer Disk Diffusion Agar method (Clinical and Laboratory Standards Institute) and VITEK-2. RESULTS A total of 48,474 samples were received, out of which 10,134 (21%) had growth. Respiratory specimens showed the maximum isolation of pathogens (42% n = 4292). The predominant bacterial pathogens were gram negative (n = 8972; 88.5%), whereas gram positives were only 11.5% (n = 1162) of the total organisms. Among the gram positives, the most common was Staphylococcus aureus (64.6%), and among gram negatives, the most common pathogen was Acinetobacter baumanni (38.6%). The weighted average of the drug-resistance profile across all gram positives was >50% for fluoroquinolones (levofloxacin, ciprofloxacin), gentamicin, erythromycin, and ampicillin, and in the case of gram negatives it was >90% for ampicillin-sulbactam, ticarcillin, cefazolin, cefotaxime, and ceftriaxone. Thirty-two patients were found to have candidemia, out of which 6 were C. albicans and the rest were nonalbican. Six neurosurgery patients had infection with C. auris, 4 from blood samples and 2 from urine. CONCLUSIONS This study will add to the current knowledge and provide a better understanding of pathogen profile and resistance patterns in traumatic brain injury patients.
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Affiliation(s)
- Sharin Varma
- Department of Microbiology, Jai Prakash Narayan Apex Trauma centre, All India institute of medical science, New Delhi, India
| | - Neha Sharad
- Department of Microbiology, Jai Prakash Narayan Apex Trauma centre, All India institute of medical science, New Delhi, India
| | - Vandana Kiro
- Department of Microbiology, Jai Prakash Narayan Apex Trauma centre, All India institute of medical science, New Delhi, India
| | - Smriti Srivastava
- Department of Microbiology, Jai Prakash Narayan Apex Trauma centre, All India institute of medical science, New Delhi, India
| | - Aparna Ningombam
- Department of Laboratory Medicine, Jai Prakash Narayan Apex Trauma centre, All India institute of medical science, New Delhi, India
| | - Ashish Bindra
- Depaertment of Neuroanaesthesia, Jai Prakash Narayan Apex Trauma centre, All India institute of medical science, New Delhi, India
| | - Deepak Gupta
- Department of Neurosurgery, Jai Prakash Narayan Apex Trauma centre, All India institute of medical science, New Delhi, India
| | - Rajesh Malhotra
- Department of Orthopaedics, Jai Prakash Narayan Apex Trauma centre, All India institute of medical science, New Delhi, India
| | - Purva Mathur
- Department of Laboratory Medicine, Jai Prakash Narayan Apex Trauma centre, All India institute of medical science, New Delhi, India.
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Caceres E, Olivella JC, Yanez M, Viñan E, Estupiñan L, Boada N, Martin-Loeches I, Reyes LF. Risk factors and outcomes of lower respiratory tract infections after traumatic brain injury: a retrospective observational study. Front Med (Lausanne) 2023; 10:1077371. [PMID: 37138738 PMCID: PMC10150376 DOI: 10.3389/fmed.2023.1077371] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2022] [Accepted: 03/22/2023] [Indexed: 05/05/2023] Open
Abstract
Background Traumatic brain injury (TBI) is a public health problem with a high burden in terms of disability and death. Infections are a common complication, with respiratory infections being the most frequent. Most available studies have addressed the impact of ventilator-associated pneumonia (VAP) after TBI; therefore, we aim to characterize the hospital impact of a broader entity, lower respiratory tract infections (LRTIs). Methods This observational, retrospective, single-center cohort study describes the clinical features and risk factors associated with LRTIs in patients with TBI admitted to an intensive care unit (ICU). We used bivariate and multivariate logistic regressions to identify the risk factors associated with developing LRTI and determine its impact on hospital mortality. Results We included 291 patients, of whom 77% (225/291) were men. The median (IQR) age was 38 years (28-52 years). The most common cause of injury was road traffic accidents 72% (210/291), followed by falls 18% (52/291) and assault at 3% (9/291). The median (IQR) Glasgow Coma Scale (GCS) score on admission was 9 (6-14), and 47% (136/291) were classified as severe TBI, 13% (37/291) as moderate TBI, and 40% (114/291) as mild TBI. The median (IQR) injury severity score (ISS) was 24 (16-30). Nearly 48% (141/291) of patients presented at least one infection during hospitalization, and from those, 77% (109/141) were classified as LRTIs, which included tracheitis 55% (61/109), ventilator-associated pneumonia (VAP) 34% (37/109), and hospital-acquired pneumoniae (HAP) 19% (21/109). After multivariable analysis, the following variables were significantly associated with LRTIs: age (OR 1.1, 95% CI 1.01-1.2), severe TBI (OR 2.7, 95% CI 1.1-6.9), AIS thorax (OR 1.4, 95 CI 1.1-1.8), and mechanical ventilation on admission (OR 3.7, 95% CI 1.1-13.5). At the same time, hospital mortality did not differ between groups (LRTI 18.6% vs. No LRTI 20.1%, p = 0.7), and ICU and hospital length of stay (LOS) were longer in the LRTI group (median [IQR] 12 [9-17] vs. 5 [3-9], p < 0.01) and (median [IQR] 21 [13-33] vs. 10 [5-18], p = 0.01), respectively. Time on the ventilator was longer for those with LRTIs. Conclusion The most common site/location of infection in patients with TBI admitted to ICU is respiratory. Age, severe TBI, thoracic trauma, and mechanical ventilation were identified as potential risk factors. LRTI was associated with prolonged ICU, hospital stay, and more days on a ventilator, but not with mortality.
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Affiliation(s)
- Eder Caceres
- Unisabana Center for Translational Science, Universidad de La Sabana, Chía, Colombia
- Neurocritical Care Division, Critical Care Department, Clínica Universidad de La Sabana, Chía, Colombia
| | - Juan C. Olivella
- Unisabana Center for Translational Science, Universidad de La Sabana, Chía, Colombia
| | - Miguel Yanez
- Unisabana Center for Translational Science, Universidad de La Sabana, Chía, Colombia
| | - Emilio Viñan
- Unisabana Center for Translational Science, Universidad de La Sabana, Chía, Colombia
| | - Laura Estupiñan
- Unisabana Center for Translational Science, Universidad de La Sabana, Chía, Colombia
| | - Natalia Boada
- Unisabana Center for Translational Science, Universidad de La Sabana, Chía, Colombia
| | - Ignacio Martin-Loeches
- Centro de Investigación Biomédica en Red de Enfermedades Respiratorias (CIBERES), Instituto de Salud Carlos III, Madrid, Spain
- Multidisciplinary Intensive Care Research Organization (MICRO), Department of Intensive Care Medicine, St. James's University Hospital, Dublin, Ireland
- Critical Care Department, Trinity Centre for Health Sciences, Dublin, Ireland
- Hospital Clínic, IDIBAPS, Universidad de Barcelona, Barcelona, Spain
| | - Luis Felipe Reyes
- Unisabana Center for Translational Science, Universidad de La Sabana, Chía, Colombia
- Facultad de Medicina, Universidad de La Sabana, Chía, Colombia
- Pandemic Science Institute, University of Oxford, Oxford, United Kingdom
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18
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Sychev AA, Baranich AI, Savin IA, Ershova ON, Danilov GV, Strunina YV, Kurdyumova NV, Sokolova EY, Sukhorukova MV, Milekhina DA, Khomyakova IV. [Infectious complications in acute period after traumatic brain injury]. ZHURNAL VOPROSY NEIROKHIRURGII IMENI N. N. BURDENKO 2023; 87:56-62. [PMID: 37011329 DOI: 10.17116/neiro20238702156] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 04/05/2023]
Abstract
Patients with traumatic brain injury (TBI) are at high risk of infection. OBJECTIVE To delineate infections in acute period of TBI, association between intracranial lesion type and risk of infection, as well as to estimate treatment outcomes in these patients depending on infection. MATERIAL AND METHODS This study included 104 patients with TBI (80 men and 24 women) aged 33.01±14.35 years. All patients met the inclusion criteria: admission within 72 hours after TBI, age 18-75 years, ICU-stay >48 hours, available brain MRI data. Mild, moderate and severe TBI were diagnosed in 7%, 11% and 82% of patients, respectively. Analysis of infections was performed in accordance with the definitions of the Centers for Disease Control/National Healthcare Safety Network (CDC/NHSN). RESULTS Acute period of TBI is associated with high incidence of infection (73%), and prevalent infection is pneumonia (58.7%). Severe intracranial damage in acute period of TBI (grade 4-8 according to MR-based classification by A.A. Potapov and N.E. Zakharova) is associated with higher incidence of infection. Infectious complications more than twice increase duration of mechanical ventilation, ICU- and hospital-stay. CONCLUSION Infectious complications significantly affect treatment outcomes in acute period of TBI increasing duration of mechanical ventilation, ICU- and hospital-stay.
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Affiliation(s)
- A A Sychev
- Burdenko Neurosurgical Center, Moscow, Russia
| | | | - I A Savin
- Burdenko Neurosurgical Center, Moscow, Russia
| | - O N Ershova
- Burdenko Neurosurgical Center, Moscow, Russia
| | - G V Danilov
- Burdenko Neurosurgical Center, Moscow, Russia
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Mason HD, McGavern DB. How the immune system shapes neurodegenerative diseases. Trends Neurosci 2022; 45:733-748. [PMID: 36075783 PMCID: PMC9746609 DOI: 10.1016/j.tins.2022.08.001] [Citation(s) in RCA: 17] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2022] [Revised: 06/10/2022] [Accepted: 08/01/2022] [Indexed: 12/15/2022]
Abstract
Neurodegenerative diseases are a major cause of death and disability worldwide and are influenced by many factors including age, genetics, and injuries. While these diseases are often thought to result from the accumulation and spread of aberrant proteins, recent studies have demonstrated that they can be shaped by the innate and adaptive immune system. Resident myeloid cells typically mount a sustained response to the degenerating CNS, but peripheral leukocytes such as T and B cells can also alter disease trajectories. Here, we review the sometimes-dichotomous roles played by immune cells during neurodegenerative diseases and explore how brain trauma can serve as a disease initiator or accelerant. We also offer insights into how failure to properly resolve a CNS injury might promote the development of a neurodegenerative disease.
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Affiliation(s)
- Hannah D Mason
- Viral Immunology and Intravital Imaging Section, National Institute of Neurological Disorders and Stroke, National Institutes of Health, Bethesda, MD 20892, USA
| | - Dorian B McGavern
- Viral Immunology and Intravital Imaging Section, National Institute of Neurological Disorders and Stroke, National Institutes of Health, Bethesda, MD 20892, USA.
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Are infections associated with cognitive decline and neuroimaging outcomes? A historical cohort study using data from the UK Biobank study linked to electronic health records. Transl Psychiatry 2022; 12:385. [PMID: 36109502 PMCID: PMC9478085 DOI: 10.1038/s41398-022-02145-z] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/02/2022] [Revised: 08/23/2022] [Accepted: 09/01/2022] [Indexed: 11/09/2022] Open
Abstract
While there is growing evidence of associations between infections and dementia risk, associations with cognitive impairment and potential structural correlates of cognitive decline remain underexplored. Here we aimed to investigate the presence and nature of any associations between common infections, cognitive decline and neuroimaging parameters. The UK Biobank is a large volunteer cohort (over 500,000 participants recruited aged 40-69) with linkage to primary and secondary care records. Using linear mixed effects models, we compared participants with and without a history of infections for changes in cognitive function during follow-up. Linear regression models were used to investigate the association of infections with hippocampal and white matter hyperintensity (WMH) volume. 16,728 participants (median age 56.0 years [IQR 50.0-61.0]; 51.3% women) had baseline and follow-up cognitive measures. We found no evidence of an association between the presence of infection diagnoses and cognitive decline for mean correct response time (slope difference [infections versus no infections] = 0.40 ms, 95% CI: -0.17-0.96 per year), visual memory (slope difference 0.0004 log errors per year, 95% CI: -0.003-0.004, fluid intelligence (slope difference 0.007, 95% CI: -0.010-0.023) and prospective memory (OR 0.88, 95% CI: 0.68-1.14). No evidence of an association was found between infection site, setting or frequency and cognitive decline except for small associations on the visual memory test. We found no association between infections and hippocampal or WMH volume. Limitations of our study include selection bias, potential practice effects and the relatively young age of our cohort. Our findings do not support a major role for common midlife infections in contributing to cognitive decline for this cohort. Further research is warranted in individuals with more severe infections, for infections occurring later in life.
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21
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Umemura Y, Katayama Y, Kitamura T, Kiyohara K, Hirose T, Kiguchi T, Tachino J, Nakao S, Nakagawa Y, Shimazu T. Patient age affects sex-based differences in post-traumatic mortality: a national trauma registry study in Japan. Eur J Trauma Emerg Surg 2022; 48:2731-2740. [PMID: 34860254 PMCID: PMC9360104 DOI: 10.1007/s00068-021-01840-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2021] [Accepted: 11/10/2021] [Indexed: 10/26/2022]
Abstract
PURPOSE Sex-based differences in post-traumatic mortality have been widely discussed for quite some time. We hypothesized that age-related pathophysiologic changes would affect sex-based differences in post-traumatic mortality and aimed to verify the hypothesis using a nationwide trauma registry in Japan. METHODS This was a retrospective analysis of trauma patients registered in The Japanese Trauma Data Bank. We stratified the study population into the following three subsets based on age: (1) pediatric subset (age ≤ 14), (2) adult subset (age 15-50) and (3) senior adult subset (age ≥ 51). We evaluated both sex-based differences in mortality in each subset separately using multivariate logistic regression analysis and the two-way interaction effect for predicted survival between the continuous increase of age and the sexes using a nonlinear multivariate regression model. RESULTS We included 122,819 trauma patients who fulfilled the inclusion criteria and classified them into the 3 subsets according to age. Male patients were more likely to die compared to female patients only in the senior adult subset (adjusted odds ratio: 1.26; 95% confidence interval: 1.18-1.36), whereas there were no statistically significant differences in the other two subsets. Furthermore, non-linear logistic regression analysis revealed that predicted survival probability in male patients decreased more sharply in accordance with the increase of age compared to that in female patients (p for interaction: 0.051). CONCLUSION Age-related change in post-traumatic mortality was significantly different between males and females, and male patients had a relatively higher risk of death in the older population.
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Affiliation(s)
- Yutaka Umemura
- Department of Traumatology and Acute Critical Medicine, Osaka University Graduate School of Medicine, 2‑15 Yamada‑oka, Suita, Osaka 565-0871 Japan
- Department of Emergency and Critical Care, Osaka General Medical Center, 3‑1‑56 Bandai‑Higashi, Sumiyoshi‑ku, Osaka, Japan
| | - Yusuke Katayama
- Department of Traumatology and Acute Critical Medicine, Osaka University Graduate School of Medicine, 2‑15 Yamada‑oka, Suita, Osaka 565-0871 Japan
| | - Tetsuhisa Kitamura
- Division of Environmental Medicine and Population Sciences, Department of Social and Environmental Medicine, Osaka University Graduate School of Medicine, 2‑15 Yamada‑oka, Suita, Japan
| | - Kosuke Kiyohara
- Department of Food Science, Faculty of Home Economics, Otsuma Women’s University Tokyo, 12 Sanban‑cho, Chiyoda‑ku, Tokyo, Japan
| | - Tomoya Hirose
- Department of Traumatology and Acute Critical Medicine, Osaka University Graduate School of Medicine, 2‑15 Yamada‑oka, Suita, Osaka 565-0871 Japan
- Emergency and Critical Care Center, Osaka Police Hospital, 10‑31 Kitayama‑cho, Tennoji‑ku, Osaka, Japan
| | - Takeyuki Kiguchi
- Kyoto University Health Services, Yoshida‑honmachi, Sakyo‑ku, Kyoto, Japan
| | - Jotaro Tachino
- Department of Traumatology and Acute Critical Medicine, Osaka University Graduate School of Medicine, 2‑15 Yamada‑oka, Suita, Osaka 565-0871 Japan
| | - Shunichiro Nakao
- Department of Traumatology and Acute Critical Medicine, Osaka University Graduate School of Medicine, 2‑15 Yamada‑oka, Suita, Osaka 565-0871 Japan
| | - Yuko Nakagawa
- Department of Traumatology and Acute Critical Medicine, Osaka University Graduate School of Medicine, 2‑15 Yamada‑oka, Suita, Osaka 565-0871 Japan
| | - Takeshi Shimazu
- Department of Traumatology and Acute Critical Medicine, Osaka University Graduate School of Medicine, 2‑15 Yamada‑oka, Suita, Osaka 565-0871 Japan
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22
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Zhou J, Luo XY, Chen GQ, Li HL, Xu M, Liu S, Yang YL, Shi G, Zhou JX, Zhang L. Incidence, Risk Factors and Outcomes of Sepsis in Critically Ill Post-craniotomy Patients: A Single-Center Prospective Cohort Study. Front Public Health 2022; 10:895991. [PMID: 35655465 PMCID: PMC9152261 DOI: 10.3389/fpubh.2022.895991] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2022] [Accepted: 04/25/2022] [Indexed: 11/13/2022] Open
Abstract
Background Data concerning the epidemiology of sepsis in critically ill post-craniotomy patients are scarce. This study aimed to assess the incidence, risk factors, and outcomes of sepsis in this population. Methods This was a single-center prospective cohort study. Post-craniotomy patients admitted to the intensive care unit (ICU) were screened daily for the presence of infection and sepsis. Results Of the 900 included patients, 300 developed sepsis. The cumulative incidence of sepsis was 33.3% [95% confidence interval (CI), 30.2–36.4%]. Advanced age, male, hypertension, trauma, postoperative intracranial complications, and lower Glasgow Coma Scale (GCS) on the first postoperative day were independent risk factors of sepsis. Septic patients had higher hospital mortality (13.7 vs. 8.3%, P = 0.012), longer ICU length of stay (LOS) (14 vs. 4 days, P < 0.001), longer hospital LOS (31 vs. 19 days, P < 0.001), and higher total medical cost (CNY 138,394 vs. 75,918, P < 0.001) than patients without sepsis. Conclusion Sepsis is a frequent complication in critically ill post-craniotomy patients. Advanced age, male, hypertension, trauma, postoperative intracranial complications, and lower GCS on the first postoperative day were independent risk factors of sepsis.
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Affiliation(s)
- Jianfang Zhou
- Department of Critical Care Medicine, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Xu-Ying Luo
- Department of Critical Care Medicine, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Guang-Qiang Chen
- Department of Critical Care Medicine, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Hong-Liang Li
- Department of Critical Care Medicine, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Ming Xu
- Department of Critical Care Medicine, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Shuai Liu
- Department of Critical Care Medicine, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Yan-Lin Yang
- Department of Critical Care Medicine, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Guangzhi Shi
- Department of Critical Care Medicine, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Jian-Xin Zhou
- Department of Critical Care Medicine, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Linlin Zhang
- Department of Critical Care Medicine, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
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23
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Rogers MB, Simon D, Firek B, Silfies L, Fabio A, Bell MJ, Yeh A, Azar J, Cheek R, Kochanek PM, Peddada SD, Morowitz MJ. Temporal and Spatial Changes in the Microbiome Following Pediatric Severe Traumatic Brain Injury. Pediatr Crit Care Med 2022; 23:425-434. [PMID: 35283451 PMCID: PMC9203870 DOI: 10.1097/pcc.0000000000002929] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES The microbiome may be affected by trauma and critical illness. Many studies of the microbiome in critical illness are restricted to a single body site or time point and confounded by preexisting conditions. We report temporal and spatial alterations in the microbiome of previously healthy children with severe traumatic brain injury (TBI). DESIGN We collected oral, rectal, and skin swabs within 72 hours of admission and then twice weekly until ICU discharge. Samples were analyzed by 16S rRNA gene amplicon sequencing. Children undergoing elective outpatient surgery served as controls. Alpha and beta diversity comparisons were performed with Phyloseq, and differentially abundant taxa were predicted using Analysis of Composition of Microbiomes. SETTING Five quaternary-care PICUs. PATIENTS Patients less than 18 years with severe TBI requiring placement of an intracranial pressure monitor. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Three hundred twenty-seven samples were analyzed from 23 children with severe TBI and 35 controls. The community composition of initial oral (F = 3.2756, R2 = 0.0535, p = 0.012) and rectal (F = 3.0702, R2 = 0.0649, p = 0.007) samples differed between TBI and control patients. Rectal samples were depleted of commensal bacteria from Ruminococcaceae, Bacteroidaceae, and Lachnospiraceae families and enriched in Staphylococcaceae after TBI (p < 0.05). In exploratory analyses, antibiotic exposure, presence of an endotracheal tube, and occurrence of an infection were associated with greater differences of the rectal and oral microbiomes between TBI patients and healthy controls, whereas enteral nutrition was associated with smaller differences (p < 0.05). CONCLUSIONS The microbiome of children with severe TBI is characterized by early depletion of commensal bacteria, loss of site specificity, and an enrichment of potential pathogens. Additional studies are needed to determine the impact of these changes on clinical outcomes.
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Affiliation(s)
- Matthew B. Rogers
- Department of Surgery, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Dennis Simon
- Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
- Department of Pediatrics, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
- Safar Center for Resuscitation Research, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
- UPMC Children’s Hospital of Pittsburgh Neuroscience Institute, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Brian Firek
- Department of Surgery, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Laurie Silfies
- Department of Biostatistics, University of Pittsburgh Graduate School of Public Health, Pittsburgh, PA, USA
| | - Anthony Fabio
- Department of Biostatistics, University of Pittsburgh Graduate School of Public Health, Pittsburgh, PA, USA
| | - Michael J. Bell
- Division of Critical Care Medicine, Children’s National Medical Center, Washington, DC, USA
| | - Andrew Yeh
- Department of Surgery, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Justin Azar
- Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
- Department of Pediatrics, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Richard Cheek
- Department of Surgery, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Patrick M. Kochanek
- Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
- Safar Center for Resuscitation Research, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
- UPMC Children’s Hospital of Pittsburgh Neuroscience Institute, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Shyamal D. Peddada
- Department of Biostatistics, University of Pittsburgh Graduate School of Public Health, Pittsburgh, PA, USA
| | - Michael J. Morowitz
- Department of Surgery, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
- Center for Microbiome and Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
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24
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Clark A, Zelmanovich R, Vo Q, Martinez M, Nwafor DC, Lucke-Wold B. Inflammation and the role of infection: Complications and treatment options following neurotrauma. J Clin Neurosci 2022; 100:23-32. [PMID: 35381478 DOI: 10.1016/j.jocn.2022.03.043] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2021] [Revised: 02/14/2022] [Accepted: 03/29/2022] [Indexed: 02/08/2023]
Abstract
Traumatic brain injury can have devastating consequences for patients and extended hospital stays and recovery course. Recent data indicate that the initial insult causes profound changes to the immune system and leads to a pro-inflammatory state. This alteration in homeostasis predisposes patients to an increased risk of infection and underlying autoimmune conditions. Increased emphasis has been placed on understanding this process both in the clinical and preclinical literature. This review highlights the intrinsic inflammatory conditions that can occur within the initial hospital stay, discusses long-term immune consequences, highlights emerging treatment options, and delves into important pathways currently being investigated with preclinical models.
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Affiliation(s)
- Alec Clark
- University of Central Florida, College of Medicine, Orlando, USA
| | | | - Quan Vo
- Department of Neurosurgery, University of Florida, Gainesville, USA
| | - Melanie Martinez
- Department of Neurosurgery, University of Florida, Gainesville, USA
| | - Divine C Nwafor
- Department of Neurosurgery, West Virginia University, Morgantown, USA
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25
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Triamvisit S, Wongprasert W, Puttima C, Chiangmai MN, Thienjindakul N, Rodkul L, Jetjumnong C. Effect of modified care bundle for prevention of ventilator-associated pneumonia in critically-ill neurosurgical patients. Acute Crit Care 2022; 36:294-299. [PMID: 35263824 PMCID: PMC8907469 DOI: 10.4266/acc.2021.00983] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2021] [Accepted: 09/23/2021] [Indexed: 11/30/2022] Open
Abstract
Background: Care bundles for ventilator-associated pneumonia (VAP) have been shown to minimize the rate of VAP in critically ill patients. Standard care bundles may need to be modified in resource-constrained situations. The goal of this study was to see if our modified VAP-care bundles lowered the risk of VAP in neurosurgical patients. Methods: A prospective cohort study was conducted in mechanically ventilated neurosurgical patients. The VAP bundle was adjusted in the cohort group by increasing the frequency of intermittent endotracheal tube cuff pressure monitoring to six times a day while reducing oral care with 0.12% chlorhexidine to three times a day. The rate of VAP was compared to the historical control group. Results: A total of 146 and 145 patients were enrolled in control and cohort groups, respectively. The mean age of patients was 52±16 years in both groups (P=0.803). The admission Glasgow coma scores were 7.79±2.67 and 7.80±2.77 in control and cohort group, respectively (P=0.969). VAP was found in nine patients in control group but only one patient in cohort group. The occurrence rate of VAP was significantly reduced in cohort group compared to control group (0.88/1,000 vs. 6.84/1,000 ventilator days, P=0.036). Conclusions: The modified VAP bundle is effective in lowering the VAP rate in critically ill neurosurgical patients. It requires low budget and manpower and can be employed in resource-constrained settings.
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Affiliation(s)
| | | | | | | | | | - Laksika Rodkul
- Division of Nursing, Chiang Mai University Hospital, Chiang Mai, Thailand
| | - Chumpon Jetjumnong
- Neurosurgery Unit, Department of Surgery, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand
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26
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Sharma R, Casillas-Espinosa PM, Dill LK, Rewell SSJ, Hudson MR, O'Brien TJ, Shultz SR, Semple BD. Pediatric traumatic brain injury and a subsequent transient immune challenge independently influenced chronic outcomes in male mice. Brain Behav Immun 2022; 100:29-47. [PMID: 34808288 DOI: 10.1016/j.bbi.2021.11.013] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/25/2021] [Revised: 10/27/2021] [Accepted: 11/15/2021] [Indexed: 01/30/2023] Open
Abstract
Traumatic brain injury (TBI) is a major contributor to death and disability worldwide. Children are at particularly high risk of both sustaining a TBI and experiencing serious long-term consequences, such as cognitive deficits, mental health problems and post-traumatic epilepsy. Severe TBI patients are highly susceptible to nosocomial infections, which are mostly acquired within the first week of hospitalization post-TBI. Yet the potential chronic impact of such acute infections following pediatric TBI remains unclear. In this study, we hypothesized that a peripheral immune challenge, such as lipopolysaccharide (LPS)-mimicking a hospital-acquired infection-would worsen inflammatory, neurobehavioral, and seizure outcomes after experimental pediatric TBI. To test this, three-week old male C57Bl/6J mice received a moderate controlled cortical impact or sham surgery, followed by 1 mg/kg i.p. LPS (or 0.9% saline vehicle) at 4 days TBI. Mice were randomized to four groups; sham-saline, sham-LPS, TBI-saline or TBI-LPS (n = 15/group). Reduced general activity and increased anxiety-like behavior were observed within 24 h in LPS-treated mice, indicating a transient sickness response. LPS-treated mice also exhibited a reduction in body weights, which persisted chronically. From 2 months post-injury, mice underwent a battery of tests for sensorimotor, cognitive, and psychosocial behaviors. TBI resulted in hyperactivity and spatial memory deficits, independent of LPS; whereas LPS resulted in subtle deficits in spatial memory retention. At 5 months post-injury, video-electroencephalographic recordings were obtained to evaluate both spontaneous seizure activity as well as the evoked seizure response to pentylenetetrazol (PTZ). TBI increased susceptibility to PTZ-evoked seizures; whereas LPS appeared to increase the incidence of spontaneous seizures. Post-mortem analyses found that TBI, but not LPS, resulted in robust glial reactivity and loss of cortical volume. A TBI × LPS interaction in hippocampal volume suggested that TBI-LPS mice had a subtle increase in ipsilateral hippocampus tissue loss; however, this was not reflected in neuronal cell counts. Both TBI and LPS independently had modest effects on chronic hippocampal gene expression. Together, contrary to our hypothesis, we observed minimal synergy between TBI and LPS. Instead, pediatric TBI and a subsequent transient immune challenge independently influenced chronic outcomes. These findings have implications for future preclinical modeling as well as acute post-injury patient management.
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Affiliation(s)
- Rishabh Sharma
- Department of Neuroscience, Central Clinical School, Monash University, Melbourne, VIC, Australia
| | - Pablo M Casillas-Espinosa
- Department of Neuroscience, Central Clinical School, Monash University, Melbourne, VIC, Australia; Department of Neurology, Alfred Health, Prahran, VIC, Australia; Department of Medicine (Royal Melbourne Hospital), The University of Melbourne, Parkville, VIC, Australia
| | - Larissa K Dill
- Department of Neuroscience, Central Clinical School, Monash University, Melbourne, VIC, Australia; Department of Neurology, Alfred Health, Prahran, VIC, Australia
| | - Sarah S J Rewell
- Department of Neuroscience, Central Clinical School, Monash University, Melbourne, VIC, Australia; Department of Neurology, Alfred Health, Prahran, VIC, Australia
| | - Matthew R Hudson
- Department of Neuroscience, Central Clinical School, Monash University, Melbourne, VIC, Australia
| | - Terence J O'Brien
- Department of Neuroscience, Central Clinical School, Monash University, Melbourne, VIC, Australia; Department of Neurology, Alfred Health, Prahran, VIC, Australia; Department of Medicine (Royal Melbourne Hospital), The University of Melbourne, Parkville, VIC, Australia
| | - Sandy R Shultz
- Department of Neuroscience, Central Clinical School, Monash University, Melbourne, VIC, Australia; Department of Neurology, Alfred Health, Prahran, VIC, Australia; Department of Medicine (Royal Melbourne Hospital), The University of Melbourne, Parkville, VIC, Australia
| | - Bridgette D Semple
- Department of Neuroscience, Central Clinical School, Monash University, Melbourne, VIC, Australia; Department of Neurology, Alfred Health, Prahran, VIC, Australia; Department of Medicine (Royal Melbourne Hospital), The University of Melbourne, Parkville, VIC, Australia.
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27
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Sribnick EA, Popovich PG, Hall MW. Central nervous system injury-induced immune suppression. Neurosurg Focus 2022; 52:E10. [PMID: 35104790 DOI: 10.3171/2021.11.focus21586] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2021] [Accepted: 11/18/2021] [Indexed: 11/06/2022]
Abstract
Central nervous system trauma is a common cause of morbidity and mortality. Additionally, these injuries frequently occur in younger individuals, leading to lifetime expenses for patients and caregivers and the loss of opportunity for society. Despite this prevalence and multiple attempts to design a neuroprotectant, clinical trials for a pharmacological agent for the treatment of traumatic brain injury (TBI) or spinal cord injury (SCI) have provided disappointing results. Improvements in outcome from these disease processes in the past decades have been largely due to improvements in supportive care. Among the many challenges facing patients and caregivers following neurotrauma, posttraumatic nosocomial infection is a significant and potentially reversible risk factor. Multiple animal and clinical studies have provided evidence of posttraumatic systemic immune suppression, and injuries involving the CNS may be even more prone, leading to a higher risk for in-hospital infections following neurotrauma. Patients who have experienced neurotrauma with nosocomial infection have poorer recovery and higher risks of long-term morbidity and in-hospital mortality than patients without infection. As such, the etiology and reversal of postneurotrauma immune suppression is an important topic. There are multiple possible etiologies for these posttraumatic changes including the release of damage-associated molecular patterns, the activation of immunosuppressive myeloid-derived suppressor cells, and sympathetic nervous system activation. Postinjury systemic immunosuppression, particularly following neurotrauma, provides a challenge for clinicians but also an opportunity for improvement in outcome. In this review, the authors sought to outline the evidence of postinjury systemic immune suppression in both animal models and clinical research of TBI, TBI polytrauma, and SCI.
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Affiliation(s)
- Eric A Sribnick
- 1Department of Neurosurgery, Nationwide Children's Hospital, The Ohio State University College of Medicine, Columbus.,2The Abigail Wexner Research Institute at Nationwide Children's Hospital, Columbus
| | - Phillip G Popovich
- 3Department of Neuroscience.,4Center for Brain and Spinal Cord Repair.,5Belford Center for Spinal Cord Injury, and.,6Medical Scientist Training Program, The Ohio State University, College of Medicine, Columbus; and
| | - Mark W Hall
- 2The Abigail Wexner Research Institute at Nationwide Children's Hospital, Columbus.,7Division of Critical Care Medicine, Department of Pediatrics, Nationwide Children's Hospital, The Ohio State University College of Medicine, Columbus, Ohio
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28
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Peripheral Infection after Traumatic Brain Injury Augments Excitability in the Perilesional Cortex and Dentate Gyrus. Biomedicines 2021; 9:biomedicines9121946. [PMID: 34944762 PMCID: PMC8698476 DOI: 10.3390/biomedicines9121946] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2021] [Revised: 12/15/2021] [Accepted: 12/17/2021] [Indexed: 12/16/2022] Open
Abstract
Peripheral infections occur in up to 28% of patients with traumatic brain injury (TBI), which is a major etiology for structural epilepsies. We hypothesized that infection occurring after TBI acts as a “second hit” and facilitates post-traumatic epileptogenesis. Adult male Sprague–Dawley rats were subjected to lateral fluid-percussion injury or sham-operation. At 8 weeks post-injury, rats were treated with lipopolysaccharide (LPS, 5 mg/kg) to mimic Gram-negative peripheral infection. T2-weighted magnetic resonance imaging was used to detect the cortical lesion type (small focal inflammatory [TBIFI] vs. large cavity-forming [TBICF]). Spontaneous seizures were detected with video-electroencephalography, and seizure susceptibility was determined by the pentylenetetrazole (PTZ) test. Post-PTZ neuronal activation was assessed using c-Fos immunohistochemistry. LPS treatment increased the percentage of rats with PTZ-induced seizures among animals with TBIFI lesions (p < 0.05). It also increased the cumulative duration of PTZ-induced seizures (p < 0.01), particularly in the TBIFI group (p < 0.05). The number of c-Fos immunopositive cells was higher in the perilesional cortex of injured animals compared with sham-operated animals (p < 0.05), particularly in the TBI-LPS group (p < 0.05). LPS treatment increased the percentage of injured rats with bilateral c-Fos staining in the dentate gyrus (p < 0.05), particularly in the TBIFI group (p < 0.05). Our findings demonstrate that peripheral infection after TBI increases PTZ-induced seizure susceptibility and neuronal activation in the perilesional cortex and bilaterally in the dentate gyrus, particularly in animals with prolonged perilesional T2 enhancement. Our data suggest that treatment of infections and reduction of post-injury neuro-inflammation are important components of the treatment regimen aiming at preventing epileptogenesis after TBI.
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29
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Simon DW, McGeachy MJ, Kochanek PM. Targeting "Natural Born Killers" to Modulate Immune Suppression in Neurocritical Care. Neurocrit Care 2021; 35:608-610. [PMID: 34061313 DOI: 10.1007/s12028-021-01235-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2021] [Accepted: 03/15/2021] [Indexed: 01/09/2023]
Affiliation(s)
- Dennis W Simon
- Department of Critical Care Medicine, Safar Center for Resuscitation Research, School of Medicine, University of Pittsburgh, University of Pittsburgh Medical Center Children's Hospital of Pittsburgh, John G. Rangos Research Center, 6th Floor 4401 Penn Avenue, Pittsburgh, PA, USA
| | - Mandy J McGeachy
- Division of Rheumatology and Clinical Immunology, Department of Medicine, School of Medicine, University of Pittsburgh, BST South, S719 3500 Terrace Street, Pittsburgh, PA, USA
| | - Patrick M Kochanek
- Department of Critical Care Medicine, Safar Center for Resuscitation Research, School of Medicine, University of Pittsburgh, University of Pittsburgh Medical Center Children's Hospital of Pittsburgh, John G. Rangos Research Center, 6th Floor 4401 Penn Avenue, Pittsburgh, PA, USA.
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30
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Ramanan M, Shorr A, Lipman J. Ventriculitis: Infection or Inflammation. Antibiotics (Basel) 2021; 10:antibiotics10101246. [PMID: 34680826 PMCID: PMC8532926 DOI: 10.3390/antibiotics10101246] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2021] [Revised: 10/07/2021] [Accepted: 10/11/2021] [Indexed: 11/16/2022] Open
Abstract
Ventriculitis, or infection of the cerebrospinal fluid, in the presence of external ventricular drains (EVD), is an important complication and associated with substantial mortality, morbidity, and healthcare costs. Further, the conditions that require the insertion of an EVD, such as neurotrauma and subarachnoid hemorrhage, are themselves associated with inflammation of the cerebrospinal fluid. Phenotypically, patients with inflammation of the cerebrospinal fluid can present with very similar symptoms, signs, and laboratory findings to those with infection. This review examines various controversies relating to the definitions, diagnosis, challenges of differentiating infection from inflammation, prevention, and treatment of ventriculitis in patients with EVDs.
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Affiliation(s)
- Mahesh Ramanan
- Intensive Care Unit, Caboolture Hospital, Caboolture, QLD 4510, Australia
- Adult Intensive Care Services, The Prince Charles Hospital, Chermside, QLD 4032, Australia
- School of Medicine, The University of Queensland, Brisbane, QLD 4072, Australia;
- Critical Care Division, The George Institute for Global Health, University of New South Wales, Newtown, NSW 1466, Australia
- Correspondence:
| | - Andrew Shorr
- Washington Hospital Center, Medical Intensive Care Unit, Washington, DC 20010, USA;
| | - Jeffrey Lipman
- School of Medicine, The University of Queensland, Brisbane, QLD 4072, Australia;
- Jamieson Trauma Institute and Intensive Care Services, Royal Brisbane and Women’s Hospital, Herston, QLD 4029, Australia
- Nimes University Hospital, University of Montpellier, 30029 Nimes, France
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31
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Mastorakos P, Russo MV, Zhou T, Johnson K, McGavern DB. Antimicrobial immunity impedes CNS vascular repair following brain injury. Nat Immunol 2021; 22:1280-1293. [PMID: 34556874 PMCID: PMC8488012 DOI: 10.1038/s41590-021-01012-1] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2020] [Accepted: 07/27/2021] [Indexed: 12/14/2022]
Abstract
Traumatic brain injury (TBI) and cerebrovascular injury are leading causes of disability and mortality worldwide. Systemic infections often accompany these disorders and can worsen outcomes. Recovery after brain injury depends on innate immunity, but the effect of infections on this process is not well understood. Here, we demonstrate that systemically introduced microorganisms and microbial products interfered with meningeal vascular repair after TBI in a type I interferon (IFN-I)-dependent manner, with sequential infections promoting chronic disrepair. Mechanistically, we discovered that MDA5-dependent detection of an arenavirus encountered after TBI disrupted pro-angiogenic myeloid cell programming via induction of IFN-I signaling. Systemic viral infection similarly blocked restorative angiogenesis in the brain parenchyma after intracranial hemorrhage, leading to chronic IFN-I signaling, blood-brain barrier leakage and a failure to restore cognitive-motor function. Our findings reveal a common immunological mechanism by which systemic infections deviate reparative programming after central nervous system injury and offer a new therapeutic target to improve recovery.
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Affiliation(s)
- Panagiotis Mastorakos
- Viral Immunology & Intravital Imaging Section, National Institute of Neurological Disorders and Stroke, National Institutes of Health, Bethesda, MD, USA.,Department of Surgical Neurology, National Institute of Neurological Disorders and Stroke, National Institutes of Health, Bethesda, MD, USA
| | - Matthew V Russo
- Viral Immunology & Intravital Imaging Section, National Institute of Neurological Disorders and Stroke, National Institutes of Health, Bethesda, MD, USA
| | - Tianzan Zhou
- Viral Immunology & Intravital Imaging Section, National Institute of Neurological Disorders and Stroke, National Institutes of Health, Bethesda, MD, USA
| | - Kory Johnson
- National Institute of Neurological Disorders and Stroke, National Institutes of Health, Bethesda, MD, USA
| | - Dorian B McGavern
- Viral Immunology & Intravital Imaging Section, National Institute of Neurological Disorders and Stroke, National Institutes of Health, Bethesda, MD, USA.
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Levochkina M, McQuillan L, Awan N, Barton D, Maczuzak J, Bianchine C, Trombley S, Kotes E, Wiener J, Wagner A, Calcagno J, Maza A, Nierstedt R, Ferimer S, Wagner A. Neutrophil-to-Lymphocyte Ratios and Infections after Traumatic Brain Injury: Associations with Hospital Resource Utilization and Long-Term Outcome. J Clin Med 2021; 10:jcm10194365. [PMID: 34640381 PMCID: PMC8509449 DOI: 10.3390/jcm10194365] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2021] [Revised: 09/20/2021] [Accepted: 09/24/2021] [Indexed: 12/30/2022] Open
Abstract
Traumatic brain injury (TBI) induces immune dysfunction that can be captured clinically by an increase in the neutrophil-to-lymphocyte ratio (NLR). However, few studies have characterized the temporal dynamics of NLR post-TBI and its relationship with hospital-acquired infections (HAI), resource utilization, or outcome. We assessed NLR and HAI over the first 21 days post-injury in adults with moderate-to-severe TBI (n = 196) using group-based trajectory (TRAJ), changepoint, and mixed-effects multivariable regression analysis to characterize temporal dynamics. We identified two groups with unique NLR profiles: a high (n = 67) versus a low (n = 129) TRAJ group. High NLR TRAJ had higher rates (76.12% vs. 55.04%, p = 0.004) and earlier time to infection (p = 0.003). In changepoint-derived day 0–5 and 6–20 epochs, low lymphocyte TRAJ, early in recovery, resulted in more frequent HAIs (p = 0.042), subsequently increasing later NLR levels (p ≤ 0.0001). Both high NLR TRAJ and HAIs increased hospital length of stay (LOS) and days on ventilation (p ≤ 0.05 all), while only high NLR TRAJ significantly increased odds of unfavorable six-month outcome as measured by the Glasgow Outcome Scale (GOS) (p = 0.046) in multivariable regression. These findings provide insight into the temporal dynamics and interrelatedness of immune factors which collectively impact susceptibility to infection and greater hospital resource utilization, as well as influence recovery.
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Affiliation(s)
- Marina Levochkina
- Department of Physical Medicine & Rehabilitation, University of Pittsburgh, Pittsburgh, PA 15213, USA; (M.L.); (L.M.); (N.A.); (J.M.); (C.B.); (S.T.); (E.K.); (J.W.); (A.W.); (J.C.); (A.M.); (R.N.)
- Department of Infectious Diseases & Microbiology, University of Pittsburgh, Pittsburgh, PA 15213, USA
| | - Leah McQuillan
- Department of Physical Medicine & Rehabilitation, University of Pittsburgh, Pittsburgh, PA 15213, USA; (M.L.); (L.M.); (N.A.); (J.M.); (C.B.); (S.T.); (E.K.); (J.W.); (A.W.); (J.C.); (A.M.); (R.N.)
| | - Nabil Awan
- Department of Physical Medicine & Rehabilitation, University of Pittsburgh, Pittsburgh, PA 15213, USA; (M.L.); (L.M.); (N.A.); (J.M.); (C.B.); (S.T.); (E.K.); (J.W.); (A.W.); (J.C.); (A.M.); (R.N.)
- Department of Biostatistics, University of Pittsburgh, Pittsburgh, PA 15213, USA
| | - David Barton
- Department of Emergency Medicine, University of Pittsburgh, Pittsburgh, PA 15213, USA;
| | - John Maczuzak
- Department of Physical Medicine & Rehabilitation, University of Pittsburgh, Pittsburgh, PA 15213, USA; (M.L.); (L.M.); (N.A.); (J.M.); (C.B.); (S.T.); (E.K.); (J.W.); (A.W.); (J.C.); (A.M.); (R.N.)
| | - Claudia Bianchine
- Department of Physical Medicine & Rehabilitation, University of Pittsburgh, Pittsburgh, PA 15213, USA; (M.L.); (L.M.); (N.A.); (J.M.); (C.B.); (S.T.); (E.K.); (J.W.); (A.W.); (J.C.); (A.M.); (R.N.)
| | - Shannon Trombley
- Department of Physical Medicine & Rehabilitation, University of Pittsburgh, Pittsburgh, PA 15213, USA; (M.L.); (L.M.); (N.A.); (J.M.); (C.B.); (S.T.); (E.K.); (J.W.); (A.W.); (J.C.); (A.M.); (R.N.)
| | - Emma Kotes
- Department of Physical Medicine & Rehabilitation, University of Pittsburgh, Pittsburgh, PA 15213, USA; (M.L.); (L.M.); (N.A.); (J.M.); (C.B.); (S.T.); (E.K.); (J.W.); (A.W.); (J.C.); (A.M.); (R.N.)
| | - Joshua Wiener
- Department of Physical Medicine & Rehabilitation, University of Pittsburgh, Pittsburgh, PA 15213, USA; (M.L.); (L.M.); (N.A.); (J.M.); (C.B.); (S.T.); (E.K.); (J.W.); (A.W.); (J.C.); (A.M.); (R.N.)
| | - Audrey Wagner
- Department of Physical Medicine & Rehabilitation, University of Pittsburgh, Pittsburgh, PA 15213, USA; (M.L.); (L.M.); (N.A.); (J.M.); (C.B.); (S.T.); (E.K.); (J.W.); (A.W.); (J.C.); (A.M.); (R.N.)
| | - Jason Calcagno
- Department of Physical Medicine & Rehabilitation, University of Pittsburgh, Pittsburgh, PA 15213, USA; (M.L.); (L.M.); (N.A.); (J.M.); (C.B.); (S.T.); (E.K.); (J.W.); (A.W.); (J.C.); (A.M.); (R.N.)
| | - Andrew Maza
- Department of Physical Medicine & Rehabilitation, University of Pittsburgh, Pittsburgh, PA 15213, USA; (M.L.); (L.M.); (N.A.); (J.M.); (C.B.); (S.T.); (E.K.); (J.W.); (A.W.); (J.C.); (A.M.); (R.N.)
| | - Ryan Nierstedt
- Department of Physical Medicine & Rehabilitation, University of Pittsburgh, Pittsburgh, PA 15213, USA; (M.L.); (L.M.); (N.A.); (J.M.); (C.B.); (S.T.); (E.K.); (J.W.); (A.W.); (J.C.); (A.M.); (R.N.)
| | - Stephanie Ferimer
- Division of Pediatric Rehabilitation Medicine, Department of Orthopaedics, West Virginia University, Morgantown, WV 26506, USA;
| | - Amy Wagner
- Department of Physical Medicine & Rehabilitation, University of Pittsburgh, Pittsburgh, PA 15213, USA; (M.L.); (L.M.); (N.A.); (J.M.); (C.B.); (S.T.); (E.K.); (J.W.); (A.W.); (J.C.); (A.M.); (R.N.)
- Safar Center for Resuscitation Research, University of Pittsburgh, Pittsburgh, PA 15213, USA
- Department of Neuroscience, University of Pittsburgh, Pittsburgh, PA 15213, USA
- Center for Neuroscience, University of Pittsburgh, Pittsburgh, PA 15213, USA
- Clinical and Translational Science Institute, University of Pittsburgh, Pittsburgh, PA 15213, USA
- Correspondence:
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McDonald SJ, Sharkey JM, Sun M, Kaukas LM, Shultz SR, Turner RJ, Leonard AV, Brady RD, Corrigan F. Beyond the Brain: Peripheral Interactions after Traumatic Brain Injury. J Neurotrauma 2021; 37:770-781. [PMID: 32041478 DOI: 10.1089/neu.2019.6885] [Citation(s) in RCA: 65] [Impact Index Per Article: 21.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
Traumatic brain injury (TBI) is a leading cause of death and disability, and there are currently no pharmacological treatments known to improve patient outcomes. Unquestionably, contributing toward a lack of effective treatments is the highly complex and heterogenous nature of TBI. In this review, we highlight the recent surge of research that has demonstrated various central interactions with the periphery as a potential major contributor toward this heterogeneity and, in particular, the breadth of research from Australia. We describe the growing evidence of how extracranial factors, such as polytrauma and infection, can significantly alter TBI neuropathology. In addition, we highlight how dysregulation of the autonomic nervous system and the systemic inflammatory response induced by TBI can have profound pathophysiological effects on peripheral organs, such as the heart, lung, gastrointestinal tract, liver, kidney, spleen, and bone. Collectively, this review firmly establishes TBI as a systemic condition. Further, the central and peripheral interactions that can occur after TBI must be further explored and accounted for in the ongoing search for effective treatments.
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Affiliation(s)
- Stuart J McDonald
- Department Neuroscience, Monash University, Melbourne, Victoria, Australia.,Department of Physiology, Anatomy and Microbiology, La Trobe University, Bundoora, Victoria, Australia
| | - Jessica M Sharkey
- Discipline of Anatomy and Pathology, Adelaide Medical School, Faculty of Health and Medical Sciences, The University of Adelaide, Adelaide, South Australia, Australia
| | - Mujun Sun
- Department Neuroscience, Monash University, Melbourne, Victoria, Australia
| | - Lola M Kaukas
- School of Health Sciences, University of South Australia, Adelaide, South Australia, Australia
| | - Sandy R Shultz
- Department Neuroscience, Monash University, Melbourne, Victoria, Australia.,Department of Medicine, University of Melbourne, Melbourne, Victoria, Australia
| | - Renee J Turner
- Discipline of Anatomy and Pathology, Adelaide Medical School, Faculty of Health and Medical Sciences, The University of Adelaide, Adelaide, South Australia, Australia
| | - Anna V Leonard
- Discipline of Anatomy and Pathology, Adelaide Medical School, Faculty of Health and Medical Sciences, The University of Adelaide, Adelaide, South Australia, Australia
| | - Rhys D Brady
- Department Neuroscience, Monash University, Melbourne, Victoria, Australia
| | - Frances Corrigan
- School of Health Sciences, University of South Australia, Adelaide, South Australia, Australia
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Abujaber A, Fadlalla A, Gammoh D, Al-Thani H, El-Menyar A. Machine Learning Model to Predict Ventilator Associated Pneumonia in patients with Traumatic Brain Injury: The C.5 Decision Tree Approach. Brain Inj 2021; 35:1095-1102. [PMID: 34357830 DOI: 10.1080/02699052.2021.1959060] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
BACKGROUND There is paucity in the literature to predict the occurrence of Ventilator Associated Pneumonia (VAP) in patients with Traumatic Brain Injury (TBI). We aimed to build a C.5. Decision Tree (C.5 DT) machine learning model to predict VAP in patients with moderate to severe TBI. METHODS This was a retrospective study including all adult patients who were hospitalized with TBI plus head abbreviated injury scale (AIS) ≥ 3 and were mechanically ventilated in a level 1 trauma center between 2014 and 2019. RESULTS A total of 772 eligible patients were enrolled, of them 169 had VAP (22%). The C.5 DT model achieved moderate performance with 83.5% accuracy, 80.5% area under the curve, 71% precision, 86% negative predictive value, 43% sensitivity, 95% specificity and 54% F-score. Out of 24 predictors, C.5 DT identified 5 variables predicting occurrence of VAP post-moderate to severe TBI (Time from injury to emergency department arrival, blood transfusion during resuscitation, comorbidities, Injury Severity Score and pneumothorax). CONCLUSIONS This study could serve as baseline for the quest of predicting VAP in patients with TBI through the utilization of C.5. DT machine learning approach. This model helps provide timely decision support to caregivers to improve patient's outcomes.
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Affiliation(s)
- Ahmad Abujaber
- Assistant Executive Director of Nursing, Hamad Medical Corporation, Doha, Qatar
| | - Adam Fadlalla
- Management Information Systems, Business, and Economics Faculty, Qatar University, Doha, Qatar
| | - Diala Gammoh
- Industrial Engineering, University of Central Florida- USA
| | - Hassan Al-Thani
- Department of Surgery, Trauma Surgery, Hamad Medical Corporation, Doha, Qatar
| | - Ayman El-Menyar
- Department of Surgery, Trauma Surgery, Clinical Research, Hamad Medical Corporation, Doha, Qatar.,Department of Clinical Medicine, Weill Cornell Medical College, Doha, Qatar
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35
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Huang JH, Wang TJ, Wu SF, Liu CY, Fan JY. Post-craniotomy fever and its associated factors in patients with traumatic brain injury. Nurs Crit Care 2021; 27:483-492. [PMID: 34145947 DOI: 10.1111/nicc.12640] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2020] [Revised: 04/11/2021] [Accepted: 04/15/2021] [Indexed: 11/27/2022]
Abstract
BACKGROUND Fever frequently occurs in patients with traumatic brain injury and can cause secondary damage to the brain. Critical care nurses play essential roles in assessing and managing fever in these patients. AIM The study aimed to (a) examine the fever causes in and condition of neurosurgical patients with traumatic brain injury in intensive care, (b) identify the factors associated with fever, and (c) determine the effects of fever on hospital stay and prognosis. STUDY DESIGN This study is a retrospective observational design. METHODS Data were collected through chart reviews of 93 traumatic brain injury patients admitted to a teaching hospital's intensive care unit for postoperative care. Fever was defined as at least one episode of body temperature >38°C. RESULTS Of the 93 patients, 76 developed a fever within 1-week post-craniotomy. Of these, 49 were infection-related and 27 were unexplained. Results of logistic regression showed that the preoperative Glasgow coma scale score (ß = -.323; P = .013) and length of intubation (ß = .480; P = .005) were the key predictors of unexplained post-craniotomy fever, and these two variables (ß = -.494; P < .001 and ß = .479; P = .006, respectively) were also the key predictors of infection-related fever. CONCLUSION A significant portion of patients developed a fever during the first post-craniotomy week. Patients with a lower pre-craniotomy Glasgow coma scale score and a longer intubation length were at a greater risk for both infection-related fever and unexplained fever. Patients with fever had a bad outcome score. RELEVANCE TO CLINICAL PRACTICE Critical care nurses should closely monitor traumatic brain injury patients' body temperatures and employ evidence-based infection prevention and control measures to minimize their infection risks. Respiratory care and intensive care unit Liberation Bundle should be reinforced to liberate these patients from mechanical ventilation and its associated complications.
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Affiliation(s)
- Jui-Hsia Huang
- Department of Nursing, Intensive Care Unit, Ten-Chan General Hospital, Taoyuan City, Taiwan
| | - Tsae-Jyy Wang
- School of Nursing, National Taipei University of Nursing and Health Sciences, Taipei, Taiwan
| | - Shu-Fang Wu
- School of Nursing, National Taipei University of Nursing and Health Sciences, Taipei, Taiwan
| | - Chieh-Yu Liu
- Department of Speech-Language Pathology and Audiology, National Taipei University of Nursing and Health Sciences, Taipei, Taiwan
| | - Jun-Yu Fan
- Department of Nursing, Chang Gung University of Science and Technology Linkou Campus, Taoyuan City, Taiwan
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36
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Dhillon NK, Sahi S, Barmparas G, Linaval NT, Lin TL, Lahiri S, Brown CVR, Ley EJ. Cerebrospinal Fluid Cultures in Traumatic Brain Injury: Is It Worth It? A Two-Center Study. Surg Infect (Larchmt) 2021; 22:923-927. [PMID: 33956527 DOI: 10.1089/sur.2020.403] [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: 11/12/2022] Open
Abstract
Background: Patients with traumatic brain injury (TBI) frequently develop leukocytosis, fever, and tachycardia that may lead to extensive medical investigations to rule out an infectious process. Cerebrospinal fluid (CSF) is often acquired during this workup, however, the utility of this practice has not been studied previously. We hypothesized that CSF cultures would unlikely yield positive results in patients with TBI. Patients and Methods: A retrospective review was conducted of all patients with TBI admitted to two level 1 trauma centers at urban, academic institutions from January 2009 to December 2016. Data collected included patient demographics, presenting Glasgow Coma Score (GCS), injury profile, injury severity scores (ISS), regional abbreviated injury scale (AIS), hospital and intensive care unit (ICU) length of stay (LOS), ventilator days, and culture results. For purposes of the analysis, CSF cultures with Staphylococcus epidermidis, Staphylococcus aureus, or Candida underwent a chart review and were considered contaminates if indicated. Results: There were 145 patients who had CSF cultures obtained with a median age of 39 years; 77.2% were male. The majority of patients presented after blunt trauma with median GCS of 6, head AIS of 4, and ISS of 25. These patients had prolonged median ICU and hospital stays at 13 and 22 days, respectively. Six (4.1%) CSF cultures demonstrated growth. Four (2.8%) were deemed contaminants, with two growing Staphylococcus epidermidis only, one with both Staphylococcus epidermidis and Staphylococcus aureus, and one with Candida. Two cultures (1.4%) were positive and grew Enterobacter cloacae. Of note, both patients had prior instrumentation with an external ventricular drain. Conclusion: Obtaining CSF cultures in patients with TBI is of low yield, especially in patients without prior external ventricular drain. Other sources of infectious etiologies should be considered in this patient population.
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Affiliation(s)
- Navpreet K Dhillon
- Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Saad Sahi
- Department of Surgery, Dell Medical School, University of Texas at Austin, Austin, Texas, USA
| | - Galinos Barmparas
- Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Nikhil T Linaval
- Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Ting Lung Lin
- Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Shouri Lahiri
- Department of Neurology, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Carlos V R Brown
- Department of Surgery, Dell Medical School, University of Texas at Austin, Austin, Texas, USA
| | - Eric J Ley
- Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, California, USA
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Koul A, Sheikh A, Bhat S, Ahad A, Qadir R, Khurseed N, Kamil R. Nosocomial Infections in Patients with Traumatic Brain Injury: A Hospital-Based Study from North India. INDIAN JOURNAL OF NEUROSURGERY 2021. [DOI: 10.1055/s-0041-1722829] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022] Open
Abstract
Abstract
Background Traumatic brain injury (TBI) is a major global health concern, it being a leading cause of morbidity and mortality in young adults. Infections acquired in the hospital setting are one of many risk factors that are associated with higher mortality in this population. Despite significant impact on the overall outcome, infections in TBI patients are largely understudied and underreported. The purpose of this study was to study the profile of infectious complications in patients with TBI and impact of these infections on the hospital outcome of these patients.
Materials and Methods The medical records of all the patients with a diagnosis of TBI admitted in our hospital from January 2017 to January 2020 were reviewed. They were screened for presence of any predefined infection acquired at any time during their hospital stay. Data regarding demographics, focus of infection, results of various cultures, and hospital outcome was recorded.
Results A total of 60 patients with TBI who had developed nosocomial infections were included in this observational study. Patients were mostly young, with a mean age of 36.6 years. Majority (66.6%) of patients who developed infectious complications had Glasgow coma scale (GCS) score of less than 10. Respiratory tract and urinary tract were the most common sites of infections in these patients. Burkholderia cepecia and Acinetobacter baumannii were the two most common isolated organisms. All-cause mortality in this population was 23.3%.
Conclusions Most TBI patients are young, in their productive period of lives, and do not have major comorbidities. Invariably, they have low GCS scores and encounter a breach of their surface immunity due to catheters, procedures, and intubation. Such patients make an extremely significant impact on hospital resources as well as poor economic outcomes.
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Affiliation(s)
- Ajaz Koul
- Department of Medicine & Infection Diseases, Sher-i-Kashmir Institute of Medical Sciences, Soura, Srinagar, Kashmir, India
| | - Arif Sheikh
- Department of Medicine & Infection Diseases, Sher-i-Kashmir Institute of Medical Sciences, Soura, Srinagar, Kashmir, India
| | - Sajad Bhat
- Department of Medicine & Infection Diseases, Sher-i-Kashmir Institute of Medical Sciences, Soura, Srinagar, Kashmir, India
| | - Abrar Ahad
- Department of Neurosurgery, Sher-i-Kashmir Institute of Medical Sciences, SKIMS, Soura, Srinagar, Kashmir, India
| | - Ruhail Qadir
- Department of Medicine & Infection Diseases, Sher-i-Kashmir Institute of Medical Sciences, Soura, Srinagar, Kashmir, India
| | - Nayl Khurseed
- Department of Neurosurgery, Sher-i-Kashmir Institute of Medical Sciences, SKIMS, Soura, Srinagar, Kashmir, India
| | - Raja Kamil
- Department of Medicine & Infection Diseases, Sher-i-Kashmir Institute of Medical Sciences, Soura, Srinagar, Kashmir, India
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Milleville KA, Awan N, Disanto D, Kumar RG, Wagner AK. Early chronic systemic inflammation and associations with cognitive performance after moderate to severe TBI. Brain Behav Immun Health 2021; 11:100185. [PMID: 34589725 PMCID: PMC8474517 DOI: 10.1016/j.bbih.2020.100185] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2020] [Accepted: 12/03/2020] [Indexed: 12/31/2022] Open
Abstract
BACKGROUND Cognitive dysfunction adversely effects multiple functional outcomes and social roles after TBI. We hypothesize that chronic systemic inflammation exacerbates cognitive deficits post-injury and diminishes functional cognition and quality of life (QOL). Yet few studies have examined relationships between inflammation and cognition after TBI. Associations between early chronic serum inflammatory biomarker levels, cognitive outcomes, and QOL 6-months and 12-months after moderate-to-severe TBI were identified using unweighted (uILS) and weighted (wILS) inflammatory load score (ILS) formation. METHODS Adults with moderate-to-severe TBI (n = 157) completed neuropsychological testing, the Functional Impairment Measure Cognitive Subscale (FIM-Cog) and self-reported Percent Back to Normal scale 6 months (n = 139) and 12 months (n = 136) post-injury. Serial serum samples were collected 1-3 months post-TBI. Cognitive composite scores were created as equally weighted means of T-scores derived from a multidimensional neuropsychological test battery. Median inflammatory marker levels associated with 6-month and 12-month cognitive composite T-scores (p < 0.10) were selected for ILS formation. Markers were quartiled, and quartile ranks were summed to generate an uILS. Marker-specific β-weights were derived using penalized ridge regression, multiplied by standardized marker levels, and summed to generate a wILS. ILS associations with cognitive composite scores were assessed using multivariable linear regression. Structural equation models assessed ILS influences on functional cognition and QOL using 12-month FIM-Cog and Percent Back to Normal scales. RESULTS ILS component markers included: IL-1β, TNF-α, sIL-4R, sIL-6R, RANTES, and MIP-1β. Increased sIL-4R levels were positively associated with overall cognitive composite T-scores in bivariate analyses, while remaining ILS markers were negatively associated with cognition. Multivariable receiver operator curves (ROC) showed uILS added 14.98% and 31.93% relative improvement in variance captured compared to the covariates only base model (age, sex, education, Glasgow Coma Scale score) when predicting cognitive composite scores at 6 and 12 months, respectively; wILS added 33.99% and 36.87% relative improvement in variance captured. Cognitive composite mediated wILS associations with FIM-Cog scores at 12 months, and both cognitive composite and FIM-Cog scores mediated wILS associations with QOL. CONCLUSIONS Early chronic inflammatory burden is associated with cognitive performance post-TBI. wILS explains greater variance in cognitive composite T-scores than uILS. Linking inflammatory burden associated with cognitive deficits to functional outcome post-TBI demonstrates the potential impact of immunotherapy interventions aimed at improving cognitive recovery post-TBI.
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Affiliation(s)
- Kristen A. Milleville
- Department of Physical Medicine and Rehabilitation, School of Medicine, University of Pittsburgh, USA
| | - Nabil Awan
- Department of Physical Medicine and Rehabilitation, School of Medicine, University of Pittsburgh, USA
- Department of Biostatistics, Graduate School of Public Health, University of Pittsburgh, USA
| | - Dominic Disanto
- Department of Physical Medicine and Rehabilitation, School of Medicine, University of Pittsburgh, USA
- Department of Biostatistics, Graduate School of Public Health, University of Pittsburgh, USA
| | - Raj G. Kumar
- Department of Rehabilitation and Human Performance, Icahn School of Medicine at Mount Sinai, USA
| | - Amy K. Wagner
- Department of Physical Medicine and Rehabilitation, School of Medicine, University of Pittsburgh, USA
- Department of Neuroscience, University of Pittsburgh, USA
- Clinical and Translational Science Institute, University of Pittsburgh, USA
- Safar Center for Resuscitation Research, University of Pittsburgh, USA
- Center for Neuroscience, University of Pittsburgh, USA
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Faden AI, Barrett JP, Stoica BA, Henry RJ. Bidirectional Brain-Systemic Interactions and Outcomes After TBI. Trends Neurosci 2021; 44:406-418. [PMID: 33495023 DOI: 10.1016/j.tins.2020.12.004] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2020] [Revised: 12/23/2020] [Accepted: 12/31/2020] [Indexed: 12/16/2022]
Abstract
Traumatic brain injury (TBI) is a debilitating disorder associated with chronic progressive neurodegeneration and long-term neurological decline. Importantly, there is now substantial and increasing evidence that TBI can negatively impact systemic organs, including the pulmonary, gastrointestinal (GI), cardiovascular, renal, and immune system. Less well appreciated, until recently, is that such functional changes can affect both the response to subsequent insults or diseases, as well as contribute to chronic neurodegenerative processes and long-term neurological outcomes. In this review, we summarize evidence showing bidirectional interactions between the brain and systemic organs following TBI and critically assess potential underlying mechanisms.
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Affiliation(s)
- Alan I Faden
- Department of Anesthesiology and Shock, Trauma and Anesthesiology Research (STAR) Center, University of Maryland School of Medicine, Baltimore, MD, USA.
| | - James P Barrett
- Department of Anesthesiology and Shock, Trauma and Anesthesiology Research (STAR) Center, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Bogdan A Stoica
- Department of Anesthesiology and Shock, Trauma and Anesthesiology Research (STAR) Center, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Rebecca J Henry
- Department of Anesthesiology and Shock, Trauma and Anesthesiology Research (STAR) Center, University of Maryland School of Medicine, Baltimore, MD, USA
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40
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Crosstalk Between Lung and Extrapulmonary Organs in Infection and Inflammation. ADVANCES IN EXPERIMENTAL MEDICINE AND BIOLOGY 2021; 1303:333-350. [PMID: 33788201 DOI: 10.1007/978-3-030-63046-1_18] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Acute and chronic lung inflammation is a risk factor for various diseases involving lungs and extrapulmonary organs. Intercellular and interorgan networks, including crosstalk between lung and brain, intestine, heart, liver, and kidney, coordinate host immunity against infection, protect tissue, and maintain homeostasis. However, this interaction may be counterproductive and cause acute or chronic comorbidities due to dysregulated inflammation in the lung. In this chapter, we review the relationship of the lung with other key organs during normal cell processes and disease development. We focus on how pneumonia may lead to a systemic pathophysiological response to acute lung injury and chronic lung disease through organ interactions, which can facilitate the development of undesirable and even deleterious extrapulmonary sequelae.
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Doran SJ, Henry RJ, Shirey KA, Barrett JP, Ritzel RM, Lai W, Blanco JC, Faden AI, Vogel SN, Loane DJ. Early or Late Bacterial Lung Infection Increases Mortality After Traumatic Brain Injury in Male Mice and Chronically Impairs Monocyte Innate Immune Function. Crit Care Med 2020; 48:e418-e428. [PMID: 32149839 PMCID: PMC7541908 DOI: 10.1097/ccm.0000000000004273] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
OBJECTIVES Respiratory infections in the postacute phase of traumatic brain injury impede optimal recovery and contribute substantially to overall morbidity and mortality. This study investigated bidirectional innate immune responses between the injured brain and lung, using a controlled cortical impact model followed by secondary Streptococcus pneumoniae infection in mice. DESIGN Experimental study. SETTING Research laboratory. SUBJECTS Adult male C57BL/6J mice. INTERVENTIONS C57BL/6J mice were subjected to sham surgery or moderate-level controlled cortical impact and infected intranasally with S. pneumoniae (1,500 colony-forming units) or vehicle (phosphate-buffered saline) at 3 or 60 days post-injury. MAIN RESULTS At 3 days post-injury, S. pneumoniae-infected traumatic brain injury mice (TBI + Sp) had a 25% mortality rate, in contrast to no mortality in S. pneumoniae-infected sham (Sham + Sp) animals. TBI + Sp mice infected 60 days post-injury had a 60% mortality compared with 5% mortality in Sham + Sp mice. In both studies, TBI + Sp mice had poorer motor function recovery compared with TBI + PBS mice. There was increased expression of pro-inflammatory markers in cortex of TBI + Sp compared with TBI + PBS mice after both early and late infection, indicating enhanced post-traumatic neuroinflammation. In addition, monocytes from lungs of TBI + Sp mice were immunosuppressed acutely after traumatic brain injury and could not produce interleukin-1β, tumor necrosis factor-α, or reactive oxygen species. In contrast, after delayed infection monocytes from TBI + Sp mice had higher levels of interleukin-1β, tumor necrosis factor-α, and reactive oxygen species when compared with Sham + Sp mice. Increased bacterial burden and pathology was also found in lungs of TBI + Sp mice. CONCLUSIONS Traumatic brain injury causes monocyte functional impairments that may affect the host's susceptibility to respiratory infections. Chronically injured mice had greater mortality following S. pneumoniae infection, which suggests that respiratory infections even late after traumatic brain injury may pose a more serious threat than is currently appreciated.
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Affiliation(s)
- Sarah J Doran
- Department of Anesthesiology and Shock, Trauma and Anesthesiology Research (STAR) Center, University of Maryland School of Medicine, Baltimore, MD
| | - Rebecca J Henry
- Department of Anesthesiology and Shock, Trauma and Anesthesiology Research (STAR) Center, University of Maryland School of Medicine, Baltimore, MD
| | - Kari Ann Shirey
- Department of Microbiology and Immunology, University of Maryland School of Medicine, Baltimore, MD
| | - James P Barrett
- Department of Anesthesiology and Shock, Trauma and Anesthesiology Research (STAR) Center, University of Maryland School of Medicine, Baltimore, MD
| | - Rodney M Ritzel
- Department of Anesthesiology and Shock, Trauma and Anesthesiology Research (STAR) Center, University of Maryland School of Medicine, Baltimore, MD
| | - Wendy Lai
- Department of Microbiology and Immunology, University of Maryland School of Medicine, Baltimore, MD
| | | | - Alan I Faden
- Department of Anesthesiology and Shock, Trauma and Anesthesiology Research (STAR) Center, University of Maryland School of Medicine, Baltimore, MD
| | - Stefanie N Vogel
- Department of Microbiology and Immunology, University of Maryland School of Medicine, Baltimore, MD
| | - David J Loane
- Department of Anesthesiology and Shock, Trauma and Anesthesiology Research (STAR) Center, University of Maryland School of Medicine, Baltimore, MD
- School of Biochemistry and Immunology, Trinity Biomedical Sciences Institute, Trinity College, Dublin, Ireland
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Abstract
OBJECTIVES Nosocomial infection is a common source of morbidity in critically injured children including those with traumatic brain injury. Risk factors for nosocomial infection in this population, however, are poorly understood. We hypothesized that critically ill pediatric trauma patients with traumatic brain injury would demonstrate higher rates of nosocomial infection than those without traumatic brain injury. DESIGN Retrospective case-control study. SETTING PICU, single institution. PATIENTS Patients under 18 years old who were admitted to the PICU for at least 48 hours following a traumatic injury were included. Patients were admitted between September 2008 and December 2015. Patients with the following injury types were excluded: thermal injury, drowning, hanging/strangulation, acute hypoxic ischemic encephalopathy, or nonaccidental trauma. Data collected included demographics, injury information, hospital and PICU length of stay, vital signs, laboratory data, insertion and removal dates for invasive devices, surgeries performed, transfusions of blood products, and microbiology culture results. Initial Pediatric Risk of Mortality III and Pediatric Logistic Organ Dysfunction-2 scores were determined. Patients were classified as having: 1) an isolated traumatic brain injury, 2) a traumatic injury without traumatic brain injury, or 3) polytrauma with traumatic brain injury. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Two hundred three patients were included in the analyses, and 27 patients developed a nosocomial infection. Patients with polytrauma with traumatic brain injury demonstrated a significantly higher infection rate (30%) than patients with isolated traumatic brain injury (6%) or traumatic injury without traumatic brain injury (9%) (p < 0.001). This increased rate of nosocomial infection was noted on univariate analysis, on multivariable analysis, and after adjusting for other risk factors. CONCLUSIONS In this single-center, retrospective analysis of critically ill pediatric trauma patients, nosocomial infections were more frequently observed in patients admitted following polytrauma with traumatic brain injury than in patients with isolated traumatic brain injury or trauma without traumatic brain injury.
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Sun M, Brady RD, Wanrooy B, Mychasiuk R, Yamakawa GR, Casillas-Espinosa PM, Wong CHY, Shultz SR, McDonald SJ. Experimental traumatic brain injury does not lead to lung infection. J Neuroimmunol 2020; 343:577239. [PMID: 32302792 DOI: 10.1016/j.jneuroim.2020.577239] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2020] [Revised: 03/23/2020] [Accepted: 04/08/2020] [Indexed: 12/13/2022]
Abstract
Traumatic brain injury (TBI) patients often experience post-traumatic infections, especially in the lung. Pulmonary infection is associated with unfavorable outcomes and increased mortality rates in TBI patients; however, our understanding of the underlying mechanisms is poor. Here we used a lateral fluid percussion injury (LFPI) model in rats to investigate whether TBI could lead to spontaneous lung infection. Analysis of bacterial load in lung tissue indicated no occurrence of spontaneous lung infection at 24 h, 48 h, and 7 d following LFPI. This may suggest that exogenous infectious agents play a crucial role in post-TBI infection in patients.
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Affiliation(s)
- Mujun Sun
- Department of Neuroscience, Central Clinical School, Monash University, Melbourne, VIC 3004, Australia.
| | - Rhys D Brady
- Department of Neuroscience, Central Clinical School, Monash University, Melbourne, VIC 3004, Australia; Department of Medicine, The University of Melbourne, Melbourne, VIC 3052, Australia.
| | - Brooke Wanrooy
- Centre for Inflammatory Diseases, Department of Medicine, School of Clinical Sciences, Monash University, Melbourne, VIC 3168, Australia.
| | - Richelle Mychasiuk
- Department of Neuroscience, Central Clinical School, Monash University, Melbourne, VIC 3004, Australia.
| | - Glenn R Yamakawa
- Department of Neuroscience, Central Clinical School, Monash University, Melbourne, VIC 3004, Australia.
| | - Pablo M Casillas-Espinosa
- Department of Neuroscience, Central Clinical School, Monash University, Melbourne, VIC 3004, Australia; Department of Medicine, The University of Melbourne, Melbourne, VIC 3052, Australia.
| | - Connie H Y Wong
- Centre for Inflammatory Diseases, Department of Medicine, School of Clinical Sciences, Monash University, Melbourne, VIC 3168, Australia.
| | - Sandy R Shultz
- Department of Neuroscience, Central Clinical School, Monash University, Melbourne, VIC 3004, Australia; Department of Medicine, The University of Melbourne, Melbourne, VIC 3052, Australia.
| | - Stuart J McDonald
- Department of Neuroscience, Central Clinical School, Monash University, Melbourne, VIC 3004, Australia; Department of Physiology, Anatomy and Microbiology, School of Life Sciences, La Trobe University, Melbourne, VIC 3086, Australia.
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Abstract
PURPOSE OF REVIEW This article summarizes updated data and knowledge on healthcare-associated infections in the neurocritical care unit, with a focus on central nervous system infections and systemic infectious complications in patients with acute brain disease. It also reviews the concept of brain injury-induced immune modulation, an underlying mechanism to explain why the neuro-ICU population is particularly susceptible to infections. RECENT FINDINGS Healthcare-associated infections in the neuro-ICU are common: up to 40 % of meningitides in the developed world are now healthcare-associated. The number of gram-negative infections is rising. New diagnostic approaches attempt to aid in the diagnosis of healthcare-associated meningitis and ventriculitis. Healthcare-associated infections in the neurocritical care unit remain a challenge for diagnosis, treatment, and prevention. Gaining a better understanding of at-risk patients and development of preventative strategies will be the goal for future investigation.
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Affiliation(s)
- Katharina M Busl
- Departments of Neurology and Neurosurgery, McKnight Brain Institute L3-100, University of Florida College of Medicine, 1149 Newell Drive, Gainesville, FL, 32610, USA.
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Chen Y, Zhang L, Qin T, Wang Z, Li Y, Gu B. Evaluation of neurosurgical implant infection rates and associated pathogens: evidence from 1118 postoperative infections. Neurosurg Focus 2019; 47:E6. [DOI: 10.3171/2019.5.focus18582] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2018] [Accepted: 05/22/2019] [Indexed: 01/01/2023]
Abstract
OBJECTIVEVarious implanted materials are used in neurosurgery; however, there remains a lack of pooled data on infection rates (IRs) and infective bacteria over past decades. The goal of this study was to investigate implant infections in neurosurgical procedures in a longitudinal retrospective study and to evaluate the IRs of neurosurgically implanted materials and the distribution of pathogenic microorganisms.METHODSA systematic literature search was conducted using PubMed and Web of Science databases for the time period between 1968 and 2018. Neurosurgical implant infections were studied in 5 subgroups, including operations or diseases, implanted materials, bacteria, distribution by country, and time periods, which were obtained from the literature and statistically analyzed. In this meta-analysis, statistical heterogeneity across studies was tested by using p values and I2 values between studies of associated pathogens. Egger’s test was used for assessing symmetries of funnel plots with Stata 11.0 software. Methodological quality was assessed to judge the risk of bias according to the Cochrane Handbook.RESULTSA total of 22,971 patients from 227 articles satisfied the study’s eligibility criteria. Of these, 1118 cases of infection were reported, and the overall IR was 4.87%. In this study, the neurosurgical procedures or disorders with the top 3 IRs included craniotomy (IR 6.58%), cranioplasty (IR 5.89%), and motor movement disorders (IR 5.43%). Among 13 implanted materials, the implants with the top 3 IRs included polypropylene-polyester, titanium, and polyetheretherketone (PEEK), which were 8.11%, 8.15%, and 7.31%, respectively. Furthermore, the main causative pathogen was Staphylococcus aureus and the countries with the top 3 IRs were Denmark (IR 11.90%), Korea (IR 10.98%), and Mexico (IR 9.26%). Except for the low IR from 1998 to 2007, the overall implant IR after neurosurgical procedures was on the rise.CONCLUSIONSIn this study, the main pathogen in neurosurgery was S. aureus, which can provide a certain reference for the clinic. In addition, the IRs of polypropylene-polyester, titanium, and PEEK were higher than other materials, which means that more attention should be paid to them. In short, the total IR was high in neurosurgical implants and should be taken seriously.
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Affiliation(s)
- Ying Chen
- 1Department of Microbiology and Immunology, School of Medical Technology, Xuzhou Medical University; and
| | - Linyan Zhang
- 1Department of Microbiology and Immunology, School of Medical Technology, Xuzhou Medical University; and
| | - Tingting Qin
- 2Clinical Microbiology Laboratory, Affiliated Hospital of Xuzhou Medical University, Xuzhou, China
| | - Zhenzhen Wang
- 1Department of Microbiology and Immunology, School of Medical Technology, Xuzhou Medical University; and
| | - Ying Li
- 1Department of Microbiology and Immunology, School of Medical Technology, Xuzhou Medical University; and
| | - Bing Gu
- 1Department of Microbiology and Immunology, School of Medical Technology, Xuzhou Medical University; and
- 2Clinical Microbiology Laboratory, Affiliated Hospital of Xuzhou Medical University, Xuzhou, China
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Sharma R, Shultz SR, Robinson MJ, Belli A, Hibbs ML, O'Brien TJ, Semple BD. Infections after a traumatic brain injury: The complex interplay between the immune and neurological systems. Brain Behav Immun 2019; 79:63-74. [PMID: 31029794 DOI: 10.1016/j.bbi.2019.04.034] [Citation(s) in RCA: 50] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/08/2019] [Revised: 03/29/2019] [Accepted: 04/24/2019] [Indexed: 12/21/2022] Open
Abstract
Traumatic brain injury (TBI) is a serious global health issue, being the leading cause of death and disability for individuals under the age of 45, and one of the largest causes of global neurological disability. In addition to the brain injury itself, it is increasingly appreciated that a TBI may also alter the systemic immune response in a way that renders TBI patients more vulnerable to infections in the acute post-injury period. Such infections pose an additional challenge to the patient, increasing rates of mortality and morbidity, and worsening neurological outcomes. Hospitalization, surgical interventions, and a state of immunosuppression induced by injury to the central nervous system (CNS), may all contribute to the high rate of infections seen in the population with TBI. Ongoing research to better understand the immunomodulators that underlie TBI-induced immunosuppression may aid in the development of effective therapeutic strategies to improve the recovery trajectory for patients. This review first describes the clinical scenario, posing the question of whether TBI patients are more susceptible to infections such as pneumonia, and if so, why? We then consider how cross-talk between the injured brain and the systemic immune system occurs, and further, how the additional immune challenge of an acquired infection can contribute to ongoing neuroinflammation and neurodegeneration after a TBI. Experimental models combining TBI with infection are discussed, as well as current treatment options available for this double-barreled insult. The aims of this review are to summarize current understanding of the bidirectional relationship between the CNS and the immune system when faced with a mechanical trauma combined with a concomitant infection, and to highlight key outstanding questions that remain in the field.
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Affiliation(s)
- Rishabh Sharma
- Department of Neuroscience, Central Clinical School at the Alfred Hospital, Monash University, Melbourne, VIC, Australia
| | - Sandy R Shultz
- Department of Neuroscience, Central Clinical School at the Alfred Hospital, Monash University, Melbourne, VIC, Australia; Department of Medicine (Royal Melbourne Hospital), Melbourne Medical School, The University of Melbourne, Parkville, VIC, Australia
| | - Marcus J Robinson
- Department of Immunology and Pathology, Central Clinical School at the Alfred Hospital, Monash University, Melbourne, VIC, Australia
| | - Antonio Belli
- Institute of Inflammation and Ageing, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
| | - Margaret L Hibbs
- Department of Immunology and Pathology, Central Clinical School at the Alfred Hospital, Monash University, Melbourne, VIC, Australia
| | - Terence J O'Brien
- Department of Neuroscience, Central Clinical School at the Alfred Hospital, Monash University, Melbourne, VIC, Australia; Department of Medicine (Royal Melbourne Hospital), Melbourne Medical School, The University of Melbourne, Parkville, VIC, Australia
| | - Bridgette D Semple
- Department of Neuroscience, Central Clinical School at the Alfred Hospital, Monash University, Melbourne, VIC, Australia; Department of Medicine (Royal Melbourne Hospital), Melbourne Medical School, The University of Melbourne, Parkville, VIC, Australia.
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Cryptococcal Meningitis in a HIV Seronegative Patient: A Rare Complication of Cerebrospinal Fluid Leak Detected with a New Cisternographic Technique. Case Rep Infect Dis 2019; 2019:3510860. [PMID: 30915245 PMCID: PMC6402215 DOI: 10.1155/2019/3510860] [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: 10/21/2018] [Revised: 01/29/2019] [Accepted: 02/10/2019] [Indexed: 12/02/2022] Open
Abstract
Immune deficiency is usually the underlying predisposing factor for cryptococcal meningitis, though there have been case reports of immunocompetent patients presenting with same. The portal of entry for Cryptococcus neoformans is the respiratory tract, and by hematogenous spread, it causes systemic symptoms. The presence of CSF leak is described to have predisposed our immunocompetent patient to infection by this organism possibly through direct spread. The gold standard for diagnosing CSF leak is by cisternography. In this case, we added a technique where nasal gauze is inserted during the procedure and scanned afterwards for dye, thus increasing the confidence of diagnosis of CSF leak through the nares. Prompt diagnosis and treatment is key to prevent adverse outcomes, and we propose that in patients with cryptococcal meningitis without any identifiable risk factor, evaluation for CSF leak should be considered especially with history of head trauma.
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The Impact of Capping Creatinine Clearance on Achieving Therapeutic Vancomycin Concentrations in Neurocritically Ill Patients with Traumatic Brain Injury. Neurocrit Care 2019; 30:126-131. [PMID: 30051194 DOI: 10.1007/s12028-018-0583-z] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
BACKGROUND Traumatic brain injury (TBI) is associated with secondary complications, including infection, and patients with TBI often exhibit augmented renal clearance (ARC). This phenomenon has been associated with subtherapeutic levels of renally cleared drugs such as vancomycin, which is dosed based on body weight and creatinine clearance (CrCl). Many clinicians, however, cap CrCl at 120 mL/min/1.73 m2 when calculating vancomycin dosing regimens. We hypothesize that capping patient CrCl, as opposed to utilizing the non-capped CrCl, when determining vancomycin dosing schemes results in subtherapeutic serum trough concentrations in patients with TBI. METHODS This was a retrospective study of adult patients with TBI admitted between April 2014 and December 2015 who received vancomycin. Population-based pharmacokinetic (PK) parameters using non-capped calculated CrCl and capped CrCl were compared with patient-specific PK parameters based on serum trough concentrations. RESULTS Thirty-two patients with TBI were included in the study. ARC was suspected in 24 (75%) patients due to a median estimated CrCl at serum trough concentration of 167.3 (127.7-197.7) mL/min. The mean dosing regimen was 17.1 (13.2-19.2) mg/kg every 8 (8-8) h. There was no difference between the median measured trough concentration and predicted value using non-capped CrCl [10.4 (7.1-15.0) vs. 11.5 (7.8-13.7) mcg/mL; p = 0.7986]. The median measured trough concentration was significantly lower than the predicted trough concentration when calculated based on capping the CrCl at 120 mL/min/1.73 m2 [16.3 (15.3-22.0) vs. 11.5 (7.8-13.7) mcg/mL; p < 0.0001]. CONCLUSIONS Patients with traumatic brain injury appeared to exhibit augmented renal clearance, leading to subtherapeutic vancomycin serum trough concentrations when doses were calculated using the traditional method of capping creatinine clearance at 120 mL/min/1.73 m2. Instead, utilizing patients' non-capped creatinine clearance when determining a vancomycin dosing regimen is more accurate and provides a better estimation of vancomycin pharmacokinetics and could be applied to other renally excreted medications.
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Wagner AK, Kumar RG. TBI Rehabilomics Research: Conceptualizing a humoral triad for designing effective rehabilitation interventions. Neuropharmacology 2018; 145:133-144. [PMID: 30222984 DOI: 10.1016/j.neuropharm.2018.09.011] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2018] [Revised: 08/14/2018] [Accepted: 09/10/2018] [Indexed: 12/11/2022]
Abstract
Most areas of medicine use biomarkers in some capacity to aid in understanding how personal biology informs clinical care. This article draws upon the Rehabilomics research model as a translational framework for programs of precision rehabilitation and intervention research focused on linking personal biology to treatment response using biopsychosocial constructs that broadly represent function and that can be applied to many clinical populations with disability. The summary applies the Rehabilomics research framework to the population with traumatic brain injury (TBI) and emphasizes a broad vision for biomarker inclusion, beyond typical brain-derived biomarkers, to capture and/or reflect important neurological and non-neurological pathology associated with TBI as a chronic condition. Humoral signaling molecules are explored as important signaling and regulatory drivers of these chronic conditions and their impact on function. Importantly, secondary injury cascades involved in the humoral triad are influenced by the systemic response to TBI and the development of non-neurological organ dysfunction (NNOD). Biomarkers have been successfully leveraged in other medical fields to inform pre-randomization patient selection for clinical trials, however, this practice largely has not been utilized in TBI research. As such, the applicability of the Rehabilomics research model to contemporary clinical trials and comparative effectiveness research designs for neurological and rehabilitation populations is emphasized. Potential points of intervention to modify inflammation, hormonal, or neurotrophic support through rehabilitation interventions are discussed. This article is part of the Special Issue entitled "Novel Treatments for Traumatic Brain Injury".
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Affiliation(s)
- A K Wagner
- Department of Physical Medicine & Rehabilitation, University of Pittsburgh, USA; Safar Center for Resuscitation Research, University of Pittsburgh, USA; Department of Neuroscience, University of Pittsburgh, USA; Center for Neuroscience, University of Pittsburgh, USA.
| | - R G Kumar
- Department of Physical Medicine & Rehabilitation, University of Pittsburgh, USA; Safar Center for Resuscitation Research, University of Pittsburgh, USA; Department of Epidemiology, University of Pittsburgh, USA
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Farrell D, Bendo AA. Perioperative Management of Severe Traumatic Brain Injury: What Is New? CURRENT ANESTHESIOLOGY REPORTS 2018; 8:279-289. [PMID: 30147453 PMCID: PMC6096919 DOI: 10.1007/s40140-018-0286-1] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
PURPOSE OF THE REVIEW Severe traumatic brain injury (TBI) continues to represent a global public health issue, and mortality and morbidity in TBI patients remain substantial. There are ongoing international collaborations to provide guidelines for perioperative care and management of severe TBI patients. In addition, new pharmacologic agents are being tested along with cognitive rehabilitation to improve functional independence and outcome in TBI patients. This review will discuss the current updates in the guidelines for the perioperative management of TBI patients and describe potential new therapies to improve functional outcomes. RECENT FINDINGS In the most recent guidelines published by The Brain Trauma Foundation, therapeutic options were reviewed based on new and revised evidence or lack of evidence. For example, changes and/or updates were made to the recommendations for the use of sedation and hypothermia in TBI patients, and new evidence was provided for the use of cerebrospinal fluid drainage as a first-line treatment for increased intracranial pressure (ICP). In addition to the guidelines, new 'multi-potential' agents that can target several mechanisms are being tested along with cognitive rehabilitation. SUMMARY The major goal of perioperative management of TBI patients is to prevent secondary damage. Therapeutic measures based on established guidelines and recommendations must be instituted promptly throughout the perioperative course to reduce morbidity and mortality.
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Affiliation(s)
- Deacon Farrell
- Downstate Medical Center, State University of New York (SUNY), 450 Clarkson Avenue, Box 6, Brooklyn, New York 11203 USA
| | - Audrée A. Bendo
- Downstate Medical Center, State University of New York (SUNY), 450 Clarkson Avenue, Box 6, Brooklyn, New York 11203 USA
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