1
|
Lin JS, Won P, Lin ME, Ayo-Ajibola O, Luu NN, Markarian A, Moayer R. Factors Associated With Head and Neck Polytrauma Presentation and Admissions at Emergency Departments of Varying Sizes. J Craniofac Surg 2024:00001665-990000000-01667. [PMID: 38830051 DOI: 10.1097/scs.0000000000010371] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2023] [Accepted: 05/04/2024] [Indexed: 06/05/2024] Open
Abstract
Timely diagnosis of acute head and neck polytrauma presenting to emergency departments (EDs) optimizes outcomes. Since ED capacity influences triage and admission, the authors utilized the National Electronic Injury Surveillance System database to understand how ED size and trauma characteristics affect head and neck polytrauma presentation and admissions. Demographics and injury characteristics from the National Electronic Injury Surveillance System database from 2018 to 2021 were analyzed to delineate factors contributing to polytrauma presence and admission through multivariable logistic regressions. The authors' 207,951-patient cohort was primarily females (48.6%), non-Hispanic (62.4%), and white (51.4%) people who averaged 57.2 years old. Nonspecific head injuries were predominant (59.7%), followed by facial trauma (22.6%) with rare substance involvement (alcohol, 6.3%; drugs, 4.1%) presenting to high-volume EDs (48.5%). Of the patients, 20% were admitted, whereas 31.1% sustained polytrauma. Substance use [alcohol, odds ratio (OR) = 4.44; drugs, OR = 2.90] increased polytrauma likelihood; neck (OR = 1.35), face (OR = 1.14), and eye (OR = 1.26) associated with polytrauma more than head injuries. Burns (OR = 1.38) increased polytrauma likelihood more than internal organ injuries. Black patients sustained higher polytrauma when presented to non-small EDs (OR = 1.41-1.90) than white patients showed to small EDs. Admissions were higher for males (OR = 1.51). Relative to small EDs, large EDs demonstrated a higher increase in admissions (OR = 2.42). Neck traumas were more likely admitted than head traumas (OR = 1.71). Fractures (OR = 2.21) and burns (OR = 2.71) demonstrated an increased admission likelihood than internal organ injuries. Polytrauma presence and admissions likelihood are site, injury, and substance dependent. Understanding the impact of factors influencing polytrauma presence or admission will enhance triage to optimize outcomes.
Collapse
Affiliation(s)
- Joshua S Lin
- Caruso Department of Otolaryngology-Head and Neck Surgery, Keck School of Medicine, University of Southern California
| | - Paul Won
- Keck School of Medicine, University of Southern California, Los Angeles, CA
| | - Matthew E Lin
- Keck School of Medicine, University of Southern California, Los Angeles, CA
| | | | - Neil N Luu
- Caruso Department of Otolaryngology-Head and Neck Surgery, Keck School of Medicine, University of Southern California
| | - Alexander Markarian
- Caruso Department of Otolaryngology-Head and Neck Surgery, Keck School of Medicine, University of Southern California
| | - Roxana Moayer
- Caruso Department of Otolaryngology-Head and Neck Surgery, Keck School of Medicine, University of Southern California
| |
Collapse
|
2
|
Pilkington C, Thind T, Bowman SM, Sexton K, Kimbrough MK, Porter A, Davis B, Bennett J, Bhavaraju A, Jensen HK. Readmissions After Traumatic Brain Injury in the Nationwide Readmissions Database. J Surg Res 2024; 298:36-40. [PMID: 38552588 DOI: 10.1016/j.jss.2024.02.018] [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: 08/06/2023] [Revised: 01/03/2024] [Accepted: 02/29/2024] [Indexed: 06/03/2024]
Abstract
INTRODUCTION Readmissions after a traumatic brain injury (TBI) can have severe impacts on long-term health outcomes as well as rehabilitation. The aim of this descriptive study was to analyze the Nationwide Readmissions Database to determine possible risk factors associated with readmission for patients who previously sustained a TBI. METHODS This retrospective study used data from the Nationwide Readmissions Database to explore gender, age, injury severity score, comorbidities, index admission hospital size, discharge disposition of the patient, and cause for readmission for adults admitted with a TBI. Multivariable logistic regression was used to assess likelihood of readmission. RESULTS There was a readmission rate of 28.7% (n = 31,757) among the study population. The primary cause of readmission was either subsequent injury or sequelae of the original injury (n = 8825; 29%) followed by circulatory (n = 5894; 19%) and nervous system issues (n = 2904; 9%). There was a significantly higher risk of being readmitted in males (Female odds ratio: 0.87; confidence interval [0.851-0.922), older patients (65-79: 32.3%; > 80: 37.1%), patients with three or more comorbidities (≥ 3: 32.9%), or in patients discharged to a skilled nursing facility/intermediate care facility/rehab (SNF/ICF/Rehab odds ratio: 1.55; confidence interval [0.234-0.262]). CONCLUSIONS This study demonstrates a large proportion of patients are readmitted after sustaining a TBI. A significant number of patients are readmitted for subsequent injuries, circulatory issues, nervous system problems, and infections. Although readmissions cannot be completely avoided, defining at-risk populations is the first step of understanding how to reduce readmissions.
Collapse
Affiliation(s)
- Collin Pilkington
- College of Medicine, University of Arkansas for Medical Sciences, Little Rock, Arkansas
| | - Tarendeep Thind
- College of Medicine, University of Arkansas for Medical Sciences, Little Rock, Arkansas
| | - Stephen M Bowman
- College of Public Health, University of Arkansas for Medical Sciences, Little Rock, Arkansas
| | - Kevin Sexton
- Division of Trauma and Acute Care Surgery, Department of Surgery, University of Arkansas for Medical Sciences, Little Rock, Arkansas
| | - Mary Katherine Kimbrough
- Division of Trauma and Acute Care Surgery, Department of Surgery, University of Arkansas for Medical Sciences, Little Rock, Arkansas
| | - Austin Porter
- College of Public Health, University of Arkansas for Medical Sciences, Little Rock, Arkansas; Office of the Chief Science Officer, Arkansas Department of Health, Little Rock, Arkansas
| | - Ben Davis
- Division of Trauma and Acute Care Surgery, Department of Surgery, University of Arkansas for Medical Sciences, Little Rock, Arkansas
| | - Judy Bennett
- Division of Trauma and Acute Care Surgery, Department of Surgery, University of Arkansas for Medical Sciences, Little Rock, Arkansas
| | - Avi Bhavaraju
- Division of Trauma and Acute Care Surgery, Department of Surgery, University of Arkansas for Medical Sciences, Little Rock, Arkansas
| | - Hanna K Jensen
- Division of Trauma and Acute Care Surgery, Department of Surgery, University of Arkansas for Medical Sciences, Little Rock, Arkansas.
| |
Collapse
|
3
|
Yoon H, Ro YS, Jung E, Moon SB, Park GJ, Lee SGW, Shin SD. Serum Caffeine Concentration at the Time of Traumatic Brain Injury and Its Long-Term Clinical Outcomes. J Neurotrauma 2023; 40:2386-2395. [PMID: 37609786 DOI: 10.1089/neu.2023.0006] [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] [Indexed: 08/24/2023] Open
Abstract
Caffeine is one of the most widely consumed psychoactive drugs in the general population. It has a neuroprotective effect in degenerative neurological disorders; however, the association between caffeine and traumatic brain injury (TBI) outcomes is contradictory. The objective of this study was to evaluate the association between serum caffeine concentration at the time of injury and long-term functional outcomes of patients with TBI visiting the emergency department (ED). This was a prospective multi-center cohort study including adult patients with intracranial injury confirmed by radiological examination, who visited five participating EDs within 72 h after TBI. The main exposure was the serum caffeine level within 4 h after injury, and the study outcome was a favorable functional recovery at 6 months after injury. Multi-variable logistic regression analysis adjusted for potential confounders was performed to calculate adjusted odds ratios (AORs) with 95% confidence intervals (CIs). Among the 334 study participants, caffeine was not detected in 102 patients (30.5 %). In patients with identifiable caffeine level, serum caffeine level was categorized into tercile groups; low (0.01-0.58 μg/mL), intermediate (0.59-1.66 μg/mL), and high (1.67-10.00 μg/mL). The proportions of patients with a 6-month favorable functional recovery were 56.9% in the no-caffeine group, 79.2% in the low-caffeine group, 75.3% in the intermediate-caffeine group, and 66.7% in the high-caffeine group (p = 0.006). In multi-variable logistic regression analysis, the low- and intermediate-caffeine groups were significantly associated with a higher probability of 6-month favorable functional recovery compared with the no-caffeine group [AORs (95% CI): 2.82 (1.32-6.02) and 2.18 (1.06-4.47], respectively. This study showed a significant association between a serum caffeine concentration of 0.01 to 1.66 μg/mL and good functional recovery at 6 months after injury compared with the no-caffeine group of patients with TBI with intracranial injury. These results suggest the possibility of using serum caffeine level as a potential biomarker for TBI outcome prediction and of using caffeine as a therapeutic agent in the clinical care of patients with TBI.
Collapse
Affiliation(s)
- Hanna Yoon
- Department of Emergency Medicine, Seoul National University Hospital, Seoul, Korea
- Laboratory of Emergency Medical Services, Seoul National University Hospital Biomedical Research Institute, Seoul, Korea
| | - Young Sun Ro
- Department of Emergency Medicine, Seoul National University Hospital, Seoul, Korea
- Laboratory of Emergency Medical Services, Seoul National University Hospital Biomedical Research Institute, Seoul, Korea
- Department of Emergency Medicine, Seoul National University College of Medicine, Seoul, Korea
| | - Eujene Jung
- Laboratory of Emergency Medical Services, Seoul National University Hospital Biomedical Research Institute, Seoul, Korea
- Department of Emergency Medicine, Chonnam National University Hospital, Gwangju, Korea
| | - Sung Bae Moon
- Laboratory of Emergency Medical Services, Seoul National University Hospital Biomedical Research Institute, Seoul, Korea
- Department of Emergency Medicine, School of Medicine Kyungpook National University and Kyungpook National University Hospital, Daegu, Korea
| | - Gwan Jin Park
- Laboratory of Emergency Medical Services, Seoul National University Hospital Biomedical Research Institute, Seoul, Korea
- Department of Emergency Medicine, Chungbuk National University Hospital, Cheongju, Korea
| | - Stephen Gyung Won Lee
- Laboratory of Emergency Medical Services, Seoul National University Hospital Biomedical Research Institute, Seoul, Korea
- Department of Emergency Medicine, Seoul National University Boramae Medical Center, Seoul, Korea
| | - Sang Do Shin
- Department of Emergency Medicine, Seoul National University Hospital, Seoul, Korea
- Department of Emergency Medicine, Seoul National University College of Medicine, Seoul, Korea
| |
Collapse
|
4
|
Pappadis MR, Malagaris I, Kuo YF, Leland N, Freburger J, Goodwin JS. Care patterns and predictors of community residence among older patients after hospital discharge for traumatic brain injury. J Am Geriatr Soc 2023; 71:1806-1818. [PMID: 36840390 PMCID: PMC10330166 DOI: 10.1111/jgs.18308] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2022] [Revised: 12/27/2022] [Accepted: 12/31/2022] [Indexed: 02/26/2023]
Abstract
BACKGROUND An increasing number of older adults with traumatic brain injury (TBI) require hospitalization, but it is unknown whether they return to their community following discharge. We examined community residence following acute hospital discharge for TBI in Texas and identified factors associated with 90-day community residence and readmission. METHODS We conducted a retrospective cohort study using 100% Texas Medicare claims data of patients older than 65 years hospitalized for a TBI from January 1, 2014, through December 31, 2017, and followed for 20 weeks after discharge. Discharges to short-term and long-term acute hospital, inpatient rehabilitation facility (IRF), skilled nursing facility (SNF), long-term nursing home (NH), and hospice were identified. The primary outcome was 90-day community residence. Our secondary outcome was 90-day, all-cause readmission. RESULTS In Texas, 26,985 Medicare fee-for-service patients were hospitalized for TBI (Racial and ethnic minorities: 21.1%; Females 57.3%). At 90 days and 20 weeks following discharge, 80% and 84% were living in the community respectively. Female sex (OR = 1.16 [1.08-1.25]), Hispanic ethnicity (OR = 2.01 [1.80-2.25]), "other" race (OR = 2.19 [1.73-2.77]), and prior primary care provider (PCP; OR = 1.51 [1.40-1.62]) were associated with increased likelihood of 90-day community residence. Patients aged 75+, prior NH residence, dual eligibility, prior TBI diagnosis, and moderate-to-severe injury severity were associated with decreased likelihood of 90-day community residence. Being non-Hispanic Black (HR = 1.33 [1.20-1.46]), discharge to SNF (HR = 1.56 [1.48-1.65]) or IRF (HR = 1.49 [1.40-1.59]), having prior PCP (HR = 1.23 [1.17-1.30]), dual eligibility (HR = 1.11 [1.04-1.18]), and prior TBI diagnosis (HR = 1.05 [1.01-1.10]) were associated with increased risk of 90-day readmission. Female sex and "other" race were associated with decreased risk of 90-day readmission. CONCLUSIONS Most older adults with TBI return to the community following hospital discharge. Disparities exist in returning to the community and in risk of 90-day readmission following hospital discharge. Future studies should explore how having a PCP influences post-hospital outcomes in chronic care management of older patients with TBI.
Collapse
Affiliation(s)
- Monique R. Pappadis
- Department of Population Health and Health Disparities, School of Public and Population Health, University of Texas Medical Branch (UTMB) at Galveston, Galveston, TX, USA
- Sealy Center on Aging, UTMB, Galveston, TX, USA
| | - Ioannis Malagaris
- Department of Biostatistics and Data Science, School of Public and Population Health, UTMB, Galveston, TX, USA
| | - Yong-Fang Kuo
- Sealy Center on Aging, UTMB, Galveston, TX, USA
- Department of Biostatistics and Data Science, School of Public and Population Health, UTMB, Galveston, TX, USA
| | - Natalie Leland
- Department of Occupational Therapy, School of Health and Rehabilitation Sciences, University of Pittsburgh, Pittsburgh, PA
| | - Janet Freburger
- Department of Physical Therapy, School of Health and Rehabilitation Sciences, University of Pittsburgh, Pittsburgh, PA
| | - James S. Goodwin
- Sealy Center on Aging, UTMB, Galveston, TX, USA
- Department of Internal Medicine, Division of Geriatrics, School of Medicine, UTMB, Galveston, TX
| |
Collapse
|
5
|
Totman AA, Lamm AG, Goldstein R, Giacino JT, Bodien YG, Ryan CM, Schneider JC, Zafonte R. Longitudinal Trends in Severe Traumatic Brain Injury Inpatient Rehabilitation. J Head Trauma Rehabil 2023; 38:E186-E194. [PMID: 36730991 PMCID: PMC10102246 DOI: 10.1097/htr.0000000000000814] [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] [Indexed: 02/04/2023]
Abstract
OBJECTIVE The goal of this study is to describe national trends in inpatient rehabilitation facility (IRF) discharges for the most severely disabled cohort of patients with traumatic brain injury (TBI). METHODS Data from the Uniform Data System for Medical Rehabilitation for patients discharged from an IRF between January 1, 2002, and December 31, 2017, with a diagnosis of TBI and an admission Functional Independence Measure of 18, the lowest possible score, were obtained and analyzed. RESULTS Of the 252 112 patients with TBI discharged during the study period, 10 098 met the study criteria. From 2002 to 2017, the number of patients with an IRF admission Functional Independence Measure of 18 following TBI discharged from IRFs annually decreased from 649 to 488, modeled by a negative regression (coefficient = -2.97; P = .001), and the mean age (SD) increased from 43.0 (21.0) to 53.7 (21.3) years (coefficient = 0.70; P < .001). During the study period, the number of patients with the most severe disability on admission to IRF who were discharged annually as a proportion of total patients with TBI decreased from 5.5% to 2.5% (odds ratio = 0.95; P < .001) and their mean length of stay decreased from 41.5 (36.2) to 29.3 (24.9) days (coefficient = -0.83; P < .001]. CONCLUSION The number and proportion of patients with the most severe disability on IRF admission following TBI who are discharged from IRFs is decreasing over time. This may represent a combination of primary prevention, early mortality due to withdrawal of life-sustaining treatment, alternative discharge dispositions, or changes in admitting and reimbursement practices. Furthermore, there has been a decrease in the duration of IRF level care for these individuals, which could ultimately lead to poorer functional outcomes, particularly given the importance of specialized rehabilitative care in this population.
Collapse
Affiliation(s)
- Alissa A Totman
- Spaulding Rehabilitation Hospital, Charlestown, Massachusetts (Drs Totman, Goldstein, Giacino, Bodien, Ryan, Schneider, and Zafonte); Department of Physical Medicine and Rehabilitation, Harvard Medical School, Boston, Massachusetts (Drs Totman, Goldstein, Giacino, Bodien, Ryan, Schneider, and Zafonte); Mary Free Bed Rehabilitation Hospital, Grand Rapids, Michigan (Dr Lamm); Massachusetts General Hospital, Boston, Massachusetts (Drs Giacino, Ryan, and Zafonte); Shriners Hospitals for Children, Boston, Massachusetts (Dr Ryan); and Brigham and Women's Hospital, Boston, Massachusetts (Dr Zafonte)
| | | | | | | | | | | | | | | |
Collapse
|
6
|
Baghdadi F, Evans BA, Goodacre S, John PA, Hettiarachchi T, John A, Lyons RA, Porter A, Safari S, Siriwardena AN, Snooks H, Watkins A, Williams J, Khanom A. Building an understanding of Ethnic minority people's Service Use Relating to Emergency care for injuries: the BE SURE study protocol. BMJ Open 2023; 13:e069596. [PMID: 37185177 PMCID: PMC10151843 DOI: 10.1136/bmjopen-2022-069596] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/17/2023] Open
Abstract
INTRODUCTION Injuries are a major public health problem which can lead to disability or death. However, little is known about the incidence, presentation, management and outcomes of emergency care for patients with injuries among people from ethnic minorities in the UK. The aim of this study is to investigate what may differ for people from ethnic minorities compared with white British people when presenting with injury to ambulance and Emergency Departments (EDs). METHODS AND ANALYSIS This mixed methods study covers eight services, four ambulance services (three in England and one in Scotland) and four hospital EDs, located within each ambulance service. The study has five Work Packages (WP): (WP1) scoping review comparing mortality by ethnicity of people presenting with injury to emergency services; (WP2) retrospective analysis of linked NHS routine data from patients who present to ambulances or EDs with injury over 5 years (2016-2021); (WP3) postal questionnaire survey of 2000 patients (1000 patients from ethnic minorities and 1000 white British patients) who present with injury to ambulances or EDs including self-reported outcomes (measured by Quality of Care Monitor and Health Related Quality of Life measured by SF-12); (WP4) qualitative interviews with patients from ethnic minorities (n=40) and focus groups-four with asylum seekers and refugees and four with care providers and (WP5) a synthesis of quantitative and qualitative findings. ETHICS AND DISSEMINATION This study received a favourable opinion by the Wales Research Ethics Committee (305391). The Health Research Authority has approved the study and, on advice from the Confidentiality Advisory Group, has supported the use of confidential patient information without consent for anonymised data. Results will be shared with ambulance and ED services, government bodies and third-sector organisations through direct communications summarising scientific conference proceedings and publications.
Collapse
Affiliation(s)
| | | | - Steve Goodacre
- School of Health and Health Related Research, University of Sheffield, Sheffield, UK
| | - Paul Anthony John
- Research and Innovation Hub, Scottish Ambulance Service, Edinburgh, UK
| | | | - Ann John
- Medical School, Swansea University, Swansea, UK
| | | | | | - Solmaz Safari
- Public Contributor, c/o Medical School, Swansea University, Swansea, UK
| | | | | | | | - Julia Williams
- School of Health and Social Work, University of Hertfordshire, Hertfordshire, UK
| | | |
Collapse
|
7
|
Miles G, Shank C, Quinlan A, Cavender J. Process improvement using telemedicine consultation to prevent unnecessary interfacility transfers for low-severity blunt head trauma. BMJ Open Qual 2023; 12:bmjoq-2022-002012. [PMID: 36941010 PMCID: PMC10030876 DOI: 10.1136/bmjoq-2022-002012] [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: 06/09/2022] [Accepted: 03/01/2023] [Indexed: 03/22/2023] Open
Abstract
OBJECTIVE Mild traumatic brain injuries (MTBI) associated with intracranial haemorrhage are commonly transferred to tertiary care centres. Recent studies have shown that transfers for low-severity traumatic brain injuries may be unnecessary. Trauma systems can be overwhelmed by low acuity patients justifying standardisation of MTBI transfers. We sought to evaluate the impact of telemedicine services on mitigating unnecessary transfers for those presenting with low-severity blunt head trauma after sustaining a ground level fall (GLF). METHOD A process improvement plan was developed by a task force of transfer centre (TC) administrators, emergency department physicians (EDP), trauma surgeons and neurosurgeons (NS) to facilitate the requesting EDP and the NS on-call to converse directly to mitigate unnecessary transfers. Consecutive retrospective chart review was performed on neurosurgical transfer requests between 1 January 2021 and 31 January 2022. A comparison of transfers preintervention and postintervention (1 January 2021 to 12 September 2021)/(13 September 2021 to 31 January 2022) was performed. RESULTS The TC received 1091 neurological-based transfer requests during the study period (preintervention group: 406 neurosurgical requests; postintervention group: 353 neurosurgical requests). After consultation with the NS on-call, the number of MTBI patients remaining at their respective ED's with no neurological degradation more than doubled from 15 in the preintervention group to 37 in the postintervention group. CONCLUSION TC-mediated telemedicine conversations between the NS and the referring EDP can prevent unnecessary transfers for stable MTBI patients sustaining a GLF if needed. Outlying EDPs should be educated on this process to increase efficacy.
Collapse
Affiliation(s)
- Gayla Miles
- Trauma, Texas Health Harris Methodist Hospital Fort Worth, Fort Worth, Texas, USA
| | - Christopher Shank
- Neuro-Trauma, Texas Health Harris Methodist Hospital Fort Worth, Fort Worth, Texas, USA
| | - Ann Quinlan
- Trauma, Texas Health Harris Methodist Hospital Fort Worth, Fort Worth, Texas, USA
| | | |
Collapse
|
8
|
Flaherty S, Biswas S, Watts DD, Wilson NY, Shen Y, Garland JM, Wyse RJ, Lieser MJ, Duane TM, Offner PJ, Love JD, Shillinglaw WC, Hunt DL, Gauny RW, Fakhry SM, Curcio GJ, Gilligan D, Taylor DA, Hughes F, Barker RJ, Bissinger CM, Miller CJ, Harbour LF, Duane TM, Carrick MM, Lieser MJ, Flaherty S, Blair V, Perez J, Cervantes C, Hogan C, Ruiz CR, Tinti M, Romero CA, Jones KJ, Neeley T, Wright K, Dunne J, Eversley-Kelso T, Harte MA, Kline RA, Love JD, van Doorn E, Brock CM, Acuna DL, Shaddix JL, Rhodes H, Biswas S, Shillinglaw WC, Slivinski A, Offner PJ, Levine JH, Banton KL, Katubig B. Findings on Repeat Posttraumatic Brain Computed Tomography Scans in Older Patients With Minimal Head Trauma and the Impact of Existing Antithrombotic Use. Ann Emerg Med 2023; 81:364-374. [PMID: 36328853 DOI: 10.1016/j.annemergmed.2022.08.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2022] [Revised: 07/20/2022] [Accepted: 08/02/2022] [Indexed: 11/11/2022]
Abstract
STUDY OBJECTIVE Evaluate the utility of routine rescanning of older, mild head trauma patients with an initial negative brain computed tomography (CT), who is on a preinjury antithrombotic (AT) agent by assessing the rate of delayed intracranial hemorrhage (dICH), need for surgery, and attributable mortality. METHODS Participating centers were trained and provided data collection instruments per institutional review board-approved protocols. Data were obtained from manual chart review and electronic medical record download. Adults ≥55 years seen at Level I/II Trauma Centers, between 2017 and 2019 with suspected head trauma, Glasgow Coma Scale 14 to 15, negative initial brain CT, and no other Abbreviated Injury Scale injuries >2 were identified, grouped by preinjury AT therapy (AT- or AT+) and compared on dICH rate, need for operative neurosurgical intervention, and attributable mortality using univariate analysis (α=.05). RESULTS A total of 2,950 patients from 24 centers were enrolled; 280 (9.5%) had a repeat brain CT. In those rescanned, the dICH rate was 15/126 (11.9%) for AT- and 6/154 (3.9%) in AT+. Assuming nonrescanned patients did not suffer clinically meaningful dICH, the dICH rate would be 15/2001 (0.7%) for AT- and 6/949 (0.6%) for AT+. No surgical operations were done for dICH. All-cause mortality was 9/2950 (0.3%) and attributable mortality was 1/2950 (0.03%). The attributable death was an AT+, dICH patient whose family declined intervention. CONCLUSION In older patients with an initial Glasgow Coma Scale of 14 to 15 and a negative initial brain CT scan, the dICH rate is low (<1%) and of minimal clinical consequence, regardless of AT use. In addition, no patient had operative neurosurgical intervention. Therefore, routine rescanning is not supported based on the results of this study.
Collapse
Affiliation(s)
| | | | - Dorraine D Watts
- Center for Trauma and Acute Care Surgery Research, Clinical Services Group, HCA Healthcare, Nashville, TN
| | - Nina Y Wilson
- Center for Trauma and Acute Care Surgery Research, Clinical Services Group, HCA Healthcare, Nashville, TN
| | - Yan Shen
- Center for Trauma and Acute Care Surgery Research, Clinical Services Group, HCA Healthcare, Nashville, TN
| | - Jeneva M Garland
- Center for Trauma and Acute Care Surgery Research, Clinical Services Group, HCA Healthcare, Nashville, TN
| | - Ransom J Wyse
- Center for Trauma and Acute Care Surgery Research, Clinical Services Group, HCA Healthcare, Nashville, TN
| | - Mark J Lieser
- Department of Trauma Surgery, Research Medical Center, Kansas City, MO
| | | | | | - Joseph D Love
- Department of Surgery, Regional Medical Center Bayonet Point, Hudson, FL
| | | | - Darrell L Hunt
- Department of Surgery, TriStar Skyline Medical Center, Nashville, TN
| | - Randy W Gauny
- Trauma Services, HCA Houston Healthcare Conroe, Conroe, TX
| | - Samir M Fakhry
- Center for Trauma and Acute Care Surgery Research, Clinical Services Group, HCA Healthcare, Nashville, TN.
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
9
|
Do TH, Lu J, Palzer EF, Cramer SW, Huling JD, Johnson RA, Zhu P, Jean JN, Howard MA, Sabal LT, Hanson JT, Jonason AB, Sun KW, McGovern RA, Chen CC. Rates of operative intervention for infection after synthetic or autologous cranioplasty: a National Readmissions Database analysis. J Neurosurg 2023; 138:514-521. [PMID: 35901766 DOI: 10.3171/2022.4.jns22301] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2022] [Accepted: 04/05/2022] [Indexed: 02/04/2023]
Abstract
OBJECTIVE The aim of this study was to characterize the clinical utilization and associated charges of autologous bone flap (ABF) versus synthetic flap (SF) cranioplasty and to characterize the postoperative infection risk of SF versus ABF using the National Readmissions Database (NRD). METHODS The authors used the publicly available NRD to identify index hospitalizations from October 2015 to December 2018 involving elective ABF or SF cranioplasty after traumatic brain injury (TBI) or stroke. Subsequent readmissions were further characterized if patients underwent neurosurgical intervention for treatment of infection or suspected infection. Survey Cox proportional hazards models were used to assess risk of readmission. RESULTS An estimated 2295 SF and 2072 ABF cranioplasties were performed from October 2015 to December 2018 in the United States. While the total number of cranioplasty operations decreased during the study period, the proportion of cranioplasties utilizing SF increased (p < 0.001), particularly in male patients (p = 0.011) and those with TBI (vs stroke, p = 0.012). The median total hospital charge for SF cranioplasty was $31,200 more costly than ABF cranioplasty (p < 0.001). Of all first-time readmissions, 20% involved surgical treatment for infectious reasons. Overall, 122 SF patients (5.3%) underwent surgical treatment of infection compared with 70 ABF patients (3.4%) on readmission. After accounting for confounders using a multivariable Cox model, female patients (vs male, p = 0.003), those discharged nonroutinely (vs discharge to home or self-care, p < 0.001), and patients who underwent SF cranioplasty (vs ABF, p = 0.011) were more likely to be readmitted for reoperation. Patients undergoing cranioplasty during more recent years (e.g., 2018 vs 2015) were less likely to be readmitted for reoperation because of infection (p = 0.024). CONCLUSIONS SFs are increasingly replacing ABFs as the material of choice for cranioplasty, despite their association with increased hospital charges. Female sex, nonroutine discharge, and SF cranioplasty are associated with increased risk for reoperation after cranioplasty.
Collapse
Affiliation(s)
- Truong H Do
- 1Department of Neurological Surgery, University of Minnesota
| | - Jinci Lu
- 3University of Minnesota Medical School, Minneapolis, Minnesota
| | - Elise F Palzer
- 2School of Public Health, Division of Biostatistics, University of Minnesota; and
| | - Samuel W Cramer
- 1Department of Neurological Surgery, University of Minnesota
| | - Jared D Huling
- 2School of Public Health, Division of Biostatistics, University of Minnesota; and
| | - Reid A Johnson
- 3University of Minnesota Medical School, Minneapolis, Minnesota
| | - Ping Zhu
- 1Department of Neurological Surgery, University of Minnesota
| | - James N Jean
- 1Department of Neurological Surgery, University of Minnesota
| | | | - Luke T Sabal
- 3University of Minnesota Medical School, Minneapolis, Minnesota
| | - Jacob T Hanson
- 1Department of Neurological Surgery, University of Minnesota
| | - Alec B Jonason
- 1Department of Neurological Surgery, University of Minnesota
| | - Kevin W Sun
- 1Department of Neurological Surgery, University of Minnesota
| | | | - Clark C Chen
- 1Department of Neurological Surgery, University of Minnesota
| |
Collapse
|
10
|
Orlando A, Coresh J, Carrick MM, Quan G, Berg GM, Dhakal L, Hamilton D, Madayag R, Lascano CHP, Bar-Or D. Significant National Declines in Neurosurgical Intervention for Mild Traumatic Brain Injury with Intracranial Hemorrhage: A 13-Year Review of the National Trauma Data Bank. Neurotrauma Rep 2023; 4:137-148. [PMID: 36941880 PMCID: PMC10024583 DOI: 10.1089/neur.2022.0077] [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] [Indexed: 03/19/2023] Open
Abstract
There have been large changes over the past several decades to patient demographics in those presenting with mild traumatic brain injury (mTBI) with intracranial hemorrhage (ICH; complicated mTBI) with the potential to affect the use of neurosurgical interventions. The objective of this study was to characterize long-term trends of neurosurgical interventions in patients with complicated mTBI using 13 years of the National Trauma Data Bank (NTDB). This was a retrospective cohort study of adult (≥18 years) trauma patients included in the NTDB from 2007 to 2019 who had an emergency department Glasgow Coma Scale score 13-15, an intracranial hemorrhage (ICH), and no skull fracture. Neurosurgical intervention time trends were quantified for each ICH type using mixed-effects logistic regression with random slopes and intercepts for hospitals, as well as covariates for time and 14 demographic, injury, and hospital characteristics. In total, 666,842 ICH patients across 1060 hospitals were included. The four most common hemorrhages were isolated subdural hemorrhage (36%), isolated subarachnoid hemorrhage (24%), multiple hemorrhage types (24%), and isolated unspecified hemorrhages (9%). Overall, 49,220 (7%) patients received a neurosurgical intervention. After adjustment, the odds of neurosurgical intervention significantly decreased every 10 years by the following odds ratios (odds ratio [95% confidence interval]): 0.85 [0.78, 0.93] for isolated subdural, 0.63 [0.51, 0.77] for isolated subarachnoid, 0.50 [0.41, 0.62] for isolated unspecified, and 0.79 [0.73, 0.86] for multiple hemorrhages. There were no significant temporal trends in neurosurgical intervention odds for isolated epidural hemorrhages (0.87 [0.68, 1.12]) or isolated contusions/lacerations (1.03 [0.75, 1.41]). In the setting of complicated mTBI, the four most common ICH types were associated with significant declines in the odds of neurosurgical intervention over the past decade. It remains unclear whether changing hemorrhage characteristics or practice patterns drove these trends.
Collapse
Affiliation(s)
- Alessandro Orlando
- Johns Hopkins Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland, USA
- Address correspondence to: Alessandro Orlando, PhD, MPH, Johns Hopkins Bloomberg School of Public Health, Johns Hopkins University, 501 E. Hampden Avenue, Englewood, CO 80443, USA;
| | - Josef Coresh
- Johns Hopkins Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland, USA
| | | | - Glenda Quan
- Swedish Medical Center, Englewood, Colorado, USA
| | | | | | | | | | | | - David Bar-Or
- Medical City Plano, Plano, Texas, USA
- Swedish Medical Center, Englewood, Colorado, USA
- Wesley Medical Center, Wichita, Kansas, USA
- Penrose Hospital, Colorado Springs, Colorado, USA
- St. Anthony Hospital, Lakewood, Colorado, USA
- South Texas Health System McAllen, McAllen, Texas, USA
| |
Collapse
|
11
|
Oyesanya TO, Cary MP, Harris Walker G, Yang Q, Byom L, Prvu Bettger J. Sex and Racial/Ethnic Differences in Within-Stay Readmissions During Inpatient Rehabilitation Among Patients With Traumatic Brain Injury. Am J Phys Med Rehabil 2022; 101:1129-1133. [PMID: 35302952 PMCID: PMC9463395 DOI: 10.1097/phm.0000000000001997] [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] [Indexed: 02/04/2023]
Abstract
OBJECTIVE The aim of the study was to determine the association of sex and race/ethnicity with acute hospital readmissions ("within-stay readmissions") during inpatient rehabilitation facility care versus patients discharged home without a within-stay readmission among traumatic brain injury patients. DESIGN The study used a secondary analysis ( N = 210,440) of Uniform Data System for Medical Rehabilitation data using multiple logistic regression. RESULTS Within-stay readmissions occurred for 11.79% of female and 11.77% of male traumatic brain injury patients. Sex-specific models identified insurance, comorbidities, and complications factored differently in likelihood of within-stay readmissions among female than male patients but association of all other factors were similar per group. Within-stay readmissions differences were more pronounced by race/ethnicity: White, 11.63%; Black, 11.32%; Hispanic/Latino, 9.78%; and other, 10.61%. Descriptive bivariate analysis identified racial/ethnic patients with within-stay readmissions had greater days from traumatic brain injury to inpatient rehabilitation facility admission (White, 17.66; Black, 21.70; Hispanic/Latino, 23.81; other, 20.66) and lower admission cognitive and motor function. Factors differed across models predicting within-stay readmissions for race/ethnic groups; age, admission motor and cognitive function, complications, and length of stay were consistent across groups. CONCLUSIONS This study demonstrates disparities by race/ethnicity for inpatient rehabilitation facility within-stay readmissions among traumatic brain injury patients and factors predictive of this potentially preventable outcome by sex and race/ethnicity. Findings could inform care planning and quality improvement efforts for TBI patients.
Collapse
Affiliation(s)
| | | | | | | | - Lindsey Byom
- University of North Carolina-Chapel Hill, Department of Allied Health Sciences
| | | |
Collapse
|
12
|
Alipour M, Tebianian M, Tofigh N, Taheri RS, Mousavi SA, Naseri A, Ahmadi A, Munawar N, Shahpasand K. Active immunotherapy against pathogenic Cis pT231-tau suppresses neurodegeneration in traumatic brain injury mouse models. Neuropeptides 2022; 96:102285. [PMID: 36087426 DOI: 10.1016/j.npep.2022.102285] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/31/2022] [Revised: 08/22/2022] [Accepted: 08/25/2022] [Indexed: 10/14/2022]
Abstract
Traumatic brain injury (TBI), characterized by acute neurological impairment, is associated with a higher incidence of neurodegenerative diseases, particularly chronic traumatic encephalopathy (CTE), Alzheimer's disease (AD), and Parkinson's disease (PD), whose hallmarks include hyperphosphorylated tau protein. Recently, phosphorylated tau at Thr231 has been shown to exist in two distinct cis and trans conformations. Moreover, targeted elimination of cis P-tau by passive immunotherapy with an appropriate mAb that efficiently suppresses tau-mediated neurodegeneration in severe TBI mouse models has proven to be a useful tool to characterize the neurotoxic role of cis P-tau as an early driver of the tauopathy process after TBI. Here, we investigated whether active immunotherapy can develop sufficient neutralizing antibodies to specifically target and eliminate cis P-tau in the brain of TBI mouse models. First, we explored the therapeutic efficacy of two different vaccines. C57BL/6 J mice were immunized with either cis or trans P-tau conformational peptides plus adjuvant. After rmTBI in mice, we found that cis peptide administration developed a specific Ab that precisely targeted and neutralized cis P-tau, inhibited the development of neuropathology and brain dysfunction, and restored various structural and functional sequelae associated with TBI in chronic phases. In contrast, trans P-tau peptide application not only lacked neuroprotective properties, but also contributed to a number of neuropathological features, including progressive TBI-induced neuroinflammation, widespread tau-mediated neurodegeneration, worsening functional deficits, and brain atrophy. Taken together, our results suggest that active immunotherapy strategies against pathogenic cis P-tau can halt the process of tauopathy and would have profound clinical implications.
Collapse
Affiliation(s)
- Masoume Alipour
- Department of Brain and Cognitive Sciences, Cell Science Research Center, Royan Institute for Stem Cell Biology and Technology, ACECR, Tehran, Iran; Faculty of Basic Science and Advanced Medical Technologies, Royan Institute, ACECR, Tehran, Iran
| | - Majid Tebianian
- Biotechnology Department, Razi Vaccine and Serum Research Institute, Agricultural Research Education and Extension Organization (AREEO), Karaj, Iran
| | - Nahid Tofigh
- Department of Brain and Cognitive Sciences, Cell Science Research Center, Royan Institute for Stem Cell Biology and Technology, ACECR, Tehran, Iran
| | - Reyhaneh Sadat Taheri
- Department of Motor Behavior, Faculty of Physical Education and Sport Sciences, Allameh Tabataba'i University, Tehran, Iran
| | - Sayed Alireza Mousavi
- Department of Biology, Faculty of Basic Science, Science and Research Branch, Islamic Azad University, Tehran, Iran
| | - Asal Naseri
- Department of Biology, Faculty of Basic Science, Science and Research Branch, Islamic Azad University, Tehran, Iran
| | - Amin Ahmadi
- Department of Biomedical Sciences, Tabriz Medical University, Tabriz, Iran
| | - Nayla Munawar
- Department of Chemistry, United Arab Emirates University, United Arab Emirates
| | - Koorosh Shahpasand
- Department of Brain and Cognitive Sciences, Cell Science Research Center, Royan Institute for Stem Cell Biology and Technology, ACECR, Tehran, Iran.
| |
Collapse
|
13
|
Zhao JL, Song J, Yuan Q, Bao YF, Sun YR, Li ZQ, Xi CH, Yao HJ, Wang MH, Wu G, Du ZY, Hu J, Yu J. Characteristics and therapeutic profile of TBI patients who underwent bilateral decompressive craniectomy: experience with 151 cases. Scand J Trauma Resusc Emerg Med 2022; 30:59. [PMCID: PMC9670501 DOI: 10.1186/s13049-022-01046-w] [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: 05/29/2022] [Accepted: 11/08/2022] [Indexed: 11/18/2022] Open
Abstract
Background Decompressive craniectomy (DC) and intracranial pressure (ICP) monitoring are common approaches to reduce the death rate of Traumatic brain injury (TBI) patients, but the outcomes of these patients are unfavorable, particularly those who receive bilateral DC. The authors discuss their experience using ICP and other potential methods to improve the outcomes of TBI patients who receive bilateral DC. Methods Data from TBI patients receiving bilateral DC from Jan. 2008 to Jan. 2022 were collected via a retrospective chart review. Included patients who received unplanned contralateral DC after initial surgery were identified as unplanned secondary surgery (USS) patients. Patients’ demographics and baseline medical status; pre-, intra-, and postoperative events; and follow-up visit outcome data were analyzed. Results A total of 151 TBI patients were included. Patients who underwent USS experienced more severe outcomes as assessed using the 3-month modified Rankin Scale score (P = 0.024). In bilateral DC TBI patients, USS were associated with worsen outcomes, moreover, ICP monitoring was able to lower their death rate and was associated with a lower USS incidence. In USS patients, ICP monitoring was not associated with improved outcomes but was able to lower their mortality rate (2/19, 10.5%, vs. 10/25, 40.0%; P = 0.042). Conclusion The avoidance of USS may be associated with improved outcomes of TBI patients who underwent bilateral DC. ICP monitoring was a potential approach to lower USS rate in TBI patients, but its specific benefits were uncertain. Supplementary Information The online version contains supplementary material available at 10.1186/s13049-022-01046-w.
Collapse
Affiliation(s)
- Jian-Lan Zhao
- grid.8547.e0000 0001 0125 2443Department of Neurosurgery, National Center for Neurological Disorders, Neurosurgical Institute of Fudan University, Shanghai Clinical Medical Center of Neurosurgery, Shanghai Key Laboratory of Brain Function and Restoration and Neural Regeneration, Huashan Hospital, Fudan University, 12 Wulumuqi Zhong Road, Shanghai, 200040 China
| | - Jie Song
- grid.8547.e0000 0001 0125 2443Department of Neurosurgery and Neurocritical Care, Huashan Hospital, Fudan University, Shanghai, 200040 China
| | - Qiang Yuan
- grid.8547.e0000 0001 0125 2443Department of Neurosurgery, National Center for Neurological Disorders, Neurosurgical Institute of Fudan University, Shanghai Clinical Medical Center of Neurosurgery, Shanghai Key Laboratory of Brain Function and Restoration and Neural Regeneration, Huashan Hospital, Fudan University, 12 Wulumuqi Zhong Road, Shanghai, 200040 China
| | - Yi-Feng Bao
- grid.8547.e0000 0001 0125 2443Department of Neurosurgery, National Center for Neurological Disorders, Neurosurgical Institute of Fudan University, Shanghai Clinical Medical Center of Neurosurgery, Shanghai Key Laboratory of Brain Function and Restoration and Neural Regeneration, Huashan Hospital, Fudan University, 12 Wulumuqi Zhong Road, Shanghai, 200040 China
| | - Yi-Rui Sun
- grid.8547.e0000 0001 0125 2443Department of Neurosurgery, National Center for Neurological Disorders, Neurosurgical Institute of Fudan University, Shanghai Clinical Medical Center of Neurosurgery, Shanghai Key Laboratory of Brain Function and Restoration and Neural Regeneration, Huashan Hospital, Fudan University, 12 Wulumuqi Zhong Road, Shanghai, 200040 China
| | - Zhi-Qi Li
- grid.8547.e0000 0001 0125 2443Department of Neurosurgery, National Center for Neurological Disorders, Neurosurgical Institute of Fudan University, Shanghai Clinical Medical Center of Neurosurgery, Shanghai Key Laboratory of Brain Function and Restoration and Neural Regeneration, Huashan Hospital, Fudan University, 12 Wulumuqi Zhong Road, Shanghai, 200040 China
| | - Cai-Hua Xi
- grid.8547.e0000 0001 0125 2443Department of Neurosurgery and Neurocritical Care, Huashan Hospital, Fudan University, Shanghai, 200040 China
| | - Hai-Jun Yao
- grid.8547.e0000 0001 0125 2443Department of Neurosurgery and Neurocritical Care, Huashan Hospital, Fudan University, Shanghai, 200040 China
| | - Mei-Hua Wang
- grid.8547.e0000 0001 0125 2443Department of Neurosurgery and Neurocritical Care, Huashan Hospital, Fudan University, Shanghai, 200040 China
| | - Gang Wu
- grid.8547.e0000 0001 0125 2443Department of Neurosurgery, National Center for Neurological Disorders, Neurosurgical Institute of Fudan University, Shanghai Clinical Medical Center of Neurosurgery, Shanghai Key Laboratory of Brain Function and Restoration and Neural Regeneration, Huashan Hospital, Fudan University, 12 Wulumuqi Zhong Road, Shanghai, 200040 China
| | - Zhuo-Ying Du
- grid.8547.e0000 0001 0125 2443Department of Neurosurgery, National Center for Neurological Disorders, Neurosurgical Institute of Fudan University, Shanghai Clinical Medical Center of Neurosurgery, Shanghai Key Laboratory of Brain Function and Restoration and Neural Regeneration, Huashan Hospital, Fudan University, 12 Wulumuqi Zhong Road, Shanghai, 200040 China
| | - Jin Hu
- grid.8547.e0000 0001 0125 2443Department of Neurosurgery, National Center for Neurological Disorders, Neurosurgical Institute of Fudan University, Shanghai Clinical Medical Center of Neurosurgery, Shanghai Key Laboratory of Brain Function and Restoration and Neural Regeneration, Huashan Hospital, Fudan University, 12 Wulumuqi Zhong Road, Shanghai, 200040 China ,grid.8547.e0000 0001 0125 2443Department of Neurosurgery and Neurocritical Care, Huashan Hospital, Fudan University, Shanghai, 200040 China
| | - Jian Yu
- grid.8547.e0000 0001 0125 2443Department of Neurosurgery, National Center for Neurological Disorders, Neurosurgical Institute of Fudan University, Shanghai Clinical Medical Center of Neurosurgery, Shanghai Key Laboratory of Brain Function and Restoration and Neural Regeneration, Huashan Hospital, Fudan University, 12 Wulumuqi Zhong Road, Shanghai, 200040 China
| |
Collapse
|
14
|
Cheng Y, Zhang Y, Zhang Y, Wu YH, Zhang S. Reliability and validity of the Rowland Universal Dementia Assessment Scale for patients with traumatic brain injury. APPLIED NEUROPSYCHOLOGY. ADULT 2022; 29:1160-1166. [PMID: 33321049 DOI: 10.1080/23279095.2020.1856850] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
Objective and accurate cognitive assessment scales are essential for guiding cognitive rehabilitation following traumatic brain injury (TBI). The aim of this study was to evaluate the reliability and validity of the Rowland Universal Dementia Assessment Scale (RUDAS) for TBI and to verify the clinical application value. Fifty patients with TBI and 32 matched controls were assessed using the Mini-Mental State Examination (MMSE), Montreal Cognitive Assessment (MoCA), and a newly developed Chinese version of RUDAS. These scales were then compared for internal consistency, inter-rater reliability, test‒retest reliability, content validity, construct validity, and diagnostic efficacy. Among the TBI group, the RUDAS demonstrated acceptable internal consistency (Cronbach's α = 0.733), high inter-rater reliability (intraclass correlation coefficients [ICCs] of 0.910‒0.999), and high test‒retest reliability (total score ICC = 0.938). The correlation coefficients between RUDAS total score and individual subscores were all > 0.5 except for body orientation (r = 0.363), indicating generally good content validity. Total RUDAS scores were moderately correlated with both MMSE total scores (r = 0.701, p < 0.001) and MoCA total scores (r = 0.778, p < 0.001), indicating good construct validity. Receiving operating characteristic curve analysis yielded comparable areas under the curve for diagnostic efficacy (RUDAS, 0.844; MMSE, 0.769; MoCA, 0.824; all p > 0.05). A RUDAS score cutoff of 23.5 distinguished TBI patients from controls with 60% sensitivity and 100% specificity. Therefore, the RUDAS demonstrates both good reliability and validity for evaluating cognitive impairments in TBI patients.
Collapse
Affiliation(s)
- Yun Cheng
- Department of Rehabilitation Medicine, The Third Affiliated Hospital of Soochow University, Changzhou, China.,Department of Rehabilitation Medicine, School of Clinical Medicine, Soochow University, Soochow, China
| | - Yu Zhang
- Department of Rehabilitation Medicine, The Third Affiliated Hospital of Soochow University, Changzhou, China
| | - Yi Zhang
- Department of Rehabilitation Medicine, The Third Affiliated Hospital of Soochow University, Changzhou, China
| | - Ye-Huan Wu
- Department of Rehabilitation Medicine, The Third Affiliated Hospital of Soochow University, Changzhou, China
| | - Shuang Zhang
- Department of Rehabilitation Medicine, The Third Affiliated Hospital of Soochow University, Changzhou, China.,Department of Rehabilitation Medicine, School of Clinical Medicine, Soochow University, Soochow, China
| |
Collapse
|
15
|
Choi Y, Park JH, Hong KJ, Ro YS, Song KJ, Shin SD. Development and validation of a prehospital-stage prediction tool for traumatic brain injury: a multicentre retrospective cohort study in Korea. BMJ Open 2022; 12:e055918. [PMID: 35022177 PMCID: PMC8756263 DOI: 10.1136/bmjopen-2021-055918] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
OBJECTIVES Predicting diagnosis and prognosis of traumatic brain injury (TBI) at the prehospital stage is challenging; however, using comprehensive prehospital information and machine learning may improve the performance of the predictive model. We developed and tested predictive models for TBI that use machine learning algorithms using information that can be obtained in the prehospital stage. DESIGN This was a multicentre retrospective study. SETTING AND PARTICIPANTS This study was conducted at three tertiary academic emergency departments (EDs) located in an urban area of South Korea. The data from adult patients with severe trauma who were assessed by emergency medical service providers and transported to three participating hospitals between 2014 to 2018 were analysed. RESULTS We developed and tested five machine learning algorithms-logistic regression analyses, extreme gradient boosting, support vector machine, random forest and elastic net (EN)-to predict TBI, TBI with intracranial haemorrhage or injury (TBI-I), TBI with ED or admission result of admission or transferred (TBI with non-discharge (TBI-ND)) and TBI with ED or admission result of death (TBI-D). A total of 1169 patients were included in the final analysis, and the proportions of TBI, TBI-I, TBI-ND and TBI-D were 24.0%, 21.5%, 21.3% and 3.7%, respectively. The EN model yielded an area under receiver-operator curve of 0.799 for TBI, 0.844 for TBI-I, 0.811 for TBI-ND and 0.871 for TBI-D. The EN model also yielded the highest specificity and significant reclassification improvement. Variables related to loss of consciousness, Glasgow Coma Scale and light reflex were the three most important variables to predict all outcomes. CONCLUSION Our results inform the diagnosis and prognosis of TBI. Machine learning models resulted in significant performance improvement over that with logistic regression analyses, and the best performing model was EN.
Collapse
Affiliation(s)
- Yeongho Choi
- Laboratory of Emergency Medical Services, Seoul National University Hospital Biomedical Research Institute, Seoul, South Korea
- Department of Emergency Medicine, Seoul National University Hospital, Seoul, South Korea
| | - Jeong Ho Park
- Laboratory of Emergency Medical Services, Seoul National University Hospital Biomedical Research Institute, Seoul, South Korea
- Department of Emergency Medicine, Seoul National University Hospital, Seoul, South Korea
| | - Ki Jeong Hong
- Laboratory of Emergency Medical Services, Seoul National University Hospital Biomedical Research Institute, Seoul, South Korea
- Department of Emergency Medicine, Seoul National University Hospital, Seoul, South Korea
| | - Young Sun Ro
- Laboratory of Emergency Medical Services, Seoul National University Hospital Biomedical Research Institute, Seoul, South Korea
- Department of Emergency Medicine, Seoul National University Hospital, Seoul, South Korea
| | - Kyoung Jun Song
- Laboratory of Emergency Medical Services, Seoul National University Hospital Biomedical Research Institute, Seoul, South Korea
- Department of Emergency Medicine, Seoul Metropolitan Government Seoul National University Boramae Medical Center, Seoul, South Korea
| | - Sang Do Shin
- Laboratory of Emergency Medical Services, Seoul National University Hospital Biomedical Research Institute, Seoul, South Korea
- Department of Emergency Medicine, Seoul National University Hospital, Seoul, South Korea
| |
Collapse
|
16
|
Prabhakar Abhilash K, Abraham S, Hazra D, Nekkanti A. Head and neck trauma: Profile and factors associated with severe head injury. MEDICAL JOURNAL OF DR. D.Y. PATIL VIDYAPEETH 2022. [DOI: 10.4103/mjdrdypu.mjdrdypu_3_21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
|
17
|
Martini DN, Wilhelm J, Lee L, Brumbach BH, Chesnutt J, Skorseth P, King LA. Exploring clinical and patient characteristics for rehabilitation referrals following a concussion: a retrospective analysis. Arch Rehabil Res Clin Transl 2022; 4:100183. [PMID: 35756984 PMCID: PMC9214303 DOI: 10.1016/j.arrct.2022.100183] [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] [Indexed: 12/03/2022] Open
Abstract
Objective To explore patterns of postconcussion care at a level 1 trauma center. Design Retrospective cohort study. Setting U.S. level 1 trauma center and local satellite units. Participants Patients of any age with a concussion diagnosis that reported to level 1 trauma center and local satellite units between 2016 and 2018 (N=2417). Intervention Not applicable. Main Outcome Measures Age, sex, point of entry, rehabilitation referrals, and pre-existing comorbidity diagnosis. Results Patient age (mean [SD]) significantly differed among points of entry, from youngest to oldest: 26.0 (14.0) years in sports medicine, 29.3 (23.0) years in the emergency department, 34.6 (23.6) years at primary care providers, and 46.0 (19.7) years at specialty care departments. Sex also significantly differed among points of entry; emergency departments reported more men (55.6%), whereas the other points of entry reported more women (59.3%-65.6%). Patients were more likely to receive a referral from sports medicine (odds ratio [OR]unadjusted=75.05, P<.001), primary care providers (ORunadjusted=7.98, P<.001), and specialty care departments (ORunadjusted=7.62, P<.001) than from the emergency department. Women were more likely to receive a referral (ORunadjusted=1.92, P<.0001), regardless of point of entry. Lastly, patients with a preexisting comorbidity were more likely (ORadjusted=2.12, P<.001) to get a rehabilitation referral than patients without a comorbidity. Conclusions Point of entry, age, sex, and preexisting comorbidities are associated with postconcussion care rehabilitation referral patterns. Improving concussion education dissemination across all entry points of a level 1 trauma center may standardize the postconcussion rehabilitation referral patterns, potentially improving the time to recovery from a concussion.
Collapse
|
18
|
Cornwell RE, Arango JI, Eagye CB, Hill-Pearson C, Schwab K, Souvignier AR, Pazdan RM. Mild Traumatic Brain Injury and Postconcussive Symptom Endorsement: A Parallel Comparison Between Two Nonclinical Cohorts. Mil Med 2021; 186:e1191-e1198. [PMID: 33269800 DOI: 10.1093/milmed/usaa504] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2020] [Revised: 10/14/2020] [Accepted: 11/04/2020] [Indexed: 11/12/2022] Open
Abstract
INTRODUCTION The prevalence of mild traumatic brain injury (mTBI) is commonly estimated based on indirect metrics such as emergency department visits and self-reporting tools. The study of postconcussive symptoms faces similar challenges because of their unspecific character and indistinct causality. In this article, we compare two nonclinical, epidemiological studies that addressed these two elements and were performed within a relatively narrow period in the state of Colorado. MATERIALS AND METHODS De-identified datasets were obtained from a random digit-dialed survey study conducted by the Craig Hospital and a study surveying soldiers returning from deployment by Defense and Veteran Traumatic Brain Injury Center. Information pertinent to participants' demographics, a history of mTBI, and symptom endorsement was extracted and homogenized in order to establish a parallel comparison between the populations of the two studies. RESULTS From the 1,558 (Warrior Strong, 679; Craig Hospital, 879) records selected for analysis, 43% reported a history of at least one mTBI. The prevalence was significantly higher among individuals from the Defense and Veteran Traumatic Brain Injury Center study independent of gender or race. Repetitive injuries were reported by 15% of the total combined cohort and were more prevalent among males. Symptom endorsement was significantly higher in individuals with a positive history of mTBI, but over 80% of those with a negative history of mTBI endorsed at least one of the symptoms interrogated. Significant differences were observed between the military and the civilian populations in terms of the types and frequencies of the symptoms endorsed. CONCLUSIONS The prevalence of mTBI and associated symptoms identified in the two study populations is higher than that of previously reported. This suggests that not all individuals sustaining concussion seek medical care and highlights the limitations of using clinical reports to assess such estimates. The lack of appropriate mechanisms to determine symptom presence and causality remains a challenge. However, the differences observed in symptom reporting between cohorts raise questions about the nature of the symptoms, the impact on the quality of life for different individuals, and the effects on military health and force readiness.
Collapse
Affiliation(s)
- R Elisabeth Cornwell
- Despite being in Colorado Springs, The location of the Defense and Veterans Brain Injury Center should be Fort Carson, CO 80913, USA.,Karen Schwab's affiliation with General Dynamics is correct, but the Defense and Veterans Brain Injury Center she is affiliated to isn't the one at Fort Carson but the one in Silver Spring, MD 20910, USA
| | - Jorge I Arango
- Despite being in Colorado Springs, The location of the Defense and Veterans Brain Injury Center should be Fort Carson, CO 80913, USA.,Karen Schwab's affiliation with General Dynamics is correct, but the Defense and Veterans Brain Injury Center she is affiliated to isn't the one at Fort Carson but the one in Silver Spring, MD 20910, USA
| | - C B Eagye
- Craig Hospital, Englewood, CO 80113, USA
| | - Candace Hill-Pearson
- Despite being in Colorado Springs, The location of the Defense and Veterans Brain Injury Center should be Fort Carson, CO 80913, USA.,Karen Schwab's affiliation with General Dynamics is correct, but the Defense and Veterans Brain Injury Center she is affiliated to isn't the one at Fort Carson but the one in Silver Spring, MD 20910, USA
| | - Karen Schwab
- Despite being in Colorado Springs, The location of the Defense and Veterans Brain Injury Center should be Fort Carson, CO 80913, USA.,Karen Schwab's affiliation with General Dynamics is correct, but the Defense and Veterans Brain Injury Center she is affiliated to isn't the one at Fort Carson but the one in Silver Spring, MD 20910, USA
| | - Alicia R Souvignier
- Despite being in Colorado Springs, The location of the Defense and Veterans Brain Injury Center should be Fort Carson, CO 80913, USA.,Warrior Recovery Center, Evans Army Community Hospital, Fort Carson, CO 80913, USA
| | - Renee M Pazdan
- Despite being in Colorado Springs, The location of the Defense and Veterans Brain Injury Center should be Fort Carson, CO 80913, USA.,Warrior Recovery Center, Evans Army Community Hospital, Fort Carson, CO 80913, USA
| |
Collapse
|
19
|
Schneider ALC, Selvin E, Latour L, Turtzo LC, Coresh J, Mosley T, Ling G, Gottesman RF. Head injury and 25-year risk of dementia. Alzheimers Dement 2021; 17:1432-1441. [PMID: 33687142 PMCID: PMC9422954 DOI: 10.1002/alz.12315] [Citation(s) in RCA: 35] [Impact Index Per Article: 11.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2020] [Revised: 11/01/2020] [Accepted: 01/29/2021] [Indexed: 12/26/2022]
Abstract
INTRODUCTION Head injury is associated with significant morbidity and mortality. Long-term associations of head injury with dementia in community-based populations are less clear. METHODS Prospective cohort study of 14,376 participants (mean age 54 years at baseline, 56% female, 27% Black, 24% with head injury) enrolled in the Atherosclerosis Risk in Communities (ARIC) Study. Head injury was defined using self-report and International Classification of Diseases, Ninth/Tenth Revision (ICD-9/10) codes. Dementia was defined using cognitive assessments, informant interviews, and ICD-9/10 and death certificate codes. RESULTS Head injury was associated with risk of dementia (hazard ratio [HR] = 1.44, 95% confidence interval [CI] = 1.3-1.57), with evidence of dose-response (1 head injury: HR = 1.25, 95% CI = 1.13-1.39, 2+ head injuries: HR = 2.14, 95% CI = 1.86-2.46). There was evidence for stronger associations among female participants (HR = 1.69, 95% CI = 1.51-1.90) versus male participants (HR = 1.15, 95% CI = 1.00-1.32), P-for-interaction < .001, and among White participants (HR = 1.55, 95% CI = 1.40-1.72) versus Black participants (HR = 1.22, 95% CI = 1.02-1.45), P-for-interaction = .008. DISCUSSION In this community-based cohort with 25-year follow-up, head injury was associated with increased dementia risk in a dose-dependent manner, with stronger associations among female participants and White participants.
Collapse
Affiliation(s)
| | - Elizabeth Selvin
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health
| | | | | | - Josef Coresh
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health
| | - Thomas Mosley
- Department of Medicine, University of Mississippi Medical Center
| | - Geoffrey Ling
- Department of Neurology, Uniformed Services University of the Health Sciences
- Department of Neurology, Johns Hopkins University School of Medicine
| | - Rebecca F. Gottesman
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health
- Department of Neurology, Johns Hopkins University School of Medicine
| |
Collapse
|
20
|
Readmission Following Hospitalization for Traumatic Brain Injury: A Nationwide Study. J Head Trauma Rehabil 2021; 37:E165-E174. [PMID: 34145159 DOI: 10.1097/htr.0000000000000699] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To determine whether sociodemographic and clinical factors were associated with nonelective readmission within 30 days of hospitalization for traumatic brain injury (TBI). Secondary objectives were to examine the effects of TBI severity on readmission and characterize primary reasons for readmission. SETTING Hospitalized patients in the United States, using the 2014 Nationwide Readmission Database. PARTICIPANTS All patients hospitalized with a primary diagnosis of TBI between January 1, 2014, and November 30, 2014. We excluded patients (1) with a missing or invalid length of stay or admission date, (2) who were nonresidents, and 3) who died during their index hospitalization. DESIGN Observational study; cohort study. MAIN MEASURES Survey weighting was used to compute national estimates of TBI hospitalization and nonelective 30-day readmission. Associations between sociodemographic and clinical factors with readmission were assessed using unconditional logistic regression with and without adjustment for suspected confounders. RESULTS There were 135 542 individuals who were hospitalized for TBI; 8.9% of patients were readmitted within 30 days of discharge. Age (strongest association for 65-74 years vs 18-24 years: adjusted odds ratio [AOR], 2.57; 95% CI: 2.02-3.27), documentation of a fall (AOR, 1.24; 95% CI: 1.13-1.35), and intentional self-injury (AOR, 3.13; 95% CI: 1.88-5.21) at the index admission were positively associated with readmission. Conversely, history of a motor vehicle (AOR, 0.69; 95% CI: 0.62-0.78) or cycling (AOR, 0.56; 95% CI: 0.40-0.77) accident was negatively associated with readmission. Females were also less likely to be readmitted following hospitalization for a TBI (AOR, 0.87; 95% CI: 0.82-0.92). CONCLUSIONS Many sociodemographic and clinical factors were found to be associated with acute readmission following hospitalizations for TBI. Future studies are needed to determine the extent to which readmissions following TBI hospitalizations are preventable.
Collapse
|
21
|
De Crescenzo LA, Gabella BA, Johnson J. Interrupted time series design to evaluate ICD-9-CM to ICD-10-CM coding changes on trends in Colorado emergency department visits related to traumatic brain injury. Inj Epidemiol 2021; 8:15. [PMID: 33866966 PMCID: PMC8054413 DOI: 10.1186/s40621-021-00308-y] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2020] [Accepted: 02/16/2021] [Indexed: 11/11/2022] Open
Abstract
Background The transition in 2015 to the Tenth Revision of the International Classification of Disease, Clinical Modification (ICD-10-CM) in the US led the Centers for Disease Control and Prevention (CDC) to propose a surveillance definition of traumatic brain injury (TBI) utilizing ICD-10-CM codes. The CDC’s proposed surveillance definition excludes “unspecified injury of the head,” previously included in the ICD-9-CM TBI surveillance definition. The study purpose was to evaluate the impact of the TBI surveillance definition change on monthly rates of TBI-related emergency department (ED) visits in Colorado from 2012 to 2017. Results The monthly rate of TBI-related ED visits was 55.6 visits per 100,000 persons in January 2012. This rate in the transition month to ICD-10-CM (October 2015) decreased by 41 visits per 100,000 persons (p-value < 0.0001), compared to September 2015, and remained low through December 2017, due to the exclusion of “unspecified injury of head” (ICD-10-CM code S09.90) in the proposed TBI definition. The average increase in the rate was 0.33 visits per month (p < 0.01) prior to October 2015, and 0.04 visits after. When S09.90 was included in the model, the monthly TBI rate in Colorado remained smooth from ICD-9-CM to ICD-10-CM and the transition was no longer significant (p = 0.97). Conclusion The reduction in the monthly TBI-related ED visit rate resulted from the CDC TBI surveillance definition excluding unspecified head injury, not necessarily the coding transition itself. Public health practitioners should be aware that the definition change could lead to a drastic reduction in the magnitude and trend of TBI-related ED visits, which could affect decisions regarding the allocation of TBI resources. This study highlights a challenge in creating a standardized set of TBI ICD-10-CM codes for public health surveillance that provides comparable yet clinically relevant estimates that span the ICD transition.
Collapse
Affiliation(s)
| | - Barbara Alison Gabella
- Colorado Department of Public Health and Environment, 4300 Cherry Creek Drive South, A4, Denver, CO, USA.
| | - Jewell Johnson
- Colorado Department of Public Health and Environment, 4300 Cherry Creek Drive South, A4, Denver, CO, USA
| |
Collapse
|
22
|
Graves WC, Oyesanya TO, Gormley M, Røe C, Andelic N, Seel RT, Lu J. Pre- and in-hospital mortality for moderate-to-severe traumatic brain injuries: an analysis of the National Trauma Data Bank (2008-2014). Brain Inj 2021; 35:265-274. [PMID: 33529087 DOI: 10.1080/02699052.2021.1873419] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
Objectives: This study aimed to: (1) evaluate pre- and in-hospital mortality for moderate-to-severe TBI in the U.S. by injury type (blunt vs. penetrating) and (2) estimate annual regression-adjusted mortality from 2008-2014.Methods: Data were analyzed from the National Trauma Data Bank (N=247,648). Multivariable logistic regression analyses were performed by injury type to assess changes in mortality between study periods (early period: 2008-2010; late period: 2011-2014) and to estimate annual regression-adjusted mortality. Mortality odds ratios and 95% confidence intervals were calculated.Results: Total observed mortality was 18.8%. After covariate adjustment, patients in the late period had an increased odds of prehospital mortality compared to patients in the early period for blunt (OR: 4.69; 95%CI: 4.41-4.98) and penetrating trauma (OR: 4.71; 95%CI: 4.39-5.06). In contrast, patients in the late period had a decreased odds of in-hospital mortality compared to patients in the early period for blunt (OR: 0.95; 95%CI: 0.91-0.98) and penetrating trauma (OR: 0.92; 95%CI: 0.85-0.98).Conclusions: The decreasing in-hospital mortality trend is consistent with previous literature. Additional research is warranted to validate the observed increase in prehospital mortality and to identify best practices that can improve prehospital outcomes for patients with moderate-to-severe TBI.
Collapse
Affiliation(s)
- Whitney C Graves
- Division of Epidemiology, Department of Family Medicine and Population Health, School of Medicine, Virginia Commonwealth University, Richmond, Virgina, USA
| | - Tolu O Oyesanya
- School of Nursing, Duke University, Durham, North Carolina, USA
| | - Mirinda Gormley
- Division of Epidemiology, Department of Family Medicine and Population Health, School of Medicine, Virginia Commonwealth University, Richmond, Virgina, USA
| | - Cecilie Røe
- Department of Physical Medicine and Rehabilitation, Oslo University Hospital, Oslo, Norway.,Institute of Clinical Medicine, Faculty of Medicine, University of Oslo, Oslo, Norway
| | - Nada Andelic
- Department of Physical Medicine and Rehabilitation, Oslo University Hospital, Oslo, Norway.,Institute of Health and Society, Research Centre for Habilitation and Rehabilitation Models and Services (CHARM), Faculty of Medicine, University of Oslo, Oslo, Norway
| | - Ronald T Seel
- Center for Rehabilitation Science and Engineering (CERSE) Department of Physical Medicine and Rehabilitation, School of Medicine, Virginia Commonwealth University, Richmond, Virgina, USA
| | - Juan Lu
- Division of Epidemiology, Department of Family Medicine and Population Health, School of Medicine, Virginia Commonwealth University, Richmond, Virgina, USA
| |
Collapse
|
23
|
Shriki J, Galvagno SM. Sedation for Rapid Sequence Induction and Intubation of Neurologically Injured Patients. Emerg Med Clin North Am 2020; 39:203-216. [PMID: 33218658 DOI: 10.1016/j.emc.2020.09.012] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
There are subtle physiologic and pharmacologic principles that should be understood for patients with neurologic injuries. These principles are especially true for managing patients with traumatic brain injuries. Prevention of hypotension and hypoxemia are major goals in the management of these patients. This article discusses the physiology, pitfalls, and pharmacology necessary to skillfully care for this subset of patients with trauma. The principles endorsed in this article are applicable both for patients with traumatic brain injury and those with spinal cord injuries.
Collapse
Affiliation(s)
- Jesse Shriki
- Surgical Critical Care, R Adams Cowley Shock Trauma Center, Program in Trauma, University of Maryland School of Medicine, 22 South Greene Street, Baltimore, MD 21201, USA.
| | - Samuel M Galvagno
- Multi Trauma Critical Care Unit, R Adams Cowley Shock Trauma Center, Program in Trauma, University of Maryland School of Medicine, Baltimore, MD, USA
| |
Collapse
|
24
|
Role of Circular Ribonucleic Acids in the Treatment of Traumatic Brain and Spinal Cord Injury. Mol Neurobiol 2020; 57:4296-4304. [DOI: 10.1007/s12035-020-02027-9] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2020] [Accepted: 07/14/2020] [Indexed: 12/19/2022]
|
25
|
Clinical Predictors of 3- and 6-Month Outcome for Mild Traumatic Brain Injury Patients with a Negative Head CT Scan in the Emergency Department: A TRACK-TBI Pilot Study. Brain Sci 2020; 10:brainsci10050269. [PMID: 32369967 PMCID: PMC7287871 DOI: 10.3390/brainsci10050269] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2020] [Revised: 04/08/2020] [Accepted: 04/28/2020] [Indexed: 01/25/2023] Open
Abstract
A considerable subset of mild traumatic brain injury (mTBI) patients fail to return to baseline functional status at or beyond 3 months postinjury. Identifying at-risk patients for poor outcome in the emergency department (ED) may improve surveillance strategies and referral to care. Subjects with mTBI (Glasgow Coma Scale 13–15) and negative ED initial head CT < 24 h of injury, completing 3- or 6-month functional outcome (Glasgow Outcome Scale-Extended; GOSE), were extracted from the prospective, multicenter Transforming Research and Clinical Knowledge in Traumatic Brain Injury (TRACK-TBI) Pilot study. Outcomes were dichotomized to full recovery (GOSE = 8) vs. functional deficits (GOSE < 8). Univariate predictors with p < 0.10 were considered for multivariable regression. Adjusted odds ratios (AOR) were reported for outcome predictors. Significance was assessed at p < 0.05. Subjects who completed GOSE at 3- and 6-month were 211 (GOSE < 8: 60%) and 185 (GOSE < 8: 65%). Risk factors for 6-month GOSE < 8 included less education (AOR = 0.85 per-year increase, 95% CI: (0.74–0.98)), prior psychiatric history (AOR = 3.75 (1.73–8.12)), Asian/minority race (American Indian/Alaskan/Hawaiian/Pacific Islander) (AOR = 23.99 (2.93–196.84)), and Hispanic ethnicity (AOR = 3.48 (1.29–9.37)). Risk factors for 3-month GOSE < 8 were similar with the addition of injury by assault predicting poorer outcome (AOR = 3.53 (1.17–10.63)). In mTBI patients seen in urban trauma center EDs with negative CT, education, injury by assault, Asian/minority race, and prior psychiatric history emerged as risk factors for prolonged disability.
Collapse
|
26
|
Readmissions after nonoperative trauma: Increased mortality and costs with delayed intervention. J Trauma Acute Care Surg 2020; 88:219-229. [PMID: 31804415 DOI: 10.1097/ta.0000000000002560] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
BACKGROUND We sought to examine patterns of readmission after nonoperative trauma, including rates of delayed operative intervention and mortality. METHODS The Nationwide Readmissions Database (2013-2014) was queried for all adult trauma admissions and 30-day readmissions. Index admissions were classified as operative (OI) or nonoperative (NOI), and readmissions examined for major operative intervention (MOR). Multivariable regression modeling was used to evaluate risk for readmission requiring MOR and in-hospital mortality. RESULTS Of 2,244,570 trauma admissions, there were 59,573 readmissions: 66% after NOI, and 35% after OI. Readmission rate was higher after NOI compared with OI (3.6% vs. 1.7% p < 0.001). Readmitted NOI patients were older, with a higher proportion of Injury Severity Score ≥15 and were readmitted earlier (NOI median 8 days vs. OI 11 days). Thirty-one percent of readmitted NOI patients required MOR and experienced higher overall mortality compared with OI patients with operative readmission (NOI 2.9% vs. OI 2%, p = 0.02). Intracranial hemorrhage was an independent risk factor for NOI readmission requiring MOR in both the overall (hazard ratio, 1.11; 95% confidence interval [CI], 1.01-1.22) and Injury Severity Score of 15 or greater cohorts (hazard ratio, 1.46; 95% CI, 1.24-1.7), with a predominance of nonspine neurosurgical procedures (20.3% and 55.1%, respectively). Operative readmission after NOI cost a median of $17,364 (interquartile range, US $11,481 to US $27,816) and carried a total annual cost of US $147 million (95% CI, US $141 million to $154 million). CONCLUSIONS Nonoperative trauma patients have a higher readmission rate than operative index patients and nearly one third require operative intervention during readmission. Operative readmission carries a higher overall mortality rate in NOI patients and together accounts for nearly US $150 million in annual costs. LEVEL OF EVIDENCE Epidemiological, level III.
Collapse
|
27
|
Silverberg ND, Iaccarino MA, Panenka WJ, Iverson GL, McCulloch KL, Dams-O’Connor K, Reed N, McCrea M, Cogan AM, Park Graf MJ, Kajankova M, McKinney G, Weyer Jamora C. Management of Concussion and Mild Traumatic Brain Injury: A Synthesis of Practice Guidelines. Arch Phys Med Rehabil 2020; 101:382-393. [DOI: 10.1016/j.apmr.2019.10.179] [Citation(s) in RCA: 45] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2019] [Revised: 09/13/2019] [Accepted: 10/09/2019] [Indexed: 12/14/2022]
|
28
|
Incidence of intracranial bleeding in seniors presenting to the emergency department after a fall: A systematic review. Injury 2020; 51:157-163. [PMID: 31901331 DOI: 10.1016/j.injury.2019.12.036] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/16/2019] [Revised: 12/24/2019] [Accepted: 12/26/2019] [Indexed: 02/02/2023]
Abstract
INTRODUCTION Seniors who fall are an increasing proportion of the patients who are treated in emergency departments (ED). Falling on level-ground is the most common cause of traumatic intracranial bleeding. We aimed to determine the incidence of intracranial bleeding among all senior patients who present to ED after a fall. METHOD We performed a systematic review. Medline, EMBASE, Cochrane, and Database of Abstracts of Reviews of Effects databases, Google Scholar, bibliographies and conference abstracts were searched for articles relevant to senior ED patients who presented after a ground-level fall. Studies were included if they reported on patients aged 65 or older who had fallen. At least 80% of the population had to have suffered a ground-level fall. There were no language restrictions. We performed a meta-analysis (using the random effects model) to report the pooled incidence of intracranial bleeding within 6 weeks of the fall. RESULTS We identified eleven studies (including 11,102 patients) addressing this clinical question. Only three studies were prospective in design. The studies varied in their inclusion criteria, with two requiring evidence of head injury and four requiring the emergency physician to have ordered a head computed tomography (CT). One study excluded patients on therapeutic anticoagulation. Overall, there was a high risk of bias for eight out of eleven studies. The pooled incidence of intracranial bleeding was 5.2% (95% CI 3.2-8.2%). A sensitivity analysis excluding studies with a high risk of bias gave a pooled estimate of 5.1% (95% CI 3.6-7.2%). CONCLUSION We found a lack of high-quality evidence on senior ED patients who have fallen. The available literature suggests there is around a 5% incidence of intracranial bleeding in seniors who present to the ED after a fall.
Collapse
|
29
|
Hsia RY, Mannix RC, Guo J, Kornblith AE, Lin F, Sokolove PE, Manley GT. Revisits, readmissions, and outcomes for pediatric traumatic brain injury in California, 2005-2014. PLoS One 2020; 15:e0227981. [PMID: 31978188 PMCID: PMC6980591 DOI: 10.1371/journal.pone.0227981] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2019] [Accepted: 01/04/2020] [Indexed: 01/23/2023] Open
Abstract
Long-term outcomes related to emergency department revisit, hospital readmission, and all-cause mortality, have not been well characterized across the spectrum of pediatric traumatic brain injury (TBI). We evaluated emergency department visit outcomes up to 1 year after pediatric TBI, in comparison to a referent group of trauma patients without TBI. We performed a longitudinal, retrospective study of all pediatric trauma patients who presented to emergency departments and hospitals in California from 2005 to 2014. We compared emergency department visits, dispositions, revisits, readmissions, and mortality in pediatric trauma patients with a TBI diagnosis to those without TBI (Other Trauma patients). We identified 208,222 pediatric patients with an index diagnosis of TBI and 1,314,064 patients with an index diagnosis of Other Trauma. Population growth adjusted TBI visits increased by 5.6% while those for Other Trauma decreased by 40.7%. The majority of patients were discharged from the emergency department on their first visit (93.2% for traumatic brain injury vs. 96.5% for Other Trauma). A greater proportion of TBI patients revisited the emergency department (33.4% vs. 3.0%) or were readmitted to the hospital (0.9% vs. 0.04%) at least once within a year of discharge. The health burden within a year after a pediatric TBI visit is considerable and is greater than that of non-TBI trauma. These data suggest that outpatient strategies to monitor for short-term and longer-term sequelae after pediatric TBI are needed to improve patient outcomes, lessen the burden on families, and more appropriately allocate resources in the healthcare system.
Collapse
Affiliation(s)
- Renee Y Hsia
- Department of Emergency Medicine, University of California, San Francisco, California, United States of America.,Philip R. Lee Institute for Health Policy Studies, University of California, San Francisco, California, United States of America
| | - Rebekah C Mannix
- Division of Emergency Medicine, Boston Children's Hospital, Boston, Massachusetts, United States of America.,Department of Emergency Medicine, Brigham and Women's Hospital, Boston, Massachusetts, United States of America
| | - Joanna Guo
- Department of Emergency Medicine, University of California, San Francisco, California, United States of America
| | - Aaron E Kornblith
- Department of Emergency Medicine, University of California, San Francisco, California, United States of America
| | - Feng Lin
- Department of Biostatistics and Epidemiology, University of California, San Francisco, California, United States of America
| | - Peter E Sokolove
- Department of Emergency Medicine, University of California, San Francisco, California, United States of America
| | - Geoffrey T Manley
- Brain and Spinal Injury Center (BASIC), University of California, San Francisco, California, United States of America.,Department of Neurological Surgery, University of California, San Francisco, California, United States of America
| |
Collapse
|
30
|
Gillespie CS, Mcleavy CM, Islim AI, Prescott S, McMahon CJ. Rationalising neurosurgical head injury referrals: development and validation of the Liverpool Head Injury Tomography Score (Liverpool HITS) for mild TBI. Br J Neurosurg 2020; 34:127-134. [DOI: 10.1080/02688697.2019.1710825] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Affiliation(s)
- Conor S. Gillespie
- The Walton Centre NHS Foundation Trust, Liverpool, UK
- School of Medicine, University of Liverpool, Liverpool, UK
| | | | - Abdurrahman I. Islim
- The Walton Centre NHS Foundation Trust, Liverpool, UK
- Institute of Translational Medicine, University of Liverpool, Liverpool, UK
- Royal Liverpool and Broadgreen University Hospitals NHS Trust, Liverpool, UK
| | | | | |
Collapse
|
31
|
Hoffman H, Furst T, Jalal MS, Chin LS. Costs and predictors of 30-day readmissions after craniotomy for traumatic brain injury: a nationwide analysis. J Neurosurg 2019; 133:875-883. [PMID: 31398707 DOI: 10.3171/2019.5.jns19459] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2019] [Accepted: 05/10/2019] [Indexed: 11/06/2022]
Abstract
OBJECTIVE There is increasing interest in the use of 30-day readmission (30dRA) as a quality metric to represent hospital and provider performance. Data regarding the incidence and risk factors for 30dRA after traumatic brain injury (TBI) are sparse. The authors sought to characterize these variables using a national database. METHODS The Nationwide Readmissions Database was used to identify patients with a primary diagnosis of TBI who underwent craniotomy or craniectomy between 2010 and 2014. Our primary outcome of interest was 30dRA. Binary logistic regression was used to identify variables related to patient demographics, comorbidities, and index hospital admission that were associated with 30dRA. RESULTS A total of 25,354 patients met the inclusion criteria. The 30dRA rate during the entire study period was 15.5%. In 2010 the 30dRA rate was 16.8% and in 2014 it decreased to 15.1% (pooled OR 0.90, 95% CI 0.87-0.94). The mean cost associated with a 30dRA increased slightly but significantly, from $9999 in 2010 to $10,114 in 2014 (p = 0.021). Factors associated with increased odds of 30dRA in the binary logistic regression included increased age, greater comorbidity burden, more severe injury, tracheostomy, gastrostomy, sodium abnormality, and venous thromboembolism. In order of decreasing frequency, the most common causes for 30dRA were neurological, injury/iatrogenic, cardiovascular/cerebrovascular, infectious, and respiratory. CONCLUSIONS The incidence of 30dRA after craniotomy for TBI decreased slightly from 2010 to 2014. This study identified several variables associated with 30dRA that require confirmation in a prospective study, which could direct attempts to prevent readmissions.
Collapse
|
32
|
Niu F, Sharma A, Feng L, Ozkizilcik A, Muresanu DF, Lafuente JV, Tian ZR, Nozari A, Sharma HS. Nanowired delivery of DL-3-n-butylphthalide induces superior neuroprotection in concussive head injury. PROGRESS IN BRAIN RESEARCH 2019; 245:89-118. [DOI: 10.1016/bs.pbr.2019.03.008] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
|