The MRC CRASH Trial: study design, baseline data, and outcome in 1000 randomised patients in the pilot phase

The Best Services Trial (BeST?): a cluster randomised controlled trial comparing the clinical and cost-effectiveness of New Orleans Intervention Model with services as usual (SAU) for infants and young children entering care

BACKGROUND

Abused and neglected children are at increased risk of health problems throughout life, but negative effects may be ameliorated by nurturing family care. It is not known whether it is better to place these children permanently with substitute (foster or adoptive) families or to attempt to reform their birth families. Previously, we conducted a feasibility randomised controlled trial (RCT) of the New Orleans Intervention Model (NIM) for children aged 0-60 months coming into foster care in Glasgow. NIM is delivered by a multidisciplinary health and social care team and offers families, whose child has been taken into foster care, a structured assessment of family relationships followed by a trial of treatment aiming to improve family functioning. A recommendation is then made for the child to return home or for adoption. In the feasibility RCT, families were willing to be randomised to NIM or optimised social work services as usual and equipoise was maintained. Here we present the protocol of a substantive RCT of NIM including a new London site.

METHODS

The study is a multi-site, pragmatic, single-blind, parallel group, cluster randomised controlled superiority trial with an allocation ratio of 1:1. We plan to recruit approximately 390 families across the sites, including those recruited in our feasibility RCT. They will be randomly allocated to NIM or optimised services as usual and followed up to 2.5 years post-randomisation. The principal outcome measure will be child mental health, and secondary outcomes will be child quality of life, the time taken for the child to be placed in permanent care (rehabilitation home or adoption) and the quality of the relationship with the primary caregiver.

DISCUSSION

The study is novel in that infant mental health professionals rarely have a role in judicial decisions about children's care placements, and RCTs are rare in the judicial context. The trial will allow us to determine whether NIM is clinically and cost-effective in the UK and findings may have important implications for the use of mental health assessment and treatment as part of the decision-making about children in the care system.

Outcomes after Traumatic Brain Injury with Concomitant Severe Extracranial Injuries

Traumatic brain injury (TBI) is a leading cause of death and disability in trauma patients. Patients with TBI frequently sustain concomitant injuries in extracranial regions. The effect of severe extracranial injury (SEI) on the outcome of TBI is controversial. For 8 years, we retrospectively enrolled 485 patients with the blunt head injury with head abbreviated injury scale (AIS) ≧ 3. SEI was defined as AIS ≧ 3 injuries in the face, chest, abdomen, and pelvis/extremities. Vital signs and coagulation parameter values were also extracted from the database. Total patients were dichotomized into isolated TBI (n = 343) and TBI associated with SEI (n = 142). The differences in severity and outcome between these two groups were analyzed. To assess the relation between outcome and any variables showing significant differences in univariate analysis, we included the parameters in univariable and multivariable logistic regression analyses. Mortality was 17.8% in the isolated TBI group and 21.8% in TBI with SEI group (P = 0.38), but the Glasgow Outcome Scale (GOS) in the TBI with SEI group was unfavorable compared to the isolated TBI group (P = 0.002). Patients with SBP ≦ 90 mmHg were frequent in the TBI with SEI group. Adjusting for age, GCS, and length of hospital stay, SEI was a strong prognostic factor for mortality with adjusted ORs of 2.30. Hypotension and coagulopathy caused by SEI are considerable factors underlying the secondary insults to TBI. It is important to manage not only the brain but the whole body in the treatment of TBI patients with SEI.

Pituitary function within the first year after traumatic brain injury or subarachnoid haemorrhage

PURPOSE

Reports on long-term variations in pituitary function after traumatic brain injury (TBI) and subarachnoid haemorrhage (SAH) diverge. The aim of the current study was to evaluate the prevalence and changes in pituitary function during the first year after moderate and severe TBI and SAH and to explore the relation between pituitary function and injury variables.

METHODS

Adults with moderate and severe TBI or SAH were evaluated at 10 days, 3, 6 and 12 months post-injury/illness. Demographic, clinical, radiological, laboratory, including hormonal data were collected.

RESULTS

A total of 91 adults, 56 (15 women/41 men) with TBI and 35 (27 women/8 men) with SAH were included. Perturbations in pituitary function were frequent early after the event but declined during the first year of follow-up. The most frequent deficiency was hypogonadotrope hypogonadism which was seen in approximately 25 % of the patients. Most of the variations were transient and without clinical significance. At 12 months, two patients were on replacement with hydrocortisone, four men on testosterone and one man on replacement with growth hormone. No relations were seen between hormonal levels and injury variables.

CONCLUSIONS

Perturbations in pituitary function continue to occur during the first year after TBI and SAH, but only a few patients need replacement therapy. Our study could not identify a marker of increased risk of pituitary dysfunction that could guide routine screening. However, data demonstrate the need for systematic follow-up of pituitary function after moderate or severe TBI or SAH.

The role of prothrombotic factors in the ocular manifestations of abusive and non-abusive head trauma: a feasibility study

OBJECTIVES

Retinal hemorrhage is a cardinal manifestation of abusive head injury. Thrombophilia is relatively common in the general population and in adults can be associated with retinal hemorrhage. The specificity of retinal hemorrhage for abusive head trauma in the presence of prothrombotic factors, in particular following non-abusive head trauma, has not been investigated. Our objective was to determine whether the hypothesis that prothrombotic factors affect specificity of retinal hemorrhage to AHT can be tested. This may have important ramifications both for diagnosis and expert witness testimony.

METHODS

To investigate the feasibility of studying this issue, we conducted a prospective cohort study of children with abusive and non-abusive head trauma. Thrombophilia screening and ophthalmic examinations were performed.

RESULTS

Six of 30 admitted children were fully enrolled. Enrollment obstacles included caregiver stress, animosity towards allegations of abuse, child protection services involvement, and research phlebotomy coordination. Prevalence of thrombophilia was high in children with retinal hemorrhage and in 1 case the question of hemorrhage adjudicated as abuse was considered in light of a history of a fall.

CONCLUSION

We estimate that to answer the critical question of retinal hemorrhage specificity for abuse in the presence of thrombophilia will require 53 centers for a 1 year study or 18 centers for a 3-year study. We identify potential obstacles and interventions.

Young men were at risk of becoming lost to follow-up in a cohort of head-injured adults

OBJECTIVE

This study is to identify predictors of loss to follow-up among adults with head injury.

STUDY DESIGN AND SETTING

A prospective cohort of 1,857 adults enrolled in the Medical Research Council (MRC) CRASH trial known to be alive 2 weeks after head injury. Six-month follow-up was defined as "overdue" if over 6 months late. Patient information collected at enrollment and after 14 days was used to predict overdue follow-up. A random two-thirds of the cohort was analyzed using logistic regression and binary recursive partitioning. The regression model and decision rule derived by recursive partitioning were evaluated using the remaining third.

RESULTS

Overdue follow-up was more likely in patients aged 25-34 years (odds ratio, 1.76; 95% confidence interval [CI]=1.18-2.62), victims of assault (1.63; 1.09-2.45), patients independent after 2 weeks (1.79; 1.18-2.72) and patients for whom postcodes (2.36; 1.65-3.39), telephone numbers (1.82; 1.19-2.79) or general practitioners (1.67; 1.16-2.39) were unknown. Binary recursive partitioning specifically identified males aged younger than 43 years to be at risk.

CONCLUSION

Successful follow-up in head-injury studies requires patients' postcodes and telephone numbers to be available. Young men remain at risk of becoming lost to follow-up, presenting a challenge for researchers aiming for complete data.

Prophylaxis of Thromboembolism in Critical Care (PROTECT) Trial: a pilot study

PURPOSE

There is no randomized trial comparing low-molecular weight heparin (LMWH) and unfractionated heparin (UFH) for thromboprophylaxis in medical-surgical ICU patients. The primary objective of this randomized pilot study on LMWH vs UFH was to assess the feasibility of conducting a large randomized trial with respect to timely enrollment and blinded study drug administration, practicality of twice-weekly lower limb ultrasounds to screen for deep venous thrombosis, LMWH bioaccumulation and dose adjustment in renal insufficiency, and recruitment rates for a future trial in medical-surgical intensive care unit (ICU) patients. Its additional goals were to evaluate the suitability of the exclusion criteria and to document the range of research activities that precede accrual of patients into a trial to plan multisite management.

MATERIALS AND METHODS

By computerized telephone randomization, we allocated 129 medical-surgical ICU patients to treatment with dalteparin 5,000 IU QD SC or that with UFH 5,000 IU BID SC. Within each clinical center, only the study pharmacist was not blinded. We performed bilateral lower limb compression ultrasounds within 48 hours of ICU admission, twice weekly, on suspicion of deep venous thrombosis, and 7 days after ICU discharge. Research coordinators and investigators at 7 centers reported the time they engaged in all research activities before the first patient was randomized.

RESULTS

Timely complete study drug administration occurred after enrollment. More than 99% of scheduled doses were administered in a blinded fashion. Scheduled ultrasounds were performed without exception. No bioaccumulation of dalteparin was observed when creatinine clearance decreased to lower than 30 mL/min. Average recruitment was 2 patients/center per month before the study exclusion criteria were modified. Study startup activities required, on average, 65.5 hours of combined investigator and research coordinator time at each center. Careful examination of the accrual in the pilot study led to a reexamination of the Prophylaxis of Thromboembolism in Critical Care Trial (PROTECT) study exclusion criteria.

CONCLUSIONS

This pilot study suggests that a multicenter randomized clinical trial comparing LMWH with UFH in critically ill medical-surgical patients is feasible. Pilot studies can improve the design of larger trials and may enhance successful timely completion.

Brain injury after head trauma: pathophysiology, diagnosis, and treatment

Brain injury after impact to the head is due to both immediate mechanical effects and delayed responses of neural tissues. In horses, traumatic brain injury occurs in three main settings: (1) poll impact in horses that flip over backwards; (2) frontal/parietal impact in horses that run into a fixed object, and (3) injury to the vestibular apparatus secondary to temporohyoid osteoarthropathy. Distinct forebrain, vestibular, midbrain, hindbrain, or multifocal syndromes may be encountered in horses with traumatic brain injury. The most important components of treatment are those consistent with principles of "evidence-based medicine". Accordingly,secondary brain injury can most effectively be prevented by establishing normal blood pressure, temperature, blood glucose concentration, and tissue oxygenation. Pain must be controlled and brain swelling may be treated with infusions of hypertonic saline or mannitol. Surgical procedures, including unilateral hyoid bone transaction or elevation of skull fracture fragments, are indicated in selected cases. Optional additional treatments include use of anti-oxidants, conventional doses of corticosteroids, magnesium sulfate and drainage of CSE There is no indication for the use of massive doses of methyl prednisolone sodium succinate.