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Hayashi S, Kamo T, Momosaki R. Effectiveness of early rehabilitation interventions in patients with traumatic brain injury using a large database. PM R 2024. [PMID: 39105522 DOI: 10.1002/pmrj.13243] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2024] [Revised: 05/06/2024] [Accepted: 05/24/2024] [Indexed: 08/07/2024]
Abstract
BACKGROUND Rehabilitation is important for patients with moderate-to-severe traumatic brain injury (TBI). However, the timing of early rehabilitation initiation is ambiguous, and its safety and effectiveness are unknown. OBJECTIVE To examine the effectiveness and safety of early rehabilitation in patients with moderate-to-severe TBI using propensity score analysis and a large database. DESIGN Retrospective cohort study. SETTING A large medical database (JMDC database) of tertiary care facilities was used to compare outcomes of early and delayed rehabilitation. PATIENTS Patients aged between 20 and 90 years who were diagnosed with TBI were admitted to acute care hospitals. Inclusion criteria were patients undergoing rehabilitation within 7 days of admission with a Glasgow Coma Scale score of 3 to 12 on admission. This study included 3074 patients with moderate-to-severe TBI. INTERVENTIONS Patients were classified into an early rehabilitation group (within 2 days of admission) or a delayed rehabilitation group (3 to 7 days postadmission), depending on when rehabilitation started after TBI. Rehabilitation was defined as any type or intensity of intervention provided by a physical, occupational, and/or speech/language therapist. Interventions were not controlled. MAIN OUTCOME MEASURE(S) The primary outcome was Barthel Index (BI) efficiency (BI gain/length of stay). Secondary outcomes included BI gain (discharge BI - admission BI), incidence of aspiration pneumonia complications during hospitalization, discharge to home, mortality, and length of stay. RESULTS After applying inverse probability weighting with propensity scores, the total was 6152 patients. 3074 (50.0%) patients received early rehabilitation. The early rehabilitation group showed no difference in inpatient mortality (p = .438), improved BI efficiency (β = 0.86, p < .001), and shorter length of stay (β = -5.00, p = .018). CONCLUSIONS Early rehabilitation in patients with moderate-to-severe TBI is associated with more efficient functional improvement and reduced hospital stays without an increase in inpatient mortality.
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Affiliation(s)
- Shota Hayashi
- Department of Physical Therapy, Faculty of Rehabilitation, Gunma Paz University, Takasaki, Japan
- Department of Health Science, Gunma Paz University Graduate School of Health Sciences, Takasaki, Japan
| | - Tomohiko Kamo
- Department of Physical Therapy, Faculty of Rehabilitation, Gunma Paz University, Takasaki, Japan
| | - Ryo Momosaki
- Department of Rehabilitation Medicine, Mie University Graduate School of Medicine, Tsu, Japan
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Mofakham S, Robertson J, Lubin N, Cleri NA, Mikell CB. An Unpredictable Brain Is a Conscious, Responsive Brain. J Cogn Neurosci 2024; 36:1643-1652. [PMID: 38579270 DOI: 10.1162/jocn_a_02154] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/07/2024]
Abstract
Severe traumatic brain injuries typically result in loss of consciousness or coma. In deeply comatose patients with traumatic brain injury, cortical dynamics become simple, repetitive, and predictable. We review evidence that this low-complexity, high-predictability state results from a passive cortical state, represented by a stable repetitive attractor, that hinders the flexible formation of neuronal ensembles necessary for conscious experience. Our data and those from other groups support the hypothesis that this cortical passive state is because of the loss of thalamocortical input. We identify the unpredictability and complexity of cortical dynamics captured by local field potential as a sign of recovery from this passive coma attractor. In this Perspective article, we discuss how these electrophysiological biomarkers of the recovery of consciousness could inform the design of closed-loop stimulation paradigms to treat disorders of consciousness.
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Bath J, Barylak M, Kedda E, Harvey E, Locklear T, Martinez M, Collier B, Weppner J. Timing of withdrawal of life-sustaining therapy in traumatic brain injury: exploring indicators of poor prognosis in adult and geriatric populations. Brain Inj 2024; 38:267-272. [PMID: 38294172 DOI: 10.1080/02699052.2024.2309656] [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: 08/02/2023] [Accepted: 01/20/2024] [Indexed: 02/01/2024]
Abstract
OBJECTIVE The lack of objective prognostication tools for severe traumatic brain injury (TBI) causes variability in the application of withdrawal of life-saving treatment (WLST). We aimed to determine whether WLST in persons with severe TBI is associated with known indicators of poor prognosis. METHODS This retrospective descriptive study focused on adult (18-64 years) and geriatric (≥65 years) patients with severe TBI who were admitted between August 1, 2018 and July 31, 2021 at a Level I trauma center and subsequently underwent WLST. The data collected from the Trauma Registry and electronic health records included information regarding demographic characteristics, injury severity, clinical variables, and length of hospital stay and were used to examine the indicators of poor prognosis and WLST. RESULTS Among the 164 participants with TBI who met the inclusion criteria, 61.0% were geriatric, and 122 (74.4%) patients had 0 or only 1 of the poor prognostic indicators prior to WLST. The non-geriatric group had more indicators of poor prognosis than the geriatric group. Participants with fewer indicators of poor prognosis had a longer length-of-stay. CONCLUSION In severe TBI cases, standardized prognostication tools can help guide informed WLST decisions, particularly in geriatric patients, improving care consistency.
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Affiliation(s)
| | - Martin Barylak
- Virginia Tech Carilion School of Medicine, Roanoke, VA, USA
| | - Edward Kedda
- Edward Via College of Osteopathic Medicine, Blacksburg, VA, USA
| | | | | | | | - Bryan Collier
- Carilion Clinic, Roanoke, VA, USA
- Department of Surgery, Virginia Tech Carilion School of Medicine, Roanoke, VA, USA
| | - Justin Weppner
- Carilion Clinic, Roanoke, VA, USA
- Department of Internal Medicine, Virginia Tech Carilion School of Medicine, Roanoke, VA, USA
- Department of Internal Medicine, Edward Via College of Osteopathic Medicine, Blacksburg, VA, USA
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Niemeyer MJS, Jochems D, Van Ditshuizen JC, de Kanter J, Cremers L, van Hattem M, Den Hartog D, Houwert RM, Leenen LPH, van Wessem KJP. Clinical outcomes and end-of-life treatment in 596 patients with isolated traumatic brain injury: a retrospective comparison of two Dutch level-I trauma centers. Eur J Trauma Emerg Surg 2024:10.1007/s00068-023-02407-5. [PMID: 38226991 DOI: 10.1007/s00068-023-02407-5] [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: 08/31/2023] [Accepted: 11/12/2023] [Indexed: 01/17/2024]
Abstract
PURPOSE With an increasingly older population and rise in incidence of traumatic brain injury (TBI), end-of-life decisions have become frequent. This study investigated the rate of withdrawal of life sustaining treatment (WLST) and compared treatment outcomes in patients with isolated TBI in two Dutch level-I trauma centers. METHODS From 2011 to 2016, a retrospective cohort study of patients aged ≥ 18 years with isolated moderate-to-severe TBI (Abbreviated Injury Scale (AIS) head ≥ 3) was conducted at the University Medical Center Rotterdam (UMC-R) and the University Medical Center Utrecht (UMC-U). Demographics, radiologic injury characteristics, clinical outcomes, and functional outcomes at 3-6 months post-discharge were collected. RESULTS The study population included 596 patients (UMC-R: n = 326; UMC-U: n = 270). There were no statistical differences in age, gender, mechanism of injury, and radiologic parameters between both institutes. UMC-R patients had a higher AIShead (UMC-R: 5 [4-5] vs. UMC-U: 4 [4-5], p < 0.001). There was no difference in the prehospital Glasgow Coma Scale (GCS). However, UMC-R patients had lower GCSs in the Emergency Department and used more prehospital sedation. Total in-hospital mortality was 29% (n = 170), of which 71% (n = 123) occurred after WLST. Two percent (n = 10) remained in unresponsive wakefulness syndrome (UWS) state during follow-up. DISCUSSION This study demonstrated a high WLST rate among deceased patients with isolated TBI. Demographics and outcomes were similar for both centers even though AIShead was significantly higher in UMC-R patients. Possibly, prehospital sedation might have influenced AIS coding. Few patients persisted in UWS. Further research is needed on WLST patients in a broader spectrum of ethics, culture, and complex medical profiles, as it is a growing practice in modern critical care. LEVEL OF EVIDENCE Level III, retrospective cohort study.
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Affiliation(s)
- Menco J S Niemeyer
- Department of Trauma Surgery, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX, Utrecht, The Netherlands.
| | - Denise Jochems
- Department of Trauma Surgery, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX, Utrecht, The Netherlands
| | - Jan C Van Ditshuizen
- Trauma Research Unit, Department of Surgery, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
- Trauma Center Southwest Netherlands, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Janneke de Kanter
- Department of Radiology, UMC Division Imaging and Oncology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Lotte Cremers
- Department of Radiology, Jeroen Bosch Hospital, 's Hertogenbosch, The Netherlands
| | - Martijn van Hattem
- Department of Radiology, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Dennis Den Hartog
- Trauma Research Unit, Department of Surgery, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
- Trauma Center Southwest Netherlands, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Roderick Marijn Houwert
- Department of Trauma Surgery, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX, Utrecht, The Netherlands
| | - Luke P H Leenen
- Department of Trauma Surgery, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX, Utrecht, The Netherlands
| | - Karlijn J P van Wessem
- Department of Trauma Surgery, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX, Utrecht, The Netherlands
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Overbeek BUH, van Erp WS, Eilander HJ, Koopmans RTCM, Lavrijsen JCM. Prevalence of the Minimally Conscious State Among Institutionalized Patients in the Netherlands: A Nationwide Study. Neurology 2023; 101:e2005-e2013. [PMID: 37857492 PMCID: PMC10662977 DOI: 10.1212/wnl.0000000000207820] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2023] [Accepted: 08/03/2023] [Indexed: 10/21/2023] Open
Abstract
BACKGROUND AND OBJECTIVES The minimally conscious state (MCS) is a prolonged disorder of consciousness (pDoC) and one of the most severe outcomes of acquired brain injury. Prevalence data are scarce. The aim of this study was to establish the nationwide point prevalence of institutionalized patients in MCS in the Netherlands. METHODS This was a descriptive cross-sectional study in which all 86 Dutch hospitals, all 5 specialized pDoC rehabilitation facilities, and all 274 nursing homes were asked whether they were treating patients with a pDoC on the point prevalence date of September 15, 2021. Each patient's legal representative provided informed consent for their inclusion. Patient level of consciousness was verified using the Coma Recovery Scale-Revised (CRS-R) in a single assessment session performed in the facility of residence by an experienced physician. Data on patient demographics, etiology, level of consciousness, facility of residence, and clinical status were collected from a questionnaire by the treating physician. The prevalence of institutionalized patients in MCS of per 100,000 members of the Dutch population was calculated, based on actual census data. RESULTS Seventy patients were reported to have a pDoC, of whom 6 were excluded. The level of consciousness was verified for 49 patients while for 15, it could not be verified. Of the patients verified, 38 had a pDoC, of whom 32 were in MCS (mean age 44.8 years, 68.8% male). The prevalence of institutionalized patients in MCS is 0.2-0.3 per 100,000 Dutch inhabitants. Traumatic brain injury was present in 21 of 32 patients (65.6%). Specialized pDoC rehabilitation was received by 17 of 32 patients (53%), with the rest admitted to nursing homes. The most frequent signs of consciousness on the CRS-R were visual pursuit, reproducible movement to command, and automatic motor response. DISCUSSION This nationwide study revealed a low prevalence of institutionalized patients in MCS in the Netherlands. These findings are now being used to organize pDoC care in this country.
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Affiliation(s)
- Berno U H Overbeek
- From the Department of Primary and Community Care (B.U.H.O., W.S.v.E., H.J.E., R.T.C.M.K., J.C.M.L.), Radboud University Medical Center, Research Institute of Medical Innovation; Kalorama (B.U.H.O.), Beek-Ubbergen; Azora (B.U.H.O.), Terborg; Accolade Zorg (W.S.v.E.), Bosch en Duin; Libra Rehabilitation & Audiology (W.S.v.E.), Tilburg; and Joachim and Anna, Center for Specialized Geriatric Care (R.T.C.M.K.), Nijmegen, the Netherlands.
| | - Willemijn S van Erp
- From the Department of Primary and Community Care (B.U.H.O., W.S.v.E., H.J.E., R.T.C.M.K., J.C.M.L.), Radboud University Medical Center, Research Institute of Medical Innovation; Kalorama (B.U.H.O.), Beek-Ubbergen; Azora (B.U.H.O.), Terborg; Accolade Zorg (W.S.v.E.), Bosch en Duin; Libra Rehabilitation & Audiology (W.S.v.E.), Tilburg; and Joachim and Anna, Center for Specialized Geriatric Care (R.T.C.M.K.), Nijmegen, the Netherlands
| | - Henk J Eilander
- From the Department of Primary and Community Care (B.U.H.O., W.S.v.E., H.J.E., R.T.C.M.K., J.C.M.L.), Radboud University Medical Center, Research Institute of Medical Innovation; Kalorama (B.U.H.O.), Beek-Ubbergen; Azora (B.U.H.O.), Terborg; Accolade Zorg (W.S.v.E.), Bosch en Duin; Libra Rehabilitation & Audiology (W.S.v.E.), Tilburg; and Joachim and Anna, Center for Specialized Geriatric Care (R.T.C.M.K.), Nijmegen, the Netherlands
| | - Raymond T C M Koopmans
- From the Department of Primary and Community Care (B.U.H.O., W.S.v.E., H.J.E., R.T.C.M.K., J.C.M.L.), Radboud University Medical Center, Research Institute of Medical Innovation; Kalorama (B.U.H.O.), Beek-Ubbergen; Azora (B.U.H.O.), Terborg; Accolade Zorg (W.S.v.E.), Bosch en Duin; Libra Rehabilitation & Audiology (W.S.v.E.), Tilburg; and Joachim and Anna, Center for Specialized Geriatric Care (R.T.C.M.K.), Nijmegen, the Netherlands
| | - Jan C M Lavrijsen
- From the Department of Primary and Community Care (B.U.H.O., W.S.v.E., H.J.E., R.T.C.M.K., J.C.M.L.), Radboud University Medical Center, Research Institute of Medical Innovation; Kalorama (B.U.H.O.), Beek-Ubbergen; Azora (B.U.H.O.), Terborg; Accolade Zorg (W.S.v.E.), Bosch en Duin; Libra Rehabilitation & Audiology (W.S.v.E.), Tilburg; and Joachim and Anna, Center for Specialized Geriatric Care (R.T.C.M.K.), Nijmegen, the Netherlands
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van Wessem KJP, Niemeyer MJS, Leenen LPH. Polytrauma patients with severe cervical spine injuries are different than with severe TBI despite similar AIS scores. Sci Rep 2022; 12:21538. [PMID: 36513675 PMCID: PMC9747955 DOI: 10.1038/s41598-022-25809-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2022] [Accepted: 12/05/2022] [Indexed: 12/15/2022] Open
Abstract
Traumatic cervical spine injuries (TCSI) are rare injuries. With increasing age the incidence of TCSI is on the rise. TCSI and traumatic brain injury (TBI) are often associated. Both TCSI and TBI are allocated to the Abbreviated Injury Scale (AIS) head region. However, the nature and outcome of these injuries are potentially different. Therefore, the aim of this study was to investigate the epidemiology, demographics and outcome of severely injured patients with severe TCSI, and compare them with polytrauma patients with severe TBI in the strict sense. Consecutive polytrauma patients aged ≥ 15 years with AIShead ≥ 3 who were admitted to a level-1 trauma center Intensive Care Unit (ICU) from 2013 to 2021 were included. Demographics, treatment, and outcome parameters were analyzed for patients who had AIShead ≥ 3 based on TCSI and compared to patients with AIShead ≥ 3 based on proper TBI. Data on follow-up were collected for TCSI patients. Two hundred eighty-four polytrauma patients (68% male, Injury Severity Score (ISS) 33) with AIShead ≥ 3 were included; Thirty-one patients (11%) had AIShead ≥ 3 based on TCSI whereas 253 (89%) had AIShead ≥ 3 based on TBI. TCSI patients had lower systolic blood pressure in the Emergency Department (ED) and stayed longer in ICU than TBI patients. There was no difference in morbidity and mortality rates. TCSI patients died due to high cervical spine injuries or respiratory insufficiency, whereas TBI patients died primarily due to TBI. TCSI was mainly located at C2, and 58% had associated spinal cord injury. Median follow-up time was 22 months. Twenty-two percent had improvement of the spinal cord injury, and 10% died during follow-up. In this study the incidence of severe TCSI in polytrauma was much lower than TBI. Cause of death in TCSI was different compared to TBI demonstrating that AIShead based on TCSI is a different entity than based on TBI. In order to avoid data misinterpretation injuries to the cervical spine should be distinguished from TBI in morbidity and mortality analysis.
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Affiliation(s)
- Karlijn J. P. van Wessem
- grid.7692.a0000000090126352Department of Trauma Surgery, University Medical Center Utrecht, Utrecht, The Netherlands ,grid.7692.a0000000090126352Department of Trauma Surgery, University Medical Center Utrecht, Suite G04.232, Heidelberglaan 100, 3584 CX Utrecht, The Netherlands
| | - Menco J. S. Niemeyer
- grid.7692.a0000000090126352Department of Trauma Surgery, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Luke P. H. Leenen
- grid.7692.a0000000090126352Department of Trauma Surgery, University Medical Center Utrecht, Utrecht, The Netherlands
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Tanizaki S, Toma Y, Miyashita K, Maeda S. The Characteristics of Withdrawal or Withholding of Life-Sustaining Treatment in Severe Traumatic Brain Injury: A Single Japanese Institutional Study. World Neurosurg X 2022; 17:100144. [PMID: 36353247 PMCID: PMC9637969 DOI: 10.1016/j.wnsx.2022.100144] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2022] [Accepted: 09/27/2022] [Indexed: 11/22/2022] Open
Abstract
OBJECTIVES There is little evidence on the factors influencing the decision to withdraw or continue life-sustaining treatment in the setting of severe traumatic brain injury in Japanese institutions. We investigated the factors associated with the withdrawal or withholding of life-sustaining treatment (WLST) for severe traumatic brain injury at a single Japanese institution. METHODS A total of 161 patients with severe traumatic brain injury were retrospectively reviewed. Patient characteristics and injury types were compared between patients with and without the WLST. RESULTS Of the 161 patients, 87 (54%) died and 52 (32%) decided to undergo WLST. In 98% of the WLST cases, the decision was made within 24 h of admission. The mean duration between WLST and death was 2 days. The predicted probabilities for mortality and unfavorable outcomes were highest in patients with WLST within 24 h. Patients with WLST were older and had a higher frequency of falls on the ground, ischemic heart disease, and acute subdural hemorrhage than those without WLST. CONCLUSIONS The decisions of almost all WLST cases were made within 24 h of admission for severe traumatic brain injury in a Japanese institution because of Japanese patients' religious and cultural backgrounds.
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Affiliation(s)
- Shinsuke Tanizaki
- Department of Emergency Medicine, Fukui Prefectural Hospital, Fukui, Japan,To whom correspondence should be addressed: Shinsuke Tanizaki, M.D.
| | - Yasuo Toma
- Department of Neurosurgery, Fukui Prefectural Hospital, Fukui, Japan
| | | | - Shigenobu Maeda
- Department of Emergency Medicine, Fukui Prefectural Hospital, Fukui, Japan
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Driessen MLS, de Jongh MAC, Sturms LM, Bloemers FW, Ten Duis HJ, Edwards MJR, Hartog DD, Leenhouts PA, Poeze M, Schipper IB, Spanjersberg RW, Wendt KW, de Wit RJ, van Zutphen SWAM, Leenen LPH. Severe isolated injuries have a high impact on resource use and mortality: a Dutch nationwide observational study. Eur J Trauma Emerg Surg 2022; 48:4267-4276. [PMID: 35445813 DOI: 10.1007/s00068-022-01972-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2022] [Accepted: 04/02/2022] [Indexed: 11/29/2022]
Abstract
PURPOSE The Berlin poly-trauma definition (BPD) has proven to be a valuable way of identifying patients with at least a 20% risk of mortality, by combining anatomical injury characteristics with the presence of physiological risk factors (PRFs). Severe isolated injuries (SII) are excluded from the BPD. This study describes the characteristics, resource use and outcomes of patients with SII according to their injured body region, and compares them with those included in the BPD. METHODS Data were extracted from the Dutch National Trauma Registry between 2015 and 2019. SII patients were defined as those with an injury with an Abbreviated Injury Scale (AIS) score ≥ 4 in one body region, with at most minor additional injuries (AIS ≤ 2). We performed an SII subgroup analysis per AIS region of injury. Multivariable linear and logistic regression models were used to calculate odds ratios (ORs) for SII subgroup patient outcomes, and resource needs. RESULTS A total of 10.344 SII patients were included; 47.8% were ICU admitted, and the overall mortality was 19.5%. The adjusted risk of death was highest for external (2.5, CI 1.9-3.2) and for head SII (2.0, CI 1.7-2.2). Patients with SII to the abdomen (2.3, CI 1.9-2.8) and thorax (1.8, CI 1.6-2.0) had a significantly higher risk of ICU admission. The highest adjusted risk of disability was recorded for spine injuries (10.3, CI 8.3-12.8). The presence of ≥ 1 PRFs was associated with higher mortality rates compared to their poly-trauma counterparts, displaying rates of at least 15% for thoracic, 17% for spine, 22% for head and 49% for external SII. CONCLUSION A severe isolated injury is a high-risk entity and should be recognized and treated as such. The addition of PRFs to the isolated anatomical injury criteria contributes to the identification of patients with SII at risk of worse outcomes.
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Affiliation(s)
- Mitchell L S Driessen
- Dutch Network Emergency Care ((LNAZ)), Newtonlaan 115, 3584 BH, Utrecht, The Netherlands.
| | - Mariska A C de Jongh
- Network Emergency Care Brabant, P.O. Box 90151, 5000 LC, Tilburg, The Netherlands
| | - Leontien M Sturms
- Dutch Network Emergency Care ((LNAZ)), Newtonlaan 115, 3584 BH, Utrecht, The Netherlands
| | - Frank W Bloemers
- Department of Surgery, Amsterdam University Medical Center, Location VU, P.O. Box 1081 HV, Amsterdam, The Netherlands
| | | | - Michael J R Edwards
- Department of Trauma Surgery, Radboud University Medical Center, 618., P.O. Box 9101, 6500 HB, Nijmegen, The Netherlands
| | - Dennis den Hartog
- Trauma Research Unit, Department of Surgery, Erasmus MC, Rotterdam, P.O. Box 3000 CA, Rotterdam, The Netherlands
| | - Peter A Leenhouts
- Department of Surgery, Amsterdam University Medical Center, Location AMC, Amsterdam, The Netherlands
| | - Martijn Poeze
- Department of Surgery, Maastricht University Medical Center, P.O. Box 5800, 6202 AZ, Maastricht, The Netherlands
| | - Inger B Schipper
- Department of Trauma Surgery, Leiden University Medical Center, P.O Box 9600, 2300 RC, Leiden, The Netherlands
| | | | - Klaus W Wendt
- Department of Trauma Surgery, University Medical Center Groningen, P.O Box 30.001, 9700 RB, Groningen,, The Netherlands
| | - Ralph J de Wit
- Department of Trauma Surgery, Medical Spectrum Twente, P.O. Box 50000, 7500 KA, Enschede, The Netherlands
| | - Stefan W A M van Zutphen
- Department of Surgery, Elisabeth Two Cities Hospital, P.O. Box 90151, 5000 LC, Tilburg, The Netherlands
| | - Luke P H Leenen
- Department of Surgery, University Medical Center Utrecht, P.O. Box 85500, 3508 GA, Utrecht, The Netherlands
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Mortality in polytrauma patients with moderate to severe TBI on par with isolated TBI patients: TBI as last frontier in polytrauma patients. Injury 2022; 53:1443-1448. [PMID: 35067344 DOI: 10.1016/j.injury.2022.01.009] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/04/2020] [Revised: 12/07/2021] [Accepted: 01/02/2022] [Indexed: 02/02/2023]
Abstract
BACKGROUND Mortality caused by Traumatic Brain Injury (TBI) remains high, despite improvements in trauma and critical care. Polytrauma is naturally associated with high mortality. This study compared mortality rates between isolated TBI (ITBI) patients and polytrauma patients with TBI (PTBI) admitted to ICU to investigate if concomitant injuries lead to higher mortality amongst TBI patients. METHODS A 3-year cohort study compared polytrauma patients with TBI (PTBI) with AIS head ≥3 (and AIS of other body regions ≥3) from a prospective collected database to isolated TBI (ITBI) patients from a retrospective collected database with AIS head ≥3 (AIS of other body regions ≤2), both admitted to a single level-I trauma center ICU. Patients <16 years of age, injury caused by asphyxiation, drowning, burns and ICU transfers from and to other hospitals were excluded. Patient demographics, shock and resuscitation parameters, multiple organ dysfunction syndrome (MODS), acute respiratory distress syndrome (ARDS), and mortality data were collected and analyzed for group differences. RESULTS 259 patients were included; 111 PTBI and 148 ITBI patients. The median age was 54 [33-67] years, 177 (68%) patients were male, median ISS was 26 [20-33]. Seventy-nine (31%) patients died. Patients with PTBI developed more ARDS (7% vs. 1%, p = 0.041) but had similar MODS rates (18% vs. 10%, p = 0.066). They also stayed longer on the ventilator (7 vs. 3 days, p=<0.001), longer in ICU (9 vs. 4 days, p=<0.001) and longer in hospital (24 vs. 11 days, p=<0.001). TBI was the most prevalent cause of death in polytrauma patients. Patients with PTBI showed no higher in-hospital mortality rate. Moreover, mortality rates were skewed towards ITBI patients (24% vs. 35%, p = 0.06). DISCUSSION There was no difference in mortality rates between PTBI and ITBI patients, suggesting TBI-severity as the predominant factor for ICU mortality in an era of ever improving acute trauma care.
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Tverdal C, Aarhus M, Rønning P, Skaansar O, Skogen K, Andelic N, Helseth E. Incidence of emergency neurosurgical TBI procedures: a population-based study. BMC Emerg Med 2022; 22:1. [PMID: 34991477 PMCID: PMC8734328 DOI: 10.1186/s12873-021-00561-w] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2021] [Accepted: 11/28/2021] [Indexed: 12/28/2022] Open
Abstract
BACKGROUND The rates of emergency neurosurgery in traumatic brain injury (TBI) patients vary between populations and trauma centers. In planning acute TBI treatment, knowledge about rates and incidence of emergency neurosurgery at the population level is of importance for organization and planning of specialized health care services. This study aimed to present incidence rates and patient characteristics for the most common TBI-related emergency neurosurgical procedures. METHODS Oslo University Hospital is the only trauma center with neurosurgical services in Southeast Norway, which has a population of 3 million. We extracted prospectively collected registry data from the Oslo TBI Registry - Neurosurgery over a five-year period (2015-2019). Incidence was calculated in person-pears (crude) and age-adjusted for standard population. We conducted multivariate multivariable logistic regression models to assess variables associated with emergency neurosurgical procedures. RESULTS A total of 2151 patients with pathological head CT scans were included. One or more emergency neurosurgical procedure was performed in 27% of patients. The crude incidence was 3.9/100,000 person-years. The age-adjusted incidences in the standard population for Europe and the world were 4.0/100,000 and 3.3/100,000, respectively. The most frequent emergency neurosurgical procedure was the insertion of an intracranial pressure monitor, followed by evacuation of the mass lesion. Male sex, road traffic accidents, severe injury (low Glasgow coma score) and CT characteristics such as midline shift and compressed/absent basal cisterns were significantly associated with an increased probability of emergency neurosurgery, while older age was associated with a decreased probability. CONCLUSIONS The incidence of emergency neurosurgery in the general population is low and reflects neurosurgery procedures performed in patients with severe injuries. Hence, emergency neurosurgery for TBIs should be centralized to major trauma centers.
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Affiliation(s)
- Cathrine Tverdal
- Department of Neurosurgery, Oslo University Hospital, P. O. Box 4956 Nydalen, 0424, Oslo, Norway.
- Faculty of Medicine, Institute of Clinical Medicine, University of Oslo, Boks 1072 Blindern, 0316, Oslo, Norway.
| | - Mads Aarhus
- Department of Neurosurgery, Oslo University Hospital, P. O. Box 4956 Nydalen, 0424, Oslo, Norway
| | - Pål Rønning
- Department of Neurosurgery, Oslo University Hospital, P. O. Box 4956 Nydalen, 0424, Oslo, Norway
| | - Ola Skaansar
- Department of Neurosurgery, Oslo University Hospital, P. O. Box 4956 Nydalen, 0424, Oslo, Norway
- Faculty of Medicine, Institute of Clinical Medicine, University of Oslo, Boks 1072 Blindern, 0316, Oslo, Norway
| | - Karoline Skogen
- Department of Neuroradiology, Oslo University Hospital, P. O. Box 4956 Nydalen, 0424, Oslo, Norway
| | - Nada Andelic
- Department of Physical Medicine and Rehabilitation, Oslo University Hospital, P. O. Box 4956 Nydalen, 0424, Oslo, Norway
- Research Centre for Habilitation and Rehabilitation Models and Services (CHARM), Faculty of Medicine, Institute of Health and Society, University of Oslo, Boks 1072 Blindern, 0316, Oslo, Norway
| | - Eirik Helseth
- Department of Neurosurgery, Oslo University Hospital, P. O. Box 4956 Nydalen, 0424, Oslo, Norway
- Faculty of Medicine, Institute of Clinical Medicine, University of Oslo, Boks 1072 Blindern, 0316, Oslo, Norway
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11
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Jochems D, van Rein E, Niemeijer M, van Heijl M, van Es MA, Nijboer T, Leenen LPH, Houwert RM, van Wessem KJP. Incidence, causes and consequences of moderate and severe traumatic brain injury as determined by Abbreviated Injury Score in the Netherlands. Sci Rep 2021; 11:19985. [PMID: 34620973 PMCID: PMC8497630 DOI: 10.1038/s41598-021-99484-6] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2021] [Accepted: 09/08/2021] [Indexed: 11/29/2022] Open
Abstract
Traumatic brain injury (TBI) is a leading cause of death and disability. Epidemiology seems to be changing. TBIs are increasingly caused by falls amongst elderly, whilst we see less polytrauma due to road traffic accidents (RTA). Data on epidemiology is essential to target prevention strategies. A nationwide retrospective cohort study was conducted. The Dutch National Trauma Database was used to identify all patients over 17 years old who were admitted to a hospital with moderate and severe TBI (AIS ≥ 3) in the Netherlands from January 2015 until December 2017. Subgroup analyses were done for the elderly and polytrauma patients. 12,295 patients were included in this study. The incidence of moderate and severe TBI was 30/100.000 person-years, 13% of whom died. Median age was 65 years and falls were the most common trauma mechanism, followed by RTAs. Amongst elderly, RTAs consisted mostly of bicycle accidents. Mortality rates were higher for elderly (18%) and polytrauma patients (24%). In this national database more elderly patients who most often sustained the injury due to a fall or an RTA were seen. Bicycle accidents were very frequent, suggesting prevention could be an important aspect in order to decrease morbidity and mortality.
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Affiliation(s)
- Denise Jochems
- Department of Surgery, University Medical Center Utrecht, PO Box 85500, 3508 GA, Utrecht, The Netherlands.
| | - Eveline van Rein
- Department of Surgery, University Medical Center Utrecht, PO Box 85500, 3508 GA, Utrecht, The Netherlands
| | - Menco Niemeijer
- Department of Surgery, University Medical Center Utrecht, PO Box 85500, 3508 GA, Utrecht, The Netherlands
| | - Mark van Heijl
- Department of Surgery, University Medical Center Utrecht, PO Box 85500, 3508 GA, Utrecht, The Netherlands
| | - Michael A van Es
- Department of Neurology, University Medical Center Utrecht and de Hoogstraat Rehabilitation, Utrecht, The Netherlands
| | - Tanja Nijboer
- Department of Experimental Psychology, Helmholtz Institute, Utrecht University, Utrecht, The Netherlands.,Center of Excellence for Rehabilitation Medicine, UMC Utrecht Brain Center, University Medical Center Utrecht, and De Hoogstraat Rehabilitation, Utrecht, The Netherlands
| | - Luke P H Leenen
- Department of Surgery, University Medical Center Utrecht, PO Box 85500, 3508 GA, Utrecht, The Netherlands
| | - R Marijn Houwert
- Department of Surgery, University Medical Center Utrecht, PO Box 85500, 3508 GA, Utrecht, The Netherlands
| | - Karlijn J P van Wessem
- Department of Surgery, University Medical Center Utrecht, PO Box 85500, 3508 GA, Utrecht, The Netherlands
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12
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Ehsani S, Reddy CK, Foreman B, Ratcliff J, Subbian V. Subspace Clustering of Physiological Data From Acute Traumatic Brain Injury Patients: Retrospective Analysis Based on the PROTECT III Trial. JMIR BIOMEDICAL ENGINEERING 2021; 6:e24698. [PMID: 38907379 PMCID: PMC11041422 DOI: 10.2196/24698] [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: 10/01/2020] [Revised: 12/31/2020] [Accepted: 01/16/2021] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND With advances in digital health technologies and proliferation of biomedical data in recent years, applications of machine learning in health care and medicine have gained considerable attention. While inpatient settings are equipped to generate rich clinical data from patients, there is a dearth of actionable information that can be used for pursuing secondary research for specific clinical conditions. OBJECTIVE This study focused on applying unsupervised machine learning techniques for traumatic brain injury (TBI), which is the leading cause of death and disability among children and adults aged less than 44 years. Specifically, we present a case study to demonstrate the feasibility and applicability of subspace clustering techniques for extracting patterns from data collected from TBI patients. METHODS Data for this study were obtained from the Progesterone for Traumatic Brain Injury, Experimental Clinical Treatment-Phase III (PROTECT III) trial, which included a cohort of 882 TBI patients. We applied subspace-clustering methods (density-based, cell-based, and clustering-oriented methods) to this data set and compared the performance of the different clustering methods. RESULTS The analyses showed the following three clusters of laboratory physiological data: (1) international normalized ratio (INR), (2) INR, chloride, and creatinine, and (3) hemoglobin and hematocrit. While all subclustering algorithms had a reasonable accuracy in classifying patients by mortality status, the density-based algorithm had a higher F1 score and coverage. CONCLUSIONS Clustering approaches serve as an important step for phenotype definition and validation in clinical domains such as TBI, where patient and injury heterogeneity are among the major reasons for failure of clinical trials. The results from this study provide a foundation to develop scalable clustering algorithms for further research and validation.
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Affiliation(s)
- Sina Ehsani
- Department of Systems and Industrial Engineering, College of Engineering, The University of Arizona, Tucson, AZ, United States
| | - Chandan K Reddy
- Department of Computer Science, Virginia Polytechnic Institute and State University, Arlington, VA, United States
| | - Brandon Foreman
- Department of Neurology & Rehabilitation Medicine, University of Cincinnati, Cincinnati, OH, United States
| | - Jonathan Ratcliff
- Department of Emergency Medicine, Emory University School of Medicine, Emory University, Atlanta, GA, United States
| | - Vignesh Subbian
- Department of Systems and Industrial Engineering, College of Engineering, The University of Arizona, Tucson, AZ, United States
- Department of Biomedical Engineering, College of Engineering, The University of Arizona, Tucson, AZ, United States
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13
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van Wessem KJP, Leenen LPH. Geriatric polytrauma patients should not be excluded from aggressive injury treatment based on age alone. Eur J Trauma Emerg Surg 2020; 48:357-365. [PMID: 33320284 PMCID: PMC7736672 DOI: 10.1007/s00068-020-01567-y] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2020] [Accepted: 11/25/2020] [Indexed: 12/02/2022]
Abstract
Purpose Age in severely injured patients has been increasing for decades. Older age is associated with increasing mortality. However, morbidity and mortality could possibly be reduced when accurate and aggressive treatment is provided. This study investigated age-related morbidity and mortality in polytrauma including age-related decisions in initial injury management and withdrawal of life-sustaining therapy (WLST). Methods A 6.5-year prospective cohort study included consecutive severely injured trauma patients admitted to a Level-1 Trauma Center ICU. Demographics, data on physiology, resuscitation, MODS/ARDS, and infectious complications were prospectively collected. Patients were divided into age subgroups (< 25, 25–49, 50–69, and ≥ 70 years) to make clinically relevant comparisons. Results 391 patients (70% males) were included with median ISS of 29 (22–36), 95% sustained blunt injuries. There was no difference in injury severity, resuscitation, urgent surgeries, nor in ventilator days, ICU-LOS, and H-LOS between age groups. Adjusted odds of MODS, ARDS and infectious complications were similar between age groups. 47% of patients ≥ 70 years died, compared to 10–16% in other age groups (P < 0.001). WLST increased with older age, contributing to more than half of deaths ≥ 70 years. TBI was the most common cause of death and decision for treatment withdrawal in all age groups. Conclusions Patients ≥ 70 years had higher mortality risk even though injury severity and complication rates were similar to other age groups. WLST increased with age with the vast majority due to brain injury. More than half of patients ≥ 70 years survived suggesting geriatric polytrauma patients should not be excluded from aggressive injury treatment based on age alone. Supplementary Information The online version contains supplementary material available at 10.1007/s00068-020-01567-y.
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Affiliation(s)
- Karlijn J P van Wessem
- Trauma Surgeon, Department of Trauma Surgery, University Medical Center Utrecht, Utrecht, The Netherlands.
| | - Luke P H Leenen
- Professor of Trauma Surgery, Department of Trauma Surgery, University Medical Center Utrecht, Utrecht, the Netherlands
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14
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Skaansar O, Tverdal C, Rønning PA, Skogen K, Brommeland T, Røise O, Aarhus M, Andelic N, Helseth E. Traumatic brain injury-the effects of patient age on treatment intensity and mortality. BMC Neurol 2020; 20:376. [PMID: 33069218 PMCID: PMC7568018 DOI: 10.1186/s12883-020-01943-6] [Citation(s) in RCA: 29] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2020] [Accepted: 09/29/2020] [Indexed: 12/21/2022] Open
Abstract
Background Ageing is associated with worse treatment outcome after traumatic brain injury (TBI). This association may lead to a self-fulfilling prophecy that affects treatment efficacy. The aim of the current study was to evaluate the role of treatment bias in patient outcomes by studying the intensity of diagnostic procedures, treatment, and overall 30-day mortality in different age groups of patients with TBI. Methods Included in this study was consecutively admitted patients with TBI, aged ≥ 15 years, with a cerebral CT showing intracranial signs of trauma, during the time-period between 2015–2018. Data were extracted from our prospective quality control registry for admitted TBI patients. As a measure of management intensity in different age groups, we made a composite score, where placement of intracranial pressure monitor, ventilator treatment, and evacuation of intracranial mass lesion each gave one point. Uni- and multivariate survival analyses were performed using logistic multinomial regression. Results A total of 1,571 patients with TBI fulfilled the inclusion criteria. The median age was 58 years (range 15–98), 70% were men, and 39% were ≥ 65 years. Head injury severity was mild in 706 patients (45%), moderate in 437 (28%), and severe in 428 (27%). Increasing age was associated with less management intensity, as measured using the composite score, irrespective of head injury severity. Multivariate analyses showed that the following parameters had a significant association with an increased risk of death within 30 days of trauma: increasing age, severe comorbidities, severe TBI, Rotterdam CT-score ≥ 3, and low management intensity. Conclusion The present study indicates that the management intensity of hospitalised patients with TBI decreased with advanced age and that low management intensity was associated with an increased risk of 30-day mortality. This suggests that the high mortality among elderly TBI patients may have an element of treatment bias and could in the future be limited with a more aggressive management regime.
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Affiliation(s)
- Ola Skaansar
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway.
| | - Cathrine Tverdal
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway.,Department of Neurosurgery, Oslo University Hospital, Oslo, Norway
| | | | - Karoline Skogen
- Department of Radiology and Nuclear Medicine, Oslo University Hospital, Oslo, Norway
| | - Tor Brommeland
- Department of Neurosurgery, Oslo University Hospital, Oslo, Norway
| | - Olav Røise
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway.,Division of Orthopaedic Surgery, Oslo University Hospital, Oslo, Norway
| | - Mads Aarhus
- Department of Neurosurgery, Oslo University Hospital, Oslo, Norway
| | - Nada Andelic
- Department of Physical Medicine and Rehabilitation, Oslo University Hospital, Oslo, Norway.,Research Centre for Habilitation and Rehabilitation Models and Services (CHARM), Faculty of Medicine, Institute of Health and Society, University of Oslo, Oslo, Norway
| | - Eirik Helseth
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway.,Department of Neurosurgery, Oslo University Hospital, Oslo, Norway
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15
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Ke X, Yang M, Luo JM, Zhang Y, Chen XY. The role of serum Dickkopf-1 in predicting 30-day death in severe traumatic brain injury. Brain Behav 2020; 10:e01589. [PMID: 32324340 PMCID: PMC7303377 DOI: 10.1002/brb3.1589] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/07/2019] [Revised: 02/06/2020] [Accepted: 02/17/2020] [Indexed: 11/30/2022] Open
Abstract
OBJECTIVE Dickkopf-1 (DKK-1), an inhibitor of the canonical/-catenin cascade of the Wnt pathway, was upregulated in brain tissues of hemorrhagic stroke rats, and its rising circulating levels were associated with poor prognosis of acute ischemic stroke patients. We attempted to ascertain the relationship between serum DKK-1 levels and 30-day death after severe traumatic brain injury (sTBI). MATERIALS AND METHODS Serum DKK-1 levels were gauged in a total of 94 sTBI patients and 94 healthy controls. Trauma severity was assessed using Glasgow Coma Scale (GCS) and Rotterdam classification based on head computerized tomography scan. Prognostic variable was 30-day death. RESULTS Compared with controls, serum DKK-1 levels were substantially elevated in patients (median value, 3.7 versus 1.0 ng/ml). Area under receiver operating characteristic curve was 0.802 (95% confidence interval (CI), 0.708-0.877) for predicting 30-day death. Adjusted logistic regression showed that serum DKK-1 levels above 3.7 ng/ml remained as an independent marker of 30-day death (odds ratio, 8.573; 95% CI, 1.386-53.020) and overall survival (hazard ratio, 7.322; 95% CI, 1.320-40.622). An intimate correlation existed between DKK-1 levels and GCS scores (r = -.649) in addition to Rotterdam classification (r = .664). CONCLUSIONS High serum levels of DKK-1 are closely associated with increasing severity and rising short-term mortality of sTBI.
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Affiliation(s)
- Xin Ke
- Department of Critical Medicine, The Taizhou First People's Hospital, Taizhou, China
| | - Ming Yang
- Department of Neurosurgery, The Taizhou First People's Hospital, Taizhou, China
| | - Jin-Ming Luo
- Department of Critical Medicine, The Taizhou First People's Hospital, Taizhou, China
| | - Yu Zhang
- Department of Critical Medicine, The Taizhou First People's Hospital, Taizhou, China
| | - Xiao-Yu Chen
- Department of Critical Medicine, The Taizhou First People's Hospital, Taizhou, China
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16
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Bedry T, Tadele H. Pattern and Outcome of Pediatric Traumatic Brain Injury at Hawassa University Comprehensive Specialized Hospital, Southern Ethiopia: Observational Cross-Sectional Study. Emerg Med Int 2020; 2020:1965231. [PMID: 32399303 PMCID: PMC7204112 DOI: 10.1155/2020/1965231] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2019] [Revised: 11/26/2019] [Accepted: 12/13/2019] [Indexed: 12/16/2022] Open
Abstract
BACKGROUND Traumatic brain injury (TBI) is the most common cause of death/disability in children. The Glasgow coma scale and other parameters are used for treatment/follow-up of TBI. Childhood TBI data are scarce from sub-Saharan Africa. The study aimed to determine the pattern and predictors of the TBI outcome in Southern Ethiopia. METHODS An observational cross-sectional study was conducted from September 2017 to September 2018 at Hawassa University Hospital. Structured questionnaires were used for data collection. Significant associations were declared at a P value of <0.05. RESULTS There were 4,258 emergency room (ER) visits during the study period, and TBI contributed to 317 (7.4%) cases. The mean age of study subjects was 7.66 ± 3.88 years. Boys, predominantly above 5 years of age, comprise 218 (68.8%) of the study subjects with a male to female ratio of 2.2 : 1. Pedestrian road traffic accidents (RTA), 120 (37.9%), and falls, 104 (32.8%), were the commonest causes of TBI. Mild, moderate, and severe TBI were documented in 231 (72.9%), 61 (19.2%), and 25 (7.9%) of cases, respectively. Most of the TBI cases presented within 24 hrs of injury, 258 (81.4%). Recovery with no neurologic deficit, 267 (84.2%); focal neurologic deficit, 30 (9.5%); depressed mentation, 10 (3.2%); and death, 10 (3.2%), were documented. Signs of increased intracranial pressure (ICP) at admission [AOR: 1.415 (95% CI: 1.4058-9.557)], severe TBI [AOR: 2.553 (95% CI: 1.965-4.524)], presence of hyperglycemia [AOR: 2.318 (95% CI: 1.873-7.874)], and presence of contusion, diffuse axonal injury (DAI), or intracranial bleeding on the head computed tomography (CT) scan [AOR: 2.45 (95% CI: 1.811-7.952)] predicted poor TBI outcome. CONCLUSION TBI contributed to 7.4% of pediatric ER visits. Pedestrian RTA and falls, early presentation (<24 hours of injury), and mild form of TBI among boys were the most common documented patterns. ICP, hyperglycemia, severe TBI, and presence of contusion, DAI, or intracranial bleeding on head CT predicted poor outcome. Strategies to ensure road safety and to prevent falls and animal-related injuries and TBI follow-up for ICP and glycemic controls are recommended.
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Affiliation(s)
- Tuji Bedry
- Department of Pediatrics and Child Health, College of Health Sciences, Dire Dawa University, Dire Dawa, Ethiopia
| | - Henok Tadele
- Department of Pediatrics and Child Health, College of Health Sciences, Addis Ababa University, Addis Ababa, Ethiopia
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17
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Hietbrink F, Houwert RM, van Wessem KJP, Simmermacher RKJ, Govaert GAM, de Jong MB, de Bruin IGJ, de Graaf J, Leenen LPH. The evolution of trauma care in the Netherlands over 20 years. Eur J Trauma Emerg Surg 2019; 46:329-335. [PMID: 31760466 PMCID: PMC7113214 DOI: 10.1007/s00068-019-01273-4] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2019] [Accepted: 11/15/2019] [Indexed: 12/14/2022]
Abstract
Introduction In 1999 an inclusive trauma system was initiated in the Netherlands and a nationwide trauma registry, including all admitted trauma patients to every hospital, was started. The Dutch trauma system is run by trauma surgeons who treat both the truncal (visceral) and extremity injuries (fractures). Materials and Methods In this comprehensive review based on previous published studies, data over the past 20 years from the central region of the Netherlands (Utrecht) was evaluated. Results It is demonstrated that the initiation of the trauma systems and the governance by the trauma surgeons led to a region-wide mortality reduction of 50% and a mortality reduction for the most severely injured of 75% in the level 1 trauma centre. Furthermore, major improvements were found in terms of efficiency, demonstrating the quality of the current system and its constructs such as the type of surgeon. Due to the major reduction in mortality over the past few years, the emphasis of trauma care evaluation shifts towards functional outcome of severely injured patients. For the upcoming years, centralisation of severely injured patients should also aim at the balance between skills in primary resuscitation and surgical stabilization versus longitudinal surgical involvement. Conclusion Further centralisation to a limited number of level 1 trauma centres in the Netherlands is necessary to consolidate experience and knowledge for the trauma surgeon. The future trauma surgeon, as specialist for injured patients, should be able to provide the vast majority of trauma care in this system. For the remaining part, intramural, regional and national collaboration is essential
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Affiliation(s)
- Falco Hietbrink
- Department of Surgery, University Medical Centre Utrecht, Heidelberglaan 100, 3584 CX, Utrecht, The Netherlands.
| | - Roderick M Houwert
- Department of Surgery, University Medical Centre Utrecht, Heidelberglaan 100, 3584 CX, Utrecht, The Netherlands
| | - Karlijn J P van Wessem
- Department of Surgery, University Medical Centre Utrecht, Heidelberglaan 100, 3584 CX, Utrecht, The Netherlands
| | - Rogier K J Simmermacher
- Department of Surgery, University Medical Centre Utrecht, Heidelberglaan 100, 3584 CX, Utrecht, The Netherlands
| | - Geertje A M Govaert
- Department of Surgery, University Medical Centre Utrecht, Heidelberglaan 100, 3584 CX, Utrecht, The Netherlands
| | - Mirjam B de Jong
- Department of Surgery, University Medical Centre Utrecht, Heidelberglaan 100, 3584 CX, Utrecht, The Netherlands
| | - Ivar G J de Bruin
- Department of Surgery, University Medical Centre Utrecht, Heidelberglaan 100, 3584 CX, Utrecht, The Netherlands
| | - Johan de Graaf
- Department of Surgery, University Medical Centre Utrecht, Heidelberglaan 100, 3584 CX, Utrecht, The Netherlands
| | - Loek P H Leenen
- Department of Surgery, University Medical Centre Utrecht, Heidelberglaan 100, 3584 CX, Utrecht, The Netherlands
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