Weekend Admission and Mortality in Patients With Traumatic Brain Injury: A Meta-analysis

Objective

Previous studies have reported the presence of a "weekend effect" with respect to mortality in serious emergency admissions, including cases of traumatic brain injury (TBI). However, the relationship between weekend hospitalization and TBI mortality has not been fully established. This study aimed to conduct a systematic review of available evidence and investigate differences in mortality among TBI patients between weekday and weekend admissions.

Methods

Electronic databases including PubMed, Cochrane Library, and Embase were used to obtain relevant articles. Mortality, as the primary outcome of interest, encompassed in-hospital or 30-day mortality. Mortality rates were compared between the 2 groups, weekend and weekday admissions. Additionally, meta-regression analysis was performed on potential confounders to verify and provide comparative results.

Results

A total of 7 studies involving 522,942 TBI patients were eligible for inclusion in the synthesis of the systematic review. Of these patients, 71.6% were admitted during weekdays, whereas 28.4% were hospitalized on weekends. The overall integrated mortality was 11.0% (57,286/522,942), with a mortality rate of 10.8% in the weekday group and 11.3% in the weekend group. Pooled analysis revealed no significant difference in mortality between the weekday and weekend groups (risk ratio, 0.99; 95% confidence interval, 0.90-1.09; p=0.78). Furthermore, the meta-regression analysis for sensitivity assessment showed no modifying effect on mortality (p=0.79).

Conclusion

This study found no difference in mortality rates between weekday and weekend admissions among TBI patients. Additional sensitivity analyses also demonstrated no significant increase in the risk of mortality in the weekend group.

Overview of Cochrane Systematic Reviews of Rehabilitation Interventions for Persons with Traumatic Brain Injury: A Mapping Synthesis

Background: The World Health Organization has identified an unmet global need for rehabilitation interventions concerning 20 non-communicable diseases, traumatic brain injury included. This overview compiles and synthesizes the quality and quantity of available evidence on the effectiveness of rehabilitation interventions for traumatic brain injury from Cochrane systematic reviews (CSRs). The results will be used to develop the Package of Interventions for Rehabilitation. Methods: All CSRs on TBI tagged in the Cochrane Rehabilitation database published between August 2009 and September 2021 were included. Evidence mapping was implemented to extract study characteristics and evidence from the CSRs. Results: Six CSRs (42 studies; n = 3983) examined the effectiveness of either non-pharmacological or pharmacological interventions after TBI. Among 19 comparisons, 3% were rated as high in quality of evidence, 9% moderate, 54% low, and 34% very low. Non-pharmacological interventions with moderate quality, hospital-based cognitive rehabilitation and cognitive didactic therapy, likely produced minimal to no changes in the return-to-work rate. Anti-epileptic drugs and neuroprotective agents resulted in a minimal difference to the frequency of late seizure episodes in post-traumatic epilepsy. Conclusions: No prominent advances in treatment options were reported in any of the CSRs. The high rate of low and very low quality of evidence makes it difficult to ascertain the effectiveness of several recommended non-pharmacological interventions.

Psychological Intervention in Traumatic Brain Injury Patients

Objective

To provide a brief and comprehensive summary of recent research regarding psychological interventions for patients surviving a traumatic brain injury.

Methods

A bibliographical search was performed in PubMed, Cochrane Library, PsycNET, Scopus, ResearchGate, and Google Scholar online databases. Analysis included distribution by year of publication, age stage of participants (paediatric, adult), location of the research team, study design, type of intervention, and main outcome variables.

Results

The initial search eliciting 1541 citations was reduced to 62 relevant papers. Most publications had adult samples (88.7%). The United States outstands as the country with more research (58.1%); Latin America countries provided no results. Cognitive behavioural therapy (CBT) was the most widely used approach for treatment of (sub)clinical mental disturbances (41.9%). Neuropsychological interventions were scarce (4.8%). Outcome measures included psychiatric disorders (e.g., posttraumatic stress disorder (PTSD), depression, and anxiety) (37.1%), postconcussive symptoms (16.1%), cognitive and functional deficits (48.1%), and social and psychological dimensions (62.9%).

Conclusions

CBT outstands as the preferred therapeutic approach for treating behavioural and emotional disturbances. Also, other related therapies such as dialectical behaviour, mindfulness, and acceptance and commitment therapies have been proposed, and probably in the years to come, more literature regarding their effectiveness will be available. On the other hand, evidence showed that interventions from the field of neuropsychology are minimal if compared with its contribution to assessment. Future research should be aimed at performing studies on more diverse populations (e.g., nonmilitary communities and paediatric and Latin American populations) and at controlling designs to examine the therapeutic efficacy of psychotherapeutic and neurocognitive rehabilitation interventions and compare amelioration by injury severity, age of patients, and clinical profile, in the hopes of creating better guidelines for practitioners.

Global Outcome Trajectories up to 10 Years After Moderate to Severe Traumatic Brain Injury

Aims: Based on important predictors, global functional outcome after traumatic brain injury (TBI) may vary significantly over time. This study sought to: (1) describe changes in the Glasgow Outcome Scale-Extended (GOSE) score in survivors of moderate to severe TBI, (2) examine longitudinal GOSE trajectories up to 10 years after injury, and (3) investigate predictors of these trajectories based on socio-demographic and injury characteristics. Methods: Socio-demographic and injury characteristics of 97 TBI survivors aged 16-55 years were recorded at baseline. GOSE was used as a measure of TBI-related global outcome and assessed at 1-, 2-, 5-, and 10-year follow-ups. Hierarchical linear models were used to examine global outcomes over time and whether those outcomes could be predicted by: time, time^*time, sex, age, partner relationship status, education, employment pre-injury, occupation, cause of injury, acute Glasgow Coma Scale score, length of post-traumatic amnesia (PTA), CT findings, and Injury Severity Score (ISS), as well as the interactions between each of the significant predictors and time^*time. Results: Between 5- and 10-year follow-ups, 37% had deteriorated, 7% had improved, and 56% showed no change in global outcome. Better GOSE trajectories were predicted by male gender (p = 0.013), younger age (p = 0.012), employment at admission (p = 0.012), white collar occupation (p = 0.014), and shorter PTA length (p = 0.001). The time^*time^*occupation type interaction effect (p = 0.001) identified different trajectory slopes between survivors in white and blue collar occupations. The time^*time^*PTA interaction effect (p = 0.023) identified a more marked increase and subsequent decrease in functional level among survivors with longer PTA duration. Conclusion: A larger proportion of survivors experienced deterioration in GOSE scores over time, supporting the concept of TBI as a chronic health condition. Younger age, pre-injury employment, and shorter PTA duration are important prognostic factors for better long-term global outcomes, supporting the existing literature, whereas male gender and white collar occupation are vaguer as prognostic factors. This information suggests that more intensive and tailored rehabilitation programs may be required to counteract a negative global outcome development in survivors with predicted worse outcome and to meet their long-term changing needs.

A new global health outcome score after trauma (GHOST) for disability, cognitive impairment, and health-related quality of life: data from a prospective cross-sectional observational study

Background:Trauma patients experience morbidity related to disability and cognitive impairment that negatively impact their health-related quality of life (HRQoL). We assessed the impact of trauma on disability, cognitive impairment and HRQoL after intensive care in patients with and without traumatic brain injury (TBI) and created a predictive score to identify patients with worse outcome. Methods:We identified 262 patients with severe trauma (ISS>15) admitted to the emergency room of a level 1 trauma center. Patients above 13 years were included. After 6 months, patients were assessed for disability, cognitive impairment, and HRQoL. A global health outcome score after trauma (GHOST) was obtained through the combination of these domains. Logistic regression analysis was considered for the effect of demographic, trauma and hospital factors on global outcome. p > 0.05. Statistics performed with SPSS 23.0. Results:Patients with the worst outcomes were older and had a longer length of Intensive Care Unit (ICU) stay. The effect of gender was found in all "GHOST dimensions". TBI was not significantly associated with worse outcome. Conclusions:No significant differences were seen on disability, cognitive impairment and decreased HRQoL in patients with or without TBI. Our GHOST score showed that female gender, older age, and longer ICU stay were significantly associated with the worst outcome. Abbreviations: AIS: Abbreviated Injury Scale; EQ-5D: EuroQol 5-dimensions; EQ-5D-3L: EuroQol 5-dimensions 3-levels; GCS: Glasgow Coma Scale; GOSE: Glasgow Outcome Scale Extended; HRQoL: Health-Related Quality of Life; ICU: Intensive Care Unit; ISS: Injury Severity Score; MMS: Mini Mental State; NICE: National Institute for Health and Care Excellence; RTS: Revised Trauma Score; TBI: Traumatic brain injury; TRISS: Trauma Injury Severity Score; VAS: Visual Analogue Scale.

Social Behavior and Impairments in Social Cognition Following Traumatic Brain Injury

OBJECTIVES

The negative effect of changes in social behavior following traumatic brain injury (TBI) are known, but much less is known about the neuropsychological impairments that may underlie and predict these changes. The current study investigated possible associations between post-injury behavior and neuropsychological competencies of emotion recognition, understanding intentions, and response selection, that have been proposed as important for social functioning.

METHODS

Forty participants with TBI and 32 matched healthy participants completed a battery of tests assessing the three functions of interest. In addition, self- and proxy reports of pre- and post-injury behavior, mood, and community integration were collected.

RESULTS

The TBI group performed significantly poorer than the comparison group on all tasks of emotion recognition, understanding intention, and on one task of response selection. Ratings of current behavior suggested significant changes in the TBI group relative to before the injury and showed significantly poorer community integration and interpersonal behavior than the comparison group. Of the three functions considered, emotion recognition was associated with both post-injury behavior and community integration and this association could not be fully explained by injury severity, time since injury, or education.

CONCLUSIONS

The current study confirmed earlier findings of associations between emotion recognition and post-TBI behavior, providing partial evidence for models proposing emotion recognition as one of the pre-requisites for adequate social functioning. (JINS, 2017, 23, 400-411).

The effects of anaemia and transfusion on patients with traumatic brain injury: A review

BACKGROUND

Anaemia in traumatic brain injury (TBI) is frequently encountered. Neurosurgical texts continue to recommend transfusion for hematocrit below 30%, despite clear evidence to do so. Transfusion should increase oxygen delivery to the brain, but it may also increase morbidity and mortality.

METHODS

This study reviewed the relevant literature to better understand the risks of anaemia and benefits of correction of anaemia by transfusion.

RESULTS

Of the 21 studies reviewed, eight found that anaemia was harmful to patients with TBI; five found no significant outcome; seven found transfusion was associated with higher rates of morbidity and mortality; two found that transfusion lowered mortality and increased brain tissue oxygen levels; and ten found no correlation between transfusion and outcome. However, the levels of anaemia severity and the outcome measurements varied widely and the majority of outcomes focused on crude measurements rather than detailed functional assessments.

CONCLUSIONS

No division of response based on gender difference or impact of anaemia in the post-hospital treatment setting was observed. A randomized control trial is recommended to determine the impact of anaemia and transfusion on detailed outcome assessment in comparison of transfusion thresholds ranging from ≤ 7 g dL^-1 to ≤ 9 g dL^-1 in patients with moderate-to-severe TBI.

Cortisol Supplement Combined with Psychotherapy and Citalopram Improves Depression Outcomes in Patients with Hypocortisolism after Traumatic Brain Injury

Depression is one of the most prevalent psychiatric disorders in people with Traumatic brain injury (TBI). Depression after TBI is closely related with social and psychological factors and hypothalamic-pituitary -adrenal (HPA) axis dysfunction. However, there is a lack of evidence regarding effective treatment approaches for depression. A total of 68 patients with depression following closed TBI were recruited. Glasgow Coma Scale score (GCS) was employed to demonstrate the severity of neurological deficits and Glasgow Outcome Scale (GOS) was employed to measure functional outcome after TBI. The severity of depression was quantified using the Beck Depression Inventory-II (BDI-II) in line with DSM-IV. Citalopram and Prednisone were administered to subjects with normal cortisol levels or hypocortisolism separately, based on psychotherapeutic interventions. We investigated the relationship between degree of depression of TBI patients and the severity and progression of TBI with the therapeutic effects of Citalopram in combination with psychotherapeutic and Prednisone in depressed patients. There was no relationship between the severity of depression and the severity and progression of TBI. The basic treatment of psychotherapeutic interventions could partially relieve depressive symptoms. Combination of psychotherapeutic support and Citalopram significantly improved depressive symptoms in patients with normal cortisol levels, but not in hypocortisolic patients. Combination of Prednisone administration with psychotherapeutic treatment and Citalopram significantly improved depression outcome in hypocortisolic patients after TBI. Hypocortisolism after TBI may regulate depression. Combination of Prednisone with psychotherapeutic treatment and Citalopram may provide better therapeutic effects in depression patients with hypocortisolism after TBI.