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Singh RD, van Dijck JTJM, van Essen TA, Lingsma HF, Polinder SS, Kompanje EJO, van Zwet EW, Steyerberg EW, de Ruiter GCW, Depreitere B, Peul WC. Randomized Evaluation of Surgery in Elderly with Traumatic Acute SubDural Hematoma (RESET-ASDH trial): study protocol for a pragmatic randomized controlled trial with multicenter parallel group design. Trials 2022; 23:242. [PMID: 35351178 PMCID: PMC8962939 DOI: 10.1186/s13063-022-06184-1] [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] [Subscribe] [Scholar Register] [Received: 12/23/2021] [Accepted: 03/17/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The rapidly increasing number of elderly (≥ 65 years old) with TBI is accompanied by substantial medical and economic consequences. An ASDH is the most common injury in elderly with TBI and the surgical versus conservative treatment of this patient group remains an important clinical dilemma. Current BTF guidelines are not based on high-quality evidence and compliance is low, allowing for large international treatment variation. The RESET-ASDH trial is an international multicenter RCT on the (cost-)effectiveness of early neurosurgical hematoma evacuation versus initial conservative treatment in elderly with a t-ASDH METHODS: In total, 300 patients will be recruited from 17 Belgian and Dutch trauma centers. Patients ≥ 65 years with at first presentation a GCS ≥ 9 and a t-ASDH > 10 mm or a t-ASDH < 10 mm and a midline shift > 5 mm, or a GCS < 9 with a traumatic ASDH < 10 mm and a midline shift < 5 mm without extracranial explanation for the comatose state, for whom clinical equipoise exists will be randomized to early surgical hematoma evacuation or initial conservative management with the possibility of delayed secondary surgery. When possible, patients or their legal representatives will be asked for consent before inclusion. When obtaining patient or proxy consent is impossible within the therapeutic time window, patients are enrolled using the deferred consent procedure. Medical-ethical approval was obtained in the Netherlands and Belgium. The choice of neurosurgical techniques will be left to the discretion of the neurosurgeon. Patients will be analyzed according to an intention-to-treat design. The primary endpoint will be functional outcome on the GOS-E after 1 year. Patient recruitment starts in 2022 with the exact timing depending on the current COVID-19 crisis and is expected to end in 2024. DISCUSSION The study results will be implemented after publication and presented on international conferences. Depending on the trial results, the current Brain Trauma Foundation guidelines will either be substantiated by high-quality evidence or will have to be altered. TRIAL REGISTRATION Nederlands Trial Register (NTR), Trial NL9012 . CLINICALTRIALS gov, Trial NCT04648436 .
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Affiliation(s)
- Ranjit D Singh
- University Neurosurgical Center Holland, LUMC, HMC and Haga Teaching Hospital, Leiden and The Hague, J11 Albinusdreef 2, 2333 ZA, Leiden, The Netherlands.
| | - Jeroen T J M van Dijck
- University Neurosurgical Center Holland, LUMC, HMC and Haga Teaching Hospital, Leiden and The Hague, J11 Albinusdreef 2, 2333 ZA, Leiden, The Netherlands
| | - Thomas A van Essen
- University Neurosurgical Center Holland, LUMC, HMC and Haga Teaching Hospital, Leiden and The Hague, J11 Albinusdreef 2, 2333 ZA, Leiden, The Netherlands
| | - Hester F Lingsma
- Centre for Medical Decision Making, Department of Public Health, Erasmus MC-University Medical Centre Rotterdam, Rotterdam, The Netherlands
| | - Suzanne S Polinder
- Department of Public Health, Erasmus MC-University Medical Centre Rotterdam, Rotterdam, The Netherlands
| | - Erwin J O Kompanje
- Department of Intensive Care, Erasmus MC-University Medical Centre Rotterdam, Rotterdam, The Netherlands
| | - Erik W van Zwet
- Department of Biomedical Data Sciences, Leiden University Medical Center, Leiden, The Netherlands
| | - Ewout W Steyerberg
- Department of Biomedical Data Sciences, Leiden University Medical Center, Leiden, The Netherlands
| | - Godard C W de Ruiter
- University Neurosurgical Center Holland, LUMC, HMC and Haga Teaching Hospital, Leiden and The Hague, J11 Albinusdreef 2, 2333 ZA, Leiden, The Netherlands
| | | | - Wilco C Peul
- University Neurosurgical Center Holland, LUMC, HMC and Haga Teaching Hospital, Leiden and The Hague, J11 Albinusdreef 2, 2333 ZA, Leiden, The Netherlands
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Lu J, Gormley M, Donaldson A, Agyemang A, Karmarkar A, Seel RT. Identifying factors associated with acute hospital discharge dispositions in patients with moderate-to-severe traumatic brain injury. Brain Inj 2022; 36:383-392. [PMID: 35213272 DOI: 10.1080/02699052.2022.2034180] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022]
Abstract
OBJECTIVE Identify sociodemographic, injury, and hospital-level factors associated with acute hospital discharge dispositions following acute hospitalization for moderate-to-severe traumatic brain injury (TBI) in the United States. METHODS The 2011-2014 National Trauma Data Bank data was used, including 466 acute care hospitals and 114,736 patients ≥16 years old who survived moderate-to-severe TBI. Outcome was acute hospital discharge dispositions: home with/without care (HC), skilled nursing home/other care facility (SNF/ICF) and inpatient rehabilitation/long-term care facility (IRF). Independent variables were patients' sociodemographic, injury, and hospital-level factors. Multilevel modeling was used to assess associations and compare likelihood of discharges. RESULTS Of all patients, 74.5%, 14.6% ,and 10.9% were discharged to HC, SNF/ICF ,and IRF, respectively. Intraclass correlation coefficients indicated that hospitals explained 14.3% and 14.8% of variations in probabilities of institution dispositions. Sociodemographic factors including older age, females, Non-Hispanic Whites, recipients of commercial insurance, and Medicare/Medicaid were significantly associated with higher institution discharges. Hospital-related factors including bed size, teaching status, trauma accreditations, and hospital locations were significantly associated with discharge dispositions. CONCLUSION Identifying factors associated with discharge dispositions after acute hospitalization of TBI is pertinent to ensure quality of care and optimal patient outcomes. Further research into hospital-related variations in acute care discharge dispositions is recommended.
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Affiliation(s)
- Juan Lu
- Division of Epidemiology, Department of Family Medicine and Population Health, School of Medicine, Virginia Commonwealth University, Richmond, Virginia, USA
| | - Mirinda Gormley
- Division of Epidemiology, Department of Family Medicine and Population Health, School of Medicine, Virginia Commonwealth University, Richmond, Virginia, USA
| | - Alexis Donaldson
- Division of Epidemiology, Department of Family Medicine and Population Health, School of Medicine, Virginia Commonwealth University, Richmond, Virginia, USA
| | - Amma Agyemang
- Center for Rehabilitation Science and Engineering (CERSE), Department of Physical Medicine and Rehabilitation, School of Medicine, Virginia Commonwealth University, Richmond, Virginia, USA
| | - Amol Karmarkar
- Center for Rehabilitation Science and Engineering (CERSE), Department of Physical Medicine and Rehabilitation, School of Medicine, Virginia Commonwealth University, Richmond, Virginia, USA
| | - Ronald T Seel
- Center for Rehabilitation Science and Engineering (CERSE), Department of Physical Medicine and Rehabilitation, School of Medicine, Virginia Commonwealth University, Richmond, Virginia, USA
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Edgar K, Roberts I, Sharples L. Including random centre effects in design, analysis and presentation of multi-centre trials. Trials 2021; 22:357. [PMID: 34022937 PMCID: PMC8140487 DOI: 10.1186/s13063-021-05266-w] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2020] [Accepted: 04/13/2021] [Indexed: 01/03/2023] Open
Abstract
Background In large multicentre trials in diverse settings, there is uncertainty about the need to adjust for centre variation in design and analysis. A key distinction is the difference between variation in outcome (independent of treatment) and variation in treatment effect. Through re-analysis of the CRASH-2 trial (2010), this study clarifies when and how to use multi-level models for multicentre studies with binary outcomes. Methods CRASH-2 randomised 20,127 trauma patients across 271 centres and 40 countries to either single-dose tranexamic acid or identical placebo, with all-cause death at 4 weeks the primary outcome. The trial data had a hierarchical structure, with patients nested in hospitals which in turn are nested within countries. Reanalysis of CRASH-2 trial data assessed treatment effect and both patient and centre level baseline covariates as fixed effects in logistic regression models. Random effects were included to assess where there was variation between countries, and between centres within countries, both in underlying risk of death and in treatment effect. Results In CRASH-2, there was significant variation between countries and between centres in death at 4 weeks, but absolutely no differences between countries or centres in the effect of treatment. Average treatment effect was not altered after accounting for centre and country variation in this study. Conclusions It is important to distinguish between underlying variation in outcomes and variation in treatment effects; the former is common but the latter is not. Stratifying randomisation by centre overcomes many statistical problems and including random intercepts in analysis may increase power and decrease bias in mean and standard error estimates. Trial registration Current Controlled Trials ISRCTN86750102, ClinicalTrials.gov NCT00375258, and South African Clinical Trial Register DOH-27-0607-1919 Supplementary Information The online version contains supplementary material available at 10.1186/s13063-021-05266-w.
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Affiliation(s)
- Kate Edgar
- Department of Medical Statistics, LSHTM, Keppel Street, London, WC1E 7HT, UK
| | - Ian Roberts
- Clinical Trials Unit, LSHTM, Keppel Street, London, WC1E 7HT, UK
| | - Linda Sharples
- Department of Medical Statistics, LSHTM, Keppel Street, London, WC1E 7HT, UK.
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Bell MJ, Kochanek PM. International traumatic brain injury research: an annus mirabilis? Lancet Neurol 2020; 18:904-905. [PMID: 31526746 DOI: 10.1016/s1474-4422(19)30289-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2019] [Accepted: 07/16/2019] [Indexed: 10/26/2022]
Affiliation(s)
- Michael J Bell
- Division of Critical Care Medicine, Children's National Medical Center, George Washington University School of Medicine, Washington DC 20010, WA, USA.
| | - Patrick M Kochanek
- Department of Critical Care Medicine and the Safar Center for Resuscitation Research, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
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Mahmood A, Roberts I, Shakur-Still H. A nested randomised trial of the effect of tranexamic acid on intracranial haemorrhage and infarction in traumatic brain injury (CRASH-3 trial intracranial bleeding mechanistic study): Statistical analysis plan. Wellcome Open Res 2019; 3:99. [PMID: 31143842 PMCID: PMC6530602 DOI: 10.12688/wellcomeopenres.14731.3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/21/2019] [Indexed: 02/02/2023] Open
Abstract
Background: The CRASH-3 trial is a randomised trial on the effect of tranexamic acid (TXA) versus placebo on death and disability in traumatic brain injury (TBI). The CRASH-3 intracranial bleeding mechanistic study (IBMS) is a randomised trial nested within the CRASH-3 trial to examine the effect of TXA versus placebo on intracranial bleeding and infarction. Methods: Patients eligible for the CRASH-3 trial, with a GCS of 12 or less or intracranial bleeding on a pre-randomisation CT scan are eligible for the IBMS. The occurrence of intracranial bleeding, infarction, haemorrhagic oedematous lesions, mass effect and haemorrhage evacuation is examined within 28 days of randomisation using routinely collected brain scans. The primary outcome is the volume of intra-parenchymal bleeding in patients randomised within three hours of injury (adjusted for prognostic covariates). Secondary outcomes include a composite "poor" outcome, progressive and new intracranial bleeding, intracranial bleeding after neurosurgery and cerebral infarcts seen up to 28 days post-randomisation. All outcomes will be compared between treatment groups. Statistical analyses: The primary outcome will be analysed using a covariate adjusted linear mixed model. The same analysis will be done separately for patients who undergo haemorrhage evacuation post-randomisation. We will express the effect of TXA on the composite outcome, new and progressive bleeding using relative risks and 95% CIs, and on cerebral infarcts using hazard ratios and 95% CIs. We will conduct sensitivity analyses assuming missing data are MCAR or MNAR. Conclusion: The IBMS will provide information on the mechanism of action of TXA in TBI. This pre-specified statistical analysis plan is a technical extension of the published protocol. Trial registration: The CRASH-3 trial was prospectively registered at the International Standard Randomised Controlled Trials registry (19 July 2011) and ClinicalTrials.gov (25 July 2011). The registries were updated with details for the IBMS on 20 December 2016.
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Affiliation(s)
- Abda Mahmood
- Clinical Trials Unit, Department of Population Health, London School of Hygiene & Tropical Medicine, London, WC1E7HT, UK
| | - Ian Roberts
- Clinical Trials Unit, Department of Population Health, London School of Hygiene & Tropical Medicine, London, WC1E7HT, UK
| | - Haleema Shakur-Still
- Clinical Trials Unit, Department of Population Health, London School of Hygiene & Tropical Medicine, London, WC1E7HT, UK
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Mahmood A, Roberts I, Shakur-Still H. A nested randomised trial of the effect of tranexamic acid on intracranial haemorrhage and infarction in traumatic brain injury (CRASH-3 trial intracranial bleeding mechanistic study): Statistical analysis plan. Wellcome Open Res 2019; 3:99. [PMID: 31143842 PMCID: PMC6530602 DOI: 10.12688/wellcomeopenres.14731.2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/02/2019] [Indexed: 02/02/2023] Open
Abstract
Background: The CRASH-3 trial is a randomised trial on the effect of tranexamic acid (TXA) on death and disability in traumatic brain injury (TBI). The CRASH-3 intracranial bleeding mechanistic study (IBMS) is a randomised trial nested within the CRASH-3 trial to examine the effect of TXA on intracranial bleeding and infarction. Methods: Patients eligible for the CRASH-3 trial, with a GCS of 12 or less or intracranial bleeding on a pre-randomisation CT scan are eligible for the IBMS. The occurrence of intracranial bleeding, infarction, haemorrhagic oedematous lesions, mass effect and haemorrhage evacuation is examined within 28 days of randomisation using routinely collected brain scans. The primary outcome is the volume of intra-parenchymal bleeding in patients randomised within three hours of injury (adjusted for prognostic covariates). Secondary outcomes include a composite "poor" outcome, progressive and new intracranial bleeding, intracranial bleeding after neurosurgery and cerebral infarcts seen up to 28 days post-randomisation. All outcomes will be compared between treatment groups. Statistical analyses: The primary outcome will be analysed using a covariate adjusted linear mixed model. The same analysis will be done separately for patients who undergo haemorrhage evacuation post-randomisation. We will express the effect of TXA on the composite outcome, new and progressive bleeding using relative risks and 95% CIs, and on cerebral infarcts using hazard ratios and 95% CIs. We will conduct sensitivity analyses assuming missing data are MCAR or MNAR. Conclusion: The IBMS will provide information on the mechanism of action of TXA in TBI. This pre-specified statistical analysis plan is a technical extension of the published protocol. Trial registration: The CRASH-3 trial was prospectively registered at the International Standard Randomised Controlled Trials registry (19 July 2011) and ClinicalTrials.gov (25 July 2011). The registries were updated with details for the IBMS on 20 December 2016.
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Affiliation(s)
- Abda Mahmood
- Clinical Trials Unit, Department of Population Health, London School of Hygiene & Tropical Medicine, London, WC1E7HT, UK
| | - Ian Roberts
- Clinical Trials Unit, Department of Population Health, London School of Hygiene & Tropical Medicine, London, WC1E7HT, UK
| | - Haleema Shakur-Still
- Clinical Trials Unit, Department of Population Health, London School of Hygiene & Tropical Medicine, London, WC1E7HT, UK
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Mahmood A, Roberts I, Shakur-Still H. A nested randomised trial of the effect of tranexamic acid on intracranial haemorrhage and infarction in traumatic brain injury (CRASH-3 trial intracranial bleeding mechanistic study): Statistical analysis plan. Wellcome Open Res 2018; 3:99. [PMID: 31143842 PMCID: PMC6530602 DOI: 10.12688/wellcomeopenres.14731.1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/03/2018] [Indexed: 02/02/2023] Open
Abstract
Background: The CRASH-3 trial is a randomised trial on the effect of tranexamic acid (TXA) on death and disability in traumatic brain injury (TBI). The CRASH-3 intracranial bleeding mechanistic study (IBMS) is a randomised trial nested within the CRASH-3 trial to examine the effect of TXA on intracranial bleeding and infarction. Methods: Patients eligible for the CRASH-3 trial, with a GCS of 12 or less or intracranial bleeding on a pre-randomisation CT scan are eligible for the IBMS. The occurrence of intracranial bleeding, infarction, haemorrhagic oedematous lesions, mass effect and haemorrhage evacuation is examined within 28 days of randomisation using routinely collected brain scans. The primary outcome is the volume of intracranial bleeding in patients randomised within three hours of injury (adjusted for prognostic covariates). Secondary outcomes include progressive and new intracranial bleeding, intracranial bleeding after neurosurgery and new cerebral infarcts up to 28 days post-randomisation. All outcomes will be compared between treatment groups. Statistical analyses: The primary outcome will be analysed using absolute measures (ANCOVA) and relative measures (ratios). The same analysis will be done separately for patients who undergo haemorrhage evacuation post-randomisation. We will express the effect of TXA on new and progressive bleeding using relative risks and 95% CIs, and on cerebral infarcts using hazard ratios and 95% CIs. If any missing post-randomisation scans appear to be missing not at random, we will conduct sensitivity analyses to explore the implications. Conclusion: The IBMS will provide information on the mechanism of action of TXA in TBI. This pre-specified statistical analysis plan is a technical extension of the published protocol. Trial registration: The CRASH-3 trial was prospectively registered at the International Standard Randomised Controlled Trials registry (19 July 2011) and ClinicalTrials.gov (25 July 2011). The registries were updated with details for the IBMS on 20 December 2016.
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Affiliation(s)
- Abda Mahmood
- Clinical Trials Unit, Department of Population Health, London School of Hygiene & Tropical Medicine, London, WC1E7HT, UK
| | - Ian Roberts
- Clinical Trials Unit, Department of Population Health, London School of Hygiene & Tropical Medicine, London, WC1E7HT, UK
| | - Haleema Shakur-Still
- Clinical Trials Unit, Department of Population Health, London School of Hygiene & Tropical Medicine, London, WC1E7HT, UK
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Glorioso TJ, Grunwald GK, Ho PM, Maddox TM. Reference effect measures for quantifying, comparing and visualizing variation from random and fixed effects in non-normal multilevel models, with applications to site variation in medical procedure use and outcomes. BMC Med Res Methodol 2018; 18:74. [PMID: 29980180 PMCID: PMC6035479 DOI: 10.1186/s12874-018-0517-7] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2017] [Accepted: 06/06/2018] [Indexed: 11/21/2022] Open
Abstract
BACKGROUND Multilevel models for non-normal outcomes are widely used in medical and health sciences research. While methods for interpreting fixed effects are well-developed, methods to quantify and interpret random cluster variation and compare it with other sources of variation are less established. Random cluster variation, sometimes referred to as general contextual effects (GCE), may be the main focus of a study; therefore, easily interpretable methods are needed to quantify GCE. We propose a Reference Effect Measure (REM) approach to 1) quantify GCE and compare it to individual subject and cluster covariate effects, and 2) quantify relative magnitudes of GCE and variation from sets of measured factors. METHODS To illustrate REM, we consider a two-level mixed logistic model with patients clustered within hospitals and a random intercept for hospitals. We compare patients at hospitals at given percentiles of the estimated random effect distribution to patients at a median or 'reference' hospital. These estimates are then compared numerically and graphically to individual fixed effects to quantify GCE in the context of effects of other measured variables (aim 1). We then extend this approach by comparing variation from the random effect distribution to variation from sets of fixed effects to understand their magnitudes relative to overall outcome variation (aim 2). RESULTS Using an example of initiation of rhythm control treatment in atrial fibrillation (AF) patients within the Veterans Affairs (VA), we use REM to demonstrate that random variation across hospitals (GCE) in initiation of treatment is substantially greater than that due to most individual patient factors, and explains at least as much variation in treatment initiation as do all patient factors combined. These results are contrasted with a relatively small GCE compared with patient factors in 1 year mortality following hospitalization for AF patients. CONCLUSIONS REM provides a means of quantifying random effect variation (GCE) with multilevel data and can be used to explore drivers of outcome variation. This method is easily interpretable and can be presented visually. REM offers a simple, interpretable approach for evaluating questions of growing importance in the study of health care systems.
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Affiliation(s)
- Thomas J. Glorioso
- VA Eastern Colorado Health Care System, 13611 E. Colfax Ave, A151, Aurora, Denver, CO 80045 USA
| | - Gary K. Grunwald
- VA Eastern Colorado Health Care System, 13611 E. Colfax Ave, A151, Aurora, Denver, CO 80045 USA
- Department of Biostatistics and Informatics, Colorado School of Public Health, University of Colorado Anschutz Medical Campus, Box B119, 13001 E. 17th Place, Aurora, CO 80045 USA
- Colorado Cardiovascular Outcomes Research Consortium, Denver, 13611 E. Colfax Ave, A151, Aurora, CO 80045 USA
| | - P. Michael Ho
- VA Eastern Colorado Health Care System, 13611 E. Colfax Ave, A151, Aurora, Denver, CO 80045 USA
- Colorado Cardiovascular Outcomes Research Consortium, Denver, 13611 E. Colfax Ave, A151, Aurora, CO 80045 USA
- Division of Cardiology, University of Colorado School of Medicine, Aurora, CO USA
| | - Thomas M. Maddox
- Division of Cardiology, Washington University School of Medicine, Campus Box 8086, 660 S. Euclid, St. Louis, MO 63110 USA
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Bembea MM, Hoskote A, Guerguerian AM. Pediatric ECMO Research: The Case for Collaboration. Front Pediatr 2018; 6:240. [PMID: 30250837 PMCID: PMC6139332 DOI: 10.3389/fped.2018.00240] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/01/2018] [Accepted: 08/13/2018] [Indexed: 12/14/2022] Open
Abstract
The use of extracorporeal membrane oxygenation (ECMO) in the pediatric age has increased considerably in the last decade, as has the complexity of cases and the variety of indications outside of the neonatal age. However, no randomized controlled trials have been attempted to date to test ECMO as an intervention in non-neonatal pediatric patients with critical illness. In this review, we provide a brief overview of the history of clinical research in pediatric ECMO and discuss methodological challenges including heterogeneity of ages and diagnoses in the pediatric ECMO population, rapid advances in technology and clinical practice related to ECMO, feasibility of enrolling critically ill children on ECMO in clinical research studies, and variability in ECMO management across institutions and countries. Lastly, we discuss opportunities and existing infrastructure for future multicenter, multi-network research collaborations for pediatric ECMO studies.
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Affiliation(s)
- Melania M Bembea
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, United States
| | - Aparna Hoskote
- Cardiorespiratory and Critical Care Division, Great Ormond Street Hospital for Children NHS Foundation Trust, London, United Kingdom
| | - Anne-Marie Guerguerian
- Department of Critical Care Medicine, Hospital for Sick Children and University of Toronto, Toronto, ON, Canada
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Maas AIR, Menon DK, Adelson PD, Andelic N, Bell MJ, Belli A, Bragge P, Brazinova A, Büki A, Chesnut RM, Citerio G, Coburn M, Cooper DJ, Crowder AT, Czeiter E, Czosnyka M, Diaz-Arrastia R, Dreier JP, Duhaime AC, Ercole A, van Essen TA, Feigin VL, Gao G, Giacino J, Gonzalez-Lara LE, Gruen RL, Gupta D, Hartings JA, Hill S, Jiang JY, Ketharanathan N, Kompanje EJO, Lanyon L, Laureys S, Lecky F, Levin H, Lingsma HF, Maegele M, Majdan M, Manley G, Marsteller J, Mascia L, McFadyen C, Mondello S, Newcombe V, Palotie A, Parizel PM, Peul W, Piercy J, Polinder S, Puybasset L, Rasmussen TE, Rossaint R, Smielewski P, Söderberg J, Stanworth SJ, Stein MB, von Steinbüchel N, Stewart W, Steyerberg EW, Stocchetti N, Synnot A, Te Ao B, Tenovuo O, Theadom A, Tibboel D, Videtta W, Wang KKW, Williams WH, Wilson L, Yaffe K, Adams H, Agnoletti V, Allanson J, Amrein K, Andaluz N, Anke A, Antoni A, van As AB, Audibert G, Azaševac A, Azouvi P, Azzolini ML, Baciu C, Badenes R, Barlow KM, Bartels R, Bauerfeind U, Beauchamp M, Beer D, Beer R, Belda FJ, Bellander BM, Bellier R, Benali H, Benard T, Beqiri V, Beretta L, Bernard F, Bertolini G, Bilotta F, Blaabjerg M, den Boogert H, Boutis K, Bouzat P, Brooks B, Brorsson C, Bullinger M, Burns E, Calappi E, Cameron P, Carise E, Castaño-León AM, Causin F, Chevallard G, Chieregato A, Christie B, Cnossen M, Coles J, Collett J, Della Corte F, Craig W, Csato G, Csomos A, Curry N, Dahyot-Fizelier C, Dawes H, DeMatteo C, Depreitere B, Dewey D, van Dijck J, Đilvesi Đ, Dippel D, Dizdarevic K, Donoghue E, Duek O, Dulière GL, Dzeko A, Eapen G, Emery CA, English S, Esser P, Ezer E, Fabricius M, Feng J, Fergusson D, Figaji A, Fleming J, Foks K, Francony G, Freedman S, Freo U, Frisvold SK, Gagnon I, Galanaud D, Gantner D, Giraud B, Glocker B, Golubovic J, Gómez López PA, Gordon WA, Gradisek P, Gravel J, Griesdale D, Grossi F, Haagsma JA, Håberg AK, Haitsma I, Van Hecke W, Helbok R, Helseth E, van Heugten C, Hoedemaekers C, Höfer S, Horton L, Hui J, Huijben JA, Hutchinson PJ, Jacobs B, van der Jagt M, Jankowski S, Janssens K, Jelaca B, Jones KM, Kamnitsas K, Kaps R, Karan M, Katila A, Kaukonen KM, De Keyser V, Kivisaari R, Kolias AG, Kolumbán B, Kolundžija K, Kondziella D, Koskinen LO, Kovács N, Kramer A, Kutsogiannis D, Kyprianou T, Lagares A, Lamontagne F, Latini R, Lauzier F, Lazar I, Ledig C, Lefering R, Legrand V, Levi L, Lightfoot R, Lozano A, MacDonald S, Major S, Manara A, Manhes P, Maréchal H, Martino C, Masala A, Masson S, Mattern J, McFadyen B, McMahon C, Meade M, Melegh B, Menovsky T, Moore L, Morgado Correia M, Morganti-Kossmann MC, Muehlan H, Mukherjee P, Murray L, van der Naalt J, Negru A, Nelson D, Nieboer D, Noirhomme Q, Nyirádi J, Oddo M, Okonkwo DO, Oldenbeuving AW, Ortolano F, Osmond M, Payen JF, Perlbarg V, Persona P, Pichon N, Piippo-Karjalainen A, Pili-Floury S, Pirinen M, Ple H, Poca MA, Posti J, Van Praag D, Ptito A, Radoi A, Ragauskas A, Raj R, Real RGL, Reed N, Rhodes J, Robertson C, Rocka S, Røe C, Røise O, Roks G, Rosand J, Rosenfeld JV, Rosenlund C, Rosenthal G, Rossi S, Rueckert D, de Ruiter GCW, Sacchi M, Sahakian BJ, Sahuquillo J, Sakowitz O, Salvato G, Sánchez-Porras R, Sándor J, Sangha G, Schäfer N, Schmidt S, Schneider KJ, Schnyer D, Schöhl H, Schoonman GG, Schou RF, Sir Ö, Skandsen T, Smeets D, Sorinola A, Stamatakis E, Stevanovic A, Stevens RD, Sundström N, Taccone FS, Takala R, Tanskanen P, Taylor MS, Telgmann R, Temkin N, Teodorani G, Thomas M, Tolias CM, Trapani T, Turgeon A, Vajkoczy P, Valadka AB, Valeinis E, Vallance S, Vámos Z, Vargiolu A, Vega E, Verheyden J, Vik A, Vilcinis R, Vleggeert-Lankamp C, Vogt L, Volovici V, Voormolen DC, Vulekovic P, Vande Vyvere T, Van Waesberghe J, Wessels L, Wildschut E, Williams G, Winkler MKL, Wolf S, Wood G, Xirouchaki N, Younsi A, Zaaroor M, Zelinkova V, Zemek R, Zumbo F. Traumatic brain injury: integrated approaches to improve prevention, clinical care, and research. Lancet Neurol 2017; 16:987-1048. [DOI: 10.1016/s1474-4422(17)30371-x] [Citation(s) in RCA: 822] [Impact Index Per Article: 117.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2016] [Revised: 07/06/2017] [Accepted: 09/27/2017] [Indexed: 12/11/2022]
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A nested mechanistic sub-study into the effect of tranexamic acid versus placebo on intracranial haemorrhage and cerebral ischaemia in isolated traumatic brain injury: study protocol for a randomised controlled trial (CRASH-3 Trial Intracranial Bleeding Mechanistic Sub-Study [CRASH-3 IBMS]). Trials 2017; 18:330. [PMID: 28716153 PMCID: PMC5513059 DOI: 10.1186/s13063-017-2073-6] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2016] [Accepted: 06/28/2017] [Indexed: 12/31/2022] Open
Abstract
Background Tranexamic acid prevents blood clots from breaking down and reduces bleeding. However, it is uncertain whether tranexamic acid is effective in traumatic brain injury. The CRASH-3 trial is a randomised controlled trial that will examine the effect of tranexamic acid (versus placebo) on death and disability in 13,000 patients with traumatic brain injury. The CRASH-3 trial hypothesizes that tranexamic acid will reduce intracranial haemorrhage, which will reduce the risk of death. Although it is possible that tranexamic acid will reduce intracranial bleeding, there is also a potential for harm. In particular, tranexamic acid may increase the risk of cerebral thrombosis and ischaemia. The protocol detailed here is for a mechanistic sub-study nested within the CRASH-3 trial. This mechanistic sub-study aims to examine the effect of tranexamic acid (versus placebo) on intracranial bleeding and cerebral ischaemia. Methods The CRASH-3 Intracranial Bleeding Mechanistic Sub-Study (CRASH-3 IBMS) is nested within a prospective, double-blind, multi-centre, parallel-arm randomised trial called the CRASH-3 trial. The CRASH-3 IBMS will be conducted in a cohort of approximately 1000 isolated traumatic brain injury patients enrolled in the CRASH-3 trial. In the CRASH-3 IBMS, brain scans acquired before and after randomisation are examined, using validated methods, for evidence of intracranial bleeding and cerebral ischaemia. The primary outcome is the total volume of intracranial bleeding measured on computed tomography after randomisation, adjusting for baseline bleeding volume. Secondary outcomes include progression of intracranial haemorrhage (from pre- to post-randomisation scans), new intracranial haemorrhage (seen on post- but not pre-randomisation scans), intracranial haemorrhage following neurosurgery, and new focal ischaemic lesions (seen on post-but not pre-randomisation scans). A linear regression model will examine whether receipt of the trial treatment can predict haemorrhage volume. Bleeding volumes and new ischaemic lesions will be compared across treatment groups using relative risks and 95% confidence intervals. Discussion The CRASH-3 IBMS will provide an insight into the mechanism of action of tranexamic acid in traumatic brain injury, as well as information about the risks and benefits. Evidence from this trial could inform the management of patients with traumatic brain injury. Trial registration The CRASH-3 trial was prospectively registered and the CRASH-3 IBMS is an addition to the original protocol registered at the International Standard Randomised Controlled Trials registry (ISRCTN15088122) 19 July 2011, and ClinicalTrials.gov on 25 July 2011 (NCT01402882). Electronic supplementary material The online version of this article (doi:10.1186/s13063-017-2073-6) contains supplementary material, which is available to authorized users.
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Gehi AK, Doros G, Glorioso TJ, Grunwald GK, Hsu J, Song Y, Turakhia MP, Turchin A, Virani SS, Maddox TM. Factors associated with rhythm control treatment decisions in patients with atrial fibrillation-Insights from the NCDR PINNACLE registry. Am Heart J 2017; 187:88-97. [PMID: 28454812 DOI: 10.1016/j.ahj.2017.02.006] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/21/2016] [Accepted: 02/08/2017] [Indexed: 10/20/2022]
Abstract
BACKGROUND Decisions to use rhythm control in atrial fibrillation (AF) should generally be dictated by patient factors, such as quality of life, heart failure, and other comorbidities. Whether or not other factors affect decisions about the use of rhythm control, and catheter ablation in particular, is unknown. METHODS A cohort of all patients diagnosed with nonvalvular AF were identified from the National Cardiovascular Data Registry's Practice Innovation and Clinical Excellence (PINNACLE) AF registry of US outpatient cardiology practices during the study period from May 1, 2008, to December 31, 2014. Overall and practice-specific rates of rhythm control (cardioversion, antiarrhythmic drug therapy, or catheter ablation) were assessed. We assessed patient and practice factors associated with rhythm control and determined the relative contribution of patient, practice, and unmeasured practice factors with its use. RESULTS Among 511,958 PINNACLE AF patients, 22.3% were treated with rhythm control and 2.9% underwent catheter ablation. Significant practice variation in rhythm control was present (median rate of rhythm control across practices 22.8%, range 0.2%-62.9%). Significant patient factors associated with rhythm control therapy included white (vs nonwhite) race (odds ratio [OR] 2.43, P<.001), private (vs nonprivate) insurance (OR 1.04, P<.001), and whether a patient was seen by an electrophysiologist (OR 1.77, P<.001). In an analysis of the relative contribution of patient, practice, and unmeasured practice factors with rhythm control, the contribution of unmeasured practice factors (95% range OR 0.29-3.44) exceeded that of either patient (95% range OR 0.46-2.30) or practice (95% range OR 0.15-2.77) factors. CONCLUSIONS One in 5 AF patients in the PINNACLE registry received rhythm control, and 1 in 50 received catheter ablation, suggesting that rhythm control may be underused. A variety of measured and unmeasured practice factors unrelated to patient characteristics play a disproportionate role in the use of rhythm control treatment decisions. Understanding the drivers of these decisions may identify inappropriate treatment variation and better inform optimal use of these therapies.
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Causes and Consequences of Treatment Variation in Moderate and Severe Traumatic Brain Injury. Crit Care Med 2017; 45:660-669. [DOI: 10.1097/ccm.0000000000002263] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Timing of withdrawal of life-sustaining therapies in severe traumatic brain injury: Impact on overall mortality. J Trauma Acute Care Surg 2016; 80:484-91. [PMID: 26595711 DOI: 10.1097/ta.0000000000000922] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND The care of patients with severe traumatic brain injury (TBI) is complex and confounded by uncertainty in prognoses. Studies have demonstrated significant unexplained variation in mortality between centers. Possible explanations include differences in the quality and intensity of care across centers, including the appropriateness and timing of withdrawal of life-sustaining therapies. We postulated that centers with a preponderance of early deaths might have a more pessimistic approach to the TBI patient, which would be reflected in an increased hospital TBI-related mortality. METHODS This is a retrospective cohort study. Time to death was used as a proxy for time to withdrawal of life-sustaining therapies. Centers were classified as early or late based on when the majority (75th percentile) of their TBI-related deaths occurred. We evaluated the association between adjusted mortality and center classification using a hierarchical multivariable model. Two hundred trauma centers contributing data to the American College of Surgeons Trauma Quality Improvement Program from 2010 through 2013 were involved. The cohort included 17,505 patients with severe isolated TBI. RESULTS One hundred eight centers were classified as early centers. The 75th percentile for time to death was 4 days among early centers versus 7 days in late centers. Mortality was 34% and 33%, respectively. After adjustment for case mix, care in an early center was not associated with increased odds of death (adjusted odds ratio, 0.95; 95% confidence interval, 0.83-1.09). Higher odds of death were independently associated with age, Glasgow Coma Scale (GCS) score, head Abbreviated Injury Scale (AIS) score, multiple comorbidities, traumatic subarachnoid hemorrhage, intracerebral mass lesions, brainstem lesions, and signs of compressed or absent basal cisterns. CONCLUSION Centers rendering early decisions related to withdrawal of life-sustaining therapies in TBI patients, as measured by time until death, do not have worse outcomes than those making later decisions. How and when these decisions are made requires further exploration to balance an opportunity for clinical improvement with appropriate resource use. LEVEL OF EVIDENCE Prognostic and epidemiologic study, level III.
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Horvat CM, Bell MJ. Bringing attention into higher focus within the traumatic brain injury research agenda. Transl Pediatr 2015; 4:320-2. [PMID: 26835394 PMCID: PMC4728995 DOI: 10.3978/j.issn.2224-4336.2015.10.05] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Affiliation(s)
- Christopher M Horvat
- Department of Critical Care Medicine and Safar Center for Resuscitation Research, University of Pittsburgh, Pittsburgh, PA, USA
| | - Michael J Bell
- Department of Critical Care Medicine and Safar Center for Resuscitation Research, University of Pittsburgh, Pittsburgh, PA, USA
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Lesko MM, O’Brien SJ, Childs C, Bouamra O, Rainey T, Lecky F. Comparison of several prognostic tools in traumatic brain injury including S100B. Brain Inj 2014; 28:987-94. [DOI: 10.3109/02699052.2014.890743] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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Maas AIR, Murray GD, Roozenbeek B, Lingsma HF, Butcher I, McHugh GS, Weir J, Lu J, Steyerberg EW. Advancing care for traumatic brain injury: findings from the IMPACT studies and perspectives on future research. Lancet Neurol 2013; 12:1200-10. [PMID: 24139680 DOI: 10.1016/s1474-4422(13)70234-5] [Citation(s) in RCA: 116] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
Research in traumatic brain injury (TBI) is challenging for several reasons; in particular, the heterogeneity between patients regarding causes, pathophysiology, treatment, and outcome. Advances in basic science have failed to translate into successful clinical treatments, and the evidence underpinning guideline recommendations is weak. Because clinical research has been hampered by non-standardised data collection, restricted multidisciplinary collaboration, and the lack of sensitivity of classification and efficacy analyses, multidisciplinary collaborations are now being fostered. Approaches to deal with heterogeneity have been developed by the IMPACT study group. These approaches can increase statistical power in clinical trials by up to 50% and are also relevant to other heterogeneous neurological diseases, such as stroke and subarachnoid haemorrhage. Rather than trying to limit heterogeneity, we might also be able to exploit it by analysing differences in treatment and outcome between countries and centres in comparative effectiveness research. This approach has great potential to advance care in patients with TBI.
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Affiliation(s)
- Andrew I R Maas
- Department of Neurosurgery, Antwerp University Hospital and University of Antwerp, Edegem, Belgium.
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Alali AS, Fowler RA, Mainprize TG, Scales DC, Kiss A, de Mestral C, Ray JG, Nathens AB. Intracranial pressure monitoring in severe traumatic brain injury: results from the American College of Surgeons Trauma Quality Improvement Program. J Neurotrauma 2013; 30:1737-46. [PMID: 23731257 DOI: 10.1089/neu.2012.2802] [Citation(s) in RCA: 139] [Impact Index Per Article: 12.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Although existing guidelines support the utilization of intracranial pressure (ICP) monitoring in patients with traumatic brain injury (TBI), the evidence suggesting benefit is limited. To evaluate the impact on outcome, we determined the relationship between ICP monitoring and mortality in centers participating in the American College of Surgeons Trauma Quality Improvement Program (TQIP). Data on 10,628 adults with severe TBI were derived from 155 TQIP centers over 2009-2011. Random-intercept multilevel modeling was used to evaluate the association between ICP monitoring and mortality after adjusting for important confounders. We evaluated this relationship at the patient level and at the institutional level. Overall mortality (n=3769) was 35%. Only 1874 (17.6%) patients underwent ICP monitoring, with a mortality of 32%. The adjusted odds ratio (OR) for mortality was 0.44 [95% confidence interval (CI), 0.31-0.63], when comparing patients with ICP monitoring to those without. It is plausible that patients receiving ICP monitoring were selected because of an anticipated favorable outcome. To overcome this limitation, we stratified hospitals into quartiles based on ICP monitoring utilization. Hospitals with higher rates of ICP monitoring use were associated with lower mortality: The adjusted OR of death was 0.52 (95% CI, 0.35-0.78) in the quartile of hospitals with highest use, compared to the lowest. ICP monitoring utilization rates explained only 9.9% of variation in mortality across centers. Results were comparable irrespective of the method of case-mix adjustment. In this observational study, ICP monitoring utilization was associated with lower mortality. However, variability in ICP monitoring rates contributed only modestly to variability in institutional mortality rates. Identifying other institutional practices that impact on mortality is an important area for future research.
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Affiliation(s)
- Aziz S Alali
- 1 Sunnybrook Research Institute , Sunnybrook Health Sciences Center, Toronto, Ontario, Canada
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Tosetti P, Hicks RR, Theriault E, Phillips A, Koroshetz W, Draghia-Akli R. Toward an international initiative for traumatic brain injury research. J Neurotrauma 2013; 30:1211-22. [PMID: 23731282 DOI: 10.1089/neu.2013.2896] [Citation(s) in RCA: 64] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
The European Commission (EC) and the National Institutes of Health (NIH) jointly sponsored a workshop on October 18-20, 2011 in Brussels to discuss the feasibility and benefits of an international collaboration in the field of traumatic brain injury (TBI) research. The workshop brought together scientists, clinicians, patients, and industry representatives from around the globe as well as funding agencies from the EU, Spain, the United States, and Canada. Sessions tackled both the possible goals and governance of a future initiative and the scientific questions that would most benefit from an integrated international effort: how to optimize data collection and sharing; injury classification; outcome measures; clinical study design; and statistical analysis. There was a clear consensus that increased dialogue and coordination of research at an international level would be beneficial for advancing TBI research, treatment, and care. To this end, the EC, the NIH, and the Canadian Institutes of Health Research expressed interest in developing a framework for an international initiative for TBI Research (InTBIR). The workshop participants recommended that InTBIR initially focus on collecting, standardizing, and sharing clinical TBI data for comparative effectiveness research, which will ultimately result in better management and treatments for TBI.
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