Trends and outcome predictors after traumatic brain injury surgery: a nationwide population-based study in Taiwan

Early hypocoagulable state in traumatic brain injury patients: incidence, predisposing factors, and outcomes in a retrospective cohort study

Coagulopathy development in traumatic brain injury (TBI) is among the significant complications that can negatively affect the clinical course and outcome of TBI patients. Timely identification of this complication is of utmost importance in the acute clinical setting. We reviewed TBI patients admitted to our trauma center from 2015 to 2021. Demographic data, mechanism of injury, findings on admission, imaging studies, procedures during hospitalization, and functional outcomes were gathered. INR with a cutoff of 1.3, platelet count less than 100 × 10⁹/L, or partial thromboplastin time greater than 40s were utilized as the markers of coagulopathy. A total of 4002 patients were included. Coagulopathy occurred in 38.1% of the patients. Age of the patients (Odds Ratio (OR) = 0.993, 95% Confidence Interval (CI) = 0.986-0.999, p = 0.028), systolic blood pressure (OR = 0.993, 95% CI = 0.989-0.998, p = 0.005), fibrinogen level (OR = 0.998, 95% CI = 0.996-0.999, p < 0.001), and hemoglobin level (OR = 0.886, 95% CI = 0.839-0.936, p < 0.001) were independently associated with coagulopathy. Furthermore, coagulopathy was independently associated with higher mortality rates and longer ICU stays. Coagulopathy had the most substantial effect on mortality of TBI patients (OR = 2.6, 95% CI = 2.1-3.3, p < 0.001), compared to other admission clinical characteristics independently associated with mortality such as fixed pupillary light reflex (OR = 1.8, 95% CI = 1.5-2.4, p < 0.001), GCS (OR = 0.91, 95% CI = 0.88-0.94, p < 0.001), and hemoglobin level (OR = 0.93, 95% CI = 0.88-0.98, p = 0.004). Early coagulopathy in TBI patients can lead to higher mortality rates. Future studies are needed to prove that early detection and correction of coagulopathy and modifiable risk factors may help improve outcomes of TBI patients.

Serum amyloid P component accumulates and persists in neurones following traumatic brain injury

The mechanisms underlying neurodegenerative sequelae of traumatic brain injury (TBI) are poorly understood. The normal plasma protein, serum amyloid P component (SAP), which is normally rigorously excluded from the brain, is directly neurocytotoxic for cerebral neurones and also binds to Aβ amyloid fibrils and neurofibrillary tangles, promoting formation and persistence of Aβ fibrils. Increased brain exposure to SAP is common to many risk factors for dementia, including TBI, and dementia at death in the elderly is significantly associated with neocortical SAP content. Here, in 18 of 30 severe TBI cases, we report immunohistochemical staining for SAP in contused brain tissue with blood-brain barrier disruption. The SAP was localized to neurofilaments in a subset of neurones and their processes, particularly damaged axons and cell bodies, and was present regardless of the time after injury. No SAP was detected on astrocytes, microglia, cerebral capillaries or serotoninergic neurones and was absent from undamaged brain. C-reactive protein, the control plasma protein most closely similar to SAP, was only detected within capillary lumina. The appearance of neurocytotoxic SAP in the brain after TBI, and its persistent, selective deposition in cerebral neurones, are consistent with a potential contribution to subsequent neurodegeneration.

Post-Acute Care for Traumatic Brain Injury Patients in Taiwan

Background

Traumatic brain injury (TBI) can result in functional impairments. Many patients with TBI require post-acute care to improve their functional skills and allow for greater self-independence and a better quality of life. Taiwan's National Health Insurance proposed a nationwide post-acute care program in 2017 for patients with traumatic brain injury. The program's goal was to maximize patients' functional recovery and make it possible for them to return to their homes and communities. This study aimed to explore the effectiveness of such programs in Taiwan.

Methods

This pilot study retrospectively evaluated a de-identified database that contained the scores of various assessments evaluated at admission and discharge. It used the data to determine the functional improvement of patients with traumatic brain injury after participating in post-acute care programs.

Results

This study collected complete data from 27 patients. After an average of 45.11 days in the program, the patients showed significant improvement in the Barthel Activity Daily Living Index, the Lawton-Brody Instrumental Activity Daily Living Scale, the Mini Nutrition Assessment, the EuroQol Five Dimensions Questionnaire, the Berg Balance Scale, the Galveston Orientation and Amnesia Test, the Rancho Los Amigos Scale, the Concise Chinese Aphasia Test, and the Mini Mental State Examination. After discharge, 96% of the patients could return to their community.

Conclusion

This pilot study concluded that the program significantly promoted functional recovery for patients and could help patients with traumatic brain injury return to their communities and reduce the risk of institutionalization. Thus, patients with the potential for functional recovery could receive post-acute care in regional or community hospitals immediately after being discharged from acute wards. In the future randomized controlled trials are needed to further confirm the clinical impact of this program.

Predictors of ICU admission and patient outcome for traumatic brain injury in a Tanzanian referral hospital: Implications for improving treatment guidelines

Traumatic brain injuries (TBI) are a critical global health challenge, with disproportionate negative impact in low- and middle-income countries (LMICs). People who suffer severe TBI in LMICs are twice as likely to die than those in high-income countries, and survivors experience substantially poorer outcomes. In the hospital, patients with severe TBI are typically seen in intensive care units (ICU) to receive advanced monitoring and lifesaving treatment. However, the quality and outcomes of ICU care in LMICs are often unclear. We analyzed secondary data from a cohort of 605 adult patients who presented to the Emergency Department (ED) of a Tanzanian hospital with a moderate or severe TBI. We examined patient characteristics and performed two binary logistic regression models to assess predictors of ICU admission and patient outcome. Patients were often young (median age = 32, SD = 15), overwhelmingly male (88.9%), and experienced long delays from time of injury to presentation in the ED (median=12 h, SD = 168). A majority of patients (87.8%) underwent surgery and 55.6% ultimately had a "good recovery" with minimal disability, while 34.0% died. Patients were more likely to be seen in the ICU if they had worse baseline symptoms and were over age 60. TBI surgery conveyed a 37% risk reduction for poor TBI outcome. However, ICU patients had a 3.91 times higher risk of poor TBI outcome as compared to those not seen in the ICU, despite controlling for baseline symptoms. The findings point to the need for targeted interventions among young men, improvements in pre-hospital transportation and care, and continued efforts to increase the quality of surgical and ICU care in this setting. It is unlikely that poorer outcome among ICU patients was indicative of poorer care in the ICU; this finding was more likely due to lack of data on several factors that inform care decisions (e.g., comorbid conditions or injuries). Nevertheless, future efforts should seek to increase the capacity of ICUs in low-resource settings to monitor and treat TBI according to international guidelines, and should improve predictive modeling to identify risk for poor outcome.

Periostin aggravates the early phase of traumatic brain injury via the MAPK/ERK pathway

OBJECTIVES

Periostin is found associated with trauma severity and mortality following head injury. In this study, the role and mechanism of periostin in the traumatic brain injury were investigated.

METHODS

Male Sprague-Dawley adult rats underwent sham or TBI modeling. Vehicle or recombinant periostin was administered intracerebroventricularly at 30 minutes post-TBI, and U0126, a specific MEK1/2 inhibitor, was administered intravenously at 30 minutes pre-TBI. Garcia neuroscore, limb function and brain water content assessments, as well as TUNEL and Western blotting assays were performed to evaluate the status of the above rats at 24 hours post-TBI. Finally, the motor test and Morris water maze test were performed to measure the effects of periostin and U0126 in the late phase of TBI.

RESULTS

Periostin expression significantly increased 24 hours post-TBI. Treatment with R-periostin aggravated post-TBI neurobehavioral impairment, brain edema, induced apoptosis and raised the quantity of phospho-p38, phospho-JNK, phospho-ERK and MMP-9, and lowered the expression of ZO-1. However, U0126, a kind of inhibitor of MEK, lowered the quantities of phospho-ERK and MMP-9, raised the expression of ZO-1, and suppressed apoptosis. U0126 also ameliorated the neurobehavioral impairments and brain edema induced by R-periostin. Additionally, U0126 didn't inhibit the expression of periostin in the early phase of TBI model. IU0126 was also able to ameliorate the pathological conditions in the late phase of TBI.

DISCUSSION

Periostin could aggravate neurobehavioral impairments and brain edema following TBI, and was involved in the early phase of TBI via the MAPK/ERK pathway.

Emergency Neurosurgery Performed by General Surgeons: A Systematic Review

BACKGROUND

In under-resourced settings, general surgeons may be called upon to perform emergency operations within other specialties. Accordingly, we aimed to characterise patient outcomes after emergency neurosurgery performed by a general surgeon or general surgery trainee.

METHODS

PubMed, Embase and the Cochrane Library were searched to 30 May 2021 for observational studies reporting outcomes after emergency neurosurgery performed by a general surgeon. Study screening, data extraction, and risk of bias using the Downs and Black checklist were performed in duplicate. Data on setting, operation undertaken, mortality rates and complications were extracted. Meta-analysis was planned but not possible due to heterogeneity. This study is registered with PROSPERO, CRD42021258097.

RESULTS

From 632 records, 14 retrospective observational studies were included, covering a total sample of 1,988 operations. Four studies were from Australia, and the remaining 10 were, respectively, from 10 other countries. Most common operations performed were decompressive surgery with burr holes or craniectomy for head trauma and insertion of intracranial pressure monitors. Rural hospitals were the most common settings. Mortality rates for procedures performed by general surgeons at latest follow-up were heterogenous, ranging from 5% for evacuation of chronic subdural haematoma in Kenya to 81% in head injured patients in a Hong Kong study.

CONCLUSIONS

This is the first systematic review that synthesises the literature to characterise patient outcomes after neurosurgical operations performed by a general surgeon. Findings from this study may benefit global surgery performed in rural, remote, military or humanitarian settings.

Neurological deteriorations in mild brain injuries: the strategy of evaluation and management

PURPOSE

Most mild traumatic brain injuries (TBIs) can be treated conservatively. However, some patients deteriorate during observation. Therefore, we tried to evaluate the characteristics of deterioration and requirement for further management in mild TBI patients.

METHODS

From 1/1/2017 to 12/31/2017, patients with mild TBI and positive results on CT scans of the brain were retrospectively studied. Patients with and without neurological deteriorations were compared. The characteristics of mild TBI patients with further neurological deterioration or the requirement for interventions were delineated.

RESULTS

One hundred ninety-two patients were enrolled. Twenty-three (12.0%) had neurological deteriorations. The proportions of deterioration occurring within 24 h, 48 h and 72 h were 23.5, 41.2 and 58%, respectively. Deteriorated patients were significantly older than those without neurological deteriorations (69.7 vs. 60.2; p = 0.020). More associated extracranial injuries were observed in deteriorated patients [injury severity score (ISS): 20.2 vs. 15.9; p = 0.005). Significantly higher proportions of intraventricular hemorrhage (8.7 vs. 1.2%; p = 0.018) and multiple lesions (78.3 vs. 53.8%; p = 0.027) were observed on the CT scans of patients with neurological deteriorations. Subset analysis showed that deteriorated patients who required neurosurgical interventions (N = 7) had significantly more initial GCS defects (13 or 14) (71.4 vs. 12.5%; p = 0.005) and more initial decreased muscle power of extremities (85.7 vs. 18.8%; p = 0.002).

CONCLUSION

More attention should be given to mild TBI patients with older age, GCS defects, decreased muscle power of the extremities, multiple lesions on CT scans and other systemic injuries (high ISS). Most deteriorations occur within 72 h after trauma.

Longitudinal fMRI task reveals neural plasticity in default mode network with disrupted executive-default coupling and selective attention after traumatic brain injury

Executive dysfunctions are common in individuals with Traumatic Brain Injury (TBI). However, change in functional neural coupling of default and executive networks in the post-acute phase (≥ 1 month after injury) patients over time has yet to be understood. During a 5-week observation period, we examined changes in the goal-oriented executive function networks in 20 TBI participants, using a face/scene matching 1-back fMRI task (Chen et al. 2011). We conducted multivariate pattern analysis to assess working memory and visual selective attention, followed by a repeat-measures ANOVA to examine longitudinal changes, with a cluster FDR at p = .001. Results showed that task accuracy significantly improved after follow-up. Significantly increased activity patterns over time were observed in the right dorsolateral prefrontal cortex and right insula. Decreased activity patterns were seen in the left posterior cingulate cortex (PCC), bilateral precuneus, right inferior occipital gyrus and right temporo-occipital junction. Improvement in task accuracy correlated with decreased activity patterns in the PCC (r = -0.478, p = 0.031) and temporo-occipital junction (r = -0.592, p = 0.006), which were interpreted as neural plastic changes. However, we did not observe the default mode network (DMN)-executive network decoupling during task performance that is found in other studies. These results suggest that fMRI of attentional task performance could serve as a potential biomarker for neural plasticity of selective attention in TBI patients in the post-acute phase.

Hospital volume-outcome relationship in severe traumatic brain injury: stratified analysis by level of trauma center

OBJECTIVE

The nature of the volume-outcome relationship in cases with severe traumatic brain injury (TBI) remains unclear, with considerable interhospital variation in patient outcomes. The objective of this study was to understand the state of the volume-outcome relationship at different levels of trauma centers in the United States.

METHODS

The authors queried the National Trauma Data Bank for the years 2007-2014 for patients with severe TBI. Case volumes for each level of trauma center organized into quintiles (Q1-Q5) served as the primary predictor. Analyzed outcomes included in-hospital mortality, total hospital length of stay (LOS), and intensive care unit (ICU) stay. Multivariable regression models were performed for in-hospital mortality, overall complications, and total hospital and ICU LOSs to adjust for possible confounders. The analysis was stratified by level designation of the trauma center. Statistical significance was established at p < 0.001 to avoid a type I error due to a large sample size.

RESULTS

A total of 122,445 patients were included. Adjusted analysis did not demonstrate a significant relationship between increasing hospital volume of severe TBI cases and in-hospital mortality, complications, and nonhome hospital discharge disposition among level I-IV trauma centers. However, among level II trauma centers, hospital LOS was longer for the highest volume quintile (adjusted mean difference [MD] for Q5: 2.83 days, 95% CI 1.40-4.26 days, p < 0.001, reference = Q1). For level III and IV trauma centers, both hospital LOS and ICU LOS were longer for the highest volume quintile (adjusted MD for Q5: LOS 4.6 days, 95% CI 2.3-7.0 days, p < 0.001; ICU LOS 3.2 days, 95% CI 1.6-4.8 days, p < 0.001).

CONCLUSIONS

Higher volumes of severe TBI cases at a lower level of trauma center may be associated with a longer LOS. These results may assist policymakers with target interventions for resource allocation and point to the need for careful prehospital decision-making in patients with severe TBI.

Validating the Quality of Life After Brain Injury Through Rasch Analysis

OBJECTIVE

The Quality of Life after Brain Injury (QOLIBRI), a cross-cultural instrument, has been validated in several languages; however, traditional psychometric approaches have critical limitations. Therefore, we applied the Rasch model for validating the 37-item QOLIBRI scale among a Chinese population with traumatic brain injury.

PARTICIPANTS AND SETTING

In total, 587 participants (mean age: 44.2 ± 15.4 years; women, 46.3%) were surveyed in neurosurgery departments at 6 hospitals in Taipei, Taiwan.

MAIN OUTCOME MEASURE

The QOLIBRI.

RESULTS

Of the 6 subscales of the QOLIBRI, 4 (cognition, self, daily life and autonomy, and social relationships) were unidimensional, valid, and reliable, whereas the remaining 2 (emotions and physical problems) exhibited poor unidimensionality, item and person reliability, and person-item targeting. Five items (energy, concentrating, getting out and about, sex life, and achievements) showed considerable differential item functioning among age groups, disability levels, and time since traumatic brain injury.

CONCLUSION

According to item response theory, we identified psychometric issues in the emotions and physical problems subscales of the QOLIBRI as well as several differential item functioning items. Future research is required to determine whether similar results are observed in other language versions of the QOLIBRI or in other countries.

Estimating the global incidence of traumatic brain injury

OBJECTIVETraumatic brain injury (TBI)-the "silent epidemic"-contributes to worldwide death and disability more than any other traumatic insult. Yet, TBI incidence and distribution across regions and socioeconomic divides remain unknown. In an effort to promote advocacy, understanding, and targeted intervention, the authors sought to quantify the case burden of TBI across World Health Organization (WHO) regions and World Bank (WB) income groups.METHODSOpen-source epidemiological data on road traffic injuries (RTIs) were used to model the incidence of TBI using literature-derived ratios. First, a systematic review on the proportion of RTIs resulting in TBI was conducted, and a meta-analysis of study-derived proportions was performed. Next, a separate systematic review identified primary source studies describing mechanisms of injury contributing to TBI, and an additional meta-analysis yielded a proportion of TBI that is secondary to the mechanism of RTI. Then, the incidence of RTI as published by the Global Burden of Disease Study 2015 was applied to these two ratios to generate the incidence and estimated case volume of TBI for each WHO region and WB income group.RESULTSRelevant articles and registries were identified via systematic review; study quality was higher in the high-income countries (HICs) than in the low- and middle-income countries (LMICs). Sixty-nine million (95% CI 64-74 million) individuals worldwide are estimated to sustain a TBI each year. The proportion of TBIs resulting from road traffic collisions was greatest in Africa and Southeast Asia (both 56%) and lowest in North America (25%). The incidence of RTI was similar in Southeast Asia (1.5% of the population per year) and Europe (1.2%). The overall incidence of TBI per 100,000 people was greatest in North America (1299 cases, 95% CI 650-1947) and Europe (1012 cases, 95% CI 911-1113) and least in Africa (801 cases, 95% CI 732-871) and the Eastern Mediterranean (897 cases, 95% CI 771-1023). The LMICs experience nearly 3 times more cases of TBI proportionally than HICs.CONCLUSIONSSixty-nine million (95% CI 64-74 million) individuals are estimated to suffer TBI from all causes each year, with the Southeast Asian and Western Pacific regions experiencing the greatest overall burden of disease. Head injury following road traffic collision is more common in LMICs, and the proportion of TBIs secondary to road traffic collision is likewise greatest in these countries. Meanwhile, the estimated incidence of TBI is highest in regions with higher-quality data, specifically in North America and Europe.

Serum periostin concentrations and outcomes after severe traumatic brain injury

BACKGROUND

Periostin, a neurite outgrowth-promoting factor, is increasingly expressed in rat brain tissues after cerebral ischemia or subarachnoid hemorrhage. However, periostin concentrations are undetermined in peripheral blood from patients with traumatic brain injury (TBI).

METHODS

In this prospective, observational study, serum periostin concentrations were measured in 130 controls and 130 severe TBI patients. We investigated its association with trauma severity reflected by Glasgow Coma Scale (GCS) score and prognosis (i.e., 30-day mortality and 30-day overall survival).

RESULTS

As compared with the controls, serum periostin concentrations were significantly increased in the patients [(median, 246.5ng/ml; interquartile range, 164.5-328.6ng/ml) vs. (median, 61.8ng/ml; interquartile range, 37.9-77.9ng/ml), P<0.001]. Periostin concentrations independently correlated with GCS scores (t=-6.199, P<0.001). Serum periostin concentrations higher than 308.2ng/ml predicted 30-day mortality with a sensitivity of 72.4% and a specificity of 78.2% [area under curve, 815; 95% confidence interval (CI), 0.737-0.878]. Periostin concentrations higher than 246.5ng/ml were independently related to 30-day mortality and 30-day overall survival with odds ratio value of 3.829 (95% CI, 1.104-13.281) and hazard ratio value of 5.667 (95% CI, 1.953-16.443) respectively.

CONCLUSIONS

Increased serum periostin concentrations clearly reflect trauma severity and mortality following TBI.

Early Brain Edema is a Predictor of In-Hospital Mortality in Traumatic Brain Injury

BACKGROUND

Identifying patients who may progress to a poor clinical outcome will encourage earlier appropriate therapeutic interventions. Brain edema may contribute to secondary injury in traumatic brain injury (TBI) and thus, may be a useful prognostic indicator.

OBJECTIVE

We determined whether the presence of brain edema on the initial computed tomography (CT) scan of TBI patients would predict poor in-hospital outcome.

METHODS

We performed a retrospective review of all trauma patients with nonpenetrating head trauma at a Level I Trauma Center. International Classification of Diseases, Ninth Revision codes indicated the presence of brain edema and we evaluated the validity of this pragmatic assessment quantitatively in a random subset of patients. In-hospital mortality was the primary outcome variable. Univariate analysis and logistic regression identified predictors of mortality in all TBI patients and those with mild TBI.

RESULTS

Over 7200 patients were included in the study, including 6225 with mild TBI. Measurements of gray and white matter CT density verified radiological assessments of brain edema. Patients with documented brain edema had a mortality rate over 10 times that of the entire study population. With logistic regression accounting for Injury Severity Score, Glasgow Coma Scale score, other CT findings, and clinical variables, brain edema predicted an eightfold greater mortality rate in all patients (odds ratio 8.0, 95% confidence interval 4.6-14.0) and fivefold greater mortality rate for mild TBI patients (odds ratio 4.9, 95% confidence interval 2.0-11.7).

CONCLUSIONS

Brain edema is an independent prognostic variable across all categories of TBI severity. By alerting emergency physicians to patients with poor predicted clinical outcomes, this finding will drive better resource allocation, earlier intervention, and reduced patient mortality.

Predictive model for 5-year mortality after breast cancer surgery in Taiwan residents

BACKGROUND

Few studies of breast cancer surgery outcomes have used longitudinal data for more than 2 years. This study aimed to validate the use of the artificial neural network (ANN) model to predict the 5-year mortality of breast cancer patients after surgery and compare predictive accuracy between the ANN model, multiple logistic regression (MLR) model, and Cox regression model.

METHODS

This study compared the MLR, Cox, and ANN models based on clinical data of 3632 breast cancer patients who underwent surgery between 1996 and 2010. An estimation dataset was used to train the model, and a validation dataset was used to evaluate model performance. The sensitivity analysis was also used to assess the relative significance of input variables in the prediction model.

RESULTS

The ANN model significantly outperformed the MLR and Cox models in predicting 5-year mortality, with higher overall performance indices. The results indicated that the 5-year postoperative mortality of breast cancer patients was significantly associated with age, Charlson comorbidity index (CCI), chemotherapy, radiotherapy, hormone therapy, and breast cancer surgery volumes of hospital and surgeon (all P < 0.05). Breast cancer surgery volume of surgeon was the most influential (sensitive) variable affecting 5-year mortality, followed by breast cancer surgery volume of hospital, age, and CCI.

CONCLUSIONS

Compared with the conventional MLR and Cox models, the ANN model was more accurate in predicting 5-year mortality of breast cancer patients who underwent surgery. The mortality predictors identified in this study can also be used to educate candidates for breast cancer surgery with respect to the course of recovery and health outcomes.

Factors Associated With Small Bowel Obstruction Following Appendectomy: A Population-Based Study

Postoperative small bowel obstruction (SBO) is a common complication of appendectomy. This study aimed to assess risk factors for SBO following appendectomy.This retrospective cohort study used the 2006 to 2008 Taiwan National Health Insurance Research Database. We evaluated adult patients with acute appendicitis who underwent open (OA) or laparoscopic appendectomy (LA) between January 1, 2006 and December 31, 2008. Excluded were patients with a history of abdominal surgery and SBO before the index operation, or abdominal surgery between the appendectomy and initial diagnosis of bowel obstruction as an identifiable cause of SBO. Factors thought to influence postoperative SBO were highlighted. The OA and LA cohorts were matched by propensity score, and the hazard ratios (HRs) and 95% confidence interval (CIs) of SBO were calculated.We enrolled 11,289 patients who underwent OA, and 11,289 matched controls who underwent LA. OA patients had significant risk of adhesive SBO compared with the LA group (adjusted HR: 1.7, 95% CI: 1.11-2.63). Further analysis revealed that that female sex (adjusted HR: 1.79, 95% CI: 1.17-2.72), CCI score of 1 or ≥2 (adjusted HR: 3.16, 95% CI: 1.76-5.67; adjusted HR: 4.03, 95% CI: 1.57-10.34), complicated appendicitis (adjusted HR: 1.68, 95% CI: 1.05-2.69), treatment in district hospitals increased risk of adhesive SBO.Female sex, complicated appendicitis, more comorbidities, and treatment in district hospitals are factors associated with a risk of SBO after appendectomy. Our findings confirmed that a laparoscopic approach is better than an open approach.

Patient comorbidities increase postoperative resource utilization after laparoscopic and open cholecystectomy

BACKGROUND

An understanding of the relationship between patient factors and healthcare resource utilization represents a major point of interest for optimizing clinical care and overall net savings, yet maintaining financial margins for provider revenues. This study aims to review resource utilization after cholecystectomy in order to characterize patient factors associated with increased postoperative ED visits and 30-day readmissions.

METHODS

A total of 53,632 open and laparoscopic cholecystectomies were reviewed from July 2009 to December 2010 in a large private payer claims database. ICD-9 and CPT codes were available for each event, as well as basic demographics. Data regarding 30-day postoperative resource utilization metrics (emergency department visits and inpatient hospitalizations) were analyzed and stratified by key patient comorbidities. Differences between subgroups were evaluated with univariate and multivariable methods.

RESULTS

Of the 53,632 patients studied, 71.2 % (38,171) were female and 28.8 % (15,461) male. Resource utilization within 30 days of surgery included: 6.6 % (3538) of patients with an ED visit and 7.7 % (4103) with an inpatient hospitalization. The most common comorbidities in the study population were: hypertension, hyperlipidemia, GERD/hiatal hernia, and diabetes mellitus. Patients with heart failure, cirrhosis, and a history of MI or acute ischemic heart disease all had a significant association with postoperative ED visit and the highest likelihood of inpatient hospitalization. Angina, diabetes, and hypertension similarly increased both ED utilization and inpatient readmissions to a lesser but still significant extent. Although patients with GERD/hiatal hernia and sleep apnea had a significant association with ED use, they did not have an increased likelihood of readmission.

CONCLUSIONS

Patient comorbidity indexing plays a major role in clinical risk stratification and resource utilization for cholecystectomy. These factors should be considered in bundled reimbursement packages and in the creation of preventive postoperative ambulatory strategies given their role in determining potential resource utilization in the postoperative setting.

Serum substance P levels are associated with severity and mortality in patients with severe traumatic brain injury

INTRODUCTION

Substance P (SP) is a member of the tachykinin family of neuropeptides, which are widely distributed throughout the central nervous system (CNS) and actively involved in inflammatory processes. SP is released early following acute injury to the CNS, promoting a neurogenic inflammatory response characterized by an increase in the permeability of the blood-brain barrier and the development of vasogenic edema. High levels of SP could lead to an exacerbated inflammatory response that could be fatal for patients with traumatic brain injury (TBI). Thus, the main goal of the present study was to determine whether serum SP levels are associated with injury severity and mortality in patients with severe TBI.

METHODS

This multicenter, observational, prospective study was carried out in six Spanish intensive care units and included patients with Glasgow Coma Scale (GCS) scores ≤ 8. Patients with an Injury Severity Score ≥ 10 in non-cranial aspects were excluded. Blood samples were collected on day 1 of TBI to measure serum SP levels. The endpoint was 30-day mortality.

RESULTS

We found higher serum SP levels (P = 0.002) in non-surviving patients (n = 27) than in surviving patients (n = 73). The area under the curve for serum SP levels with regard to predicting 30-day mortality was 0.70 (95% confidence interval (CI), 0.60 to 0.79; P < 0.001). Survival analysis showed that patients with serum SP levels >299 pg/ml had higher 30-day mortality than patients with lower levels (hazard ratio = 3.7; 95% CI, 1.75 to 7.94; P < 0.001). Multiple binomial logistic regression analysis showed that serum SP levels >299 pg/ml were associated with 30-day mortality when we controlled for APACHE II score and Marshall computed tomography lesion classification (odds ratio (OR) = 5.97; 95% CI, 1.432 to 24.851; P = 0.01) and for GCS score and age (OR = 5.71; 95% CI, 1.461 to 22.280; P = 0.01). We found a negative association between serum SP levels and GCS score (Spearman's ρ = -0.22; P = 0.03).

CONCLUSIONS

We report, for the first time to our knowledge, that serum SP levels were associated with injury severity and mortality in patients with severe TBI. These results open the possibility that SP antagonists may be useful in the treatment of patients with severe TBI.