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Krewulak KD, Hiploylee C, Ely EW, Stelfox HT, Inouye SK, Fiest KM. Adaptation and Validation of a Chart-Based Delirium Detection Tool for the ICU (CHART-DEL-ICU). J Am Geriatr Soc 2020; 69:1027-1034. [PMID: 33348428 PMCID: PMC8049975 DOI: 10.1111/jgs.16987] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2020] [Revised: 10/19/2020] [Accepted: 11/20/2020] [Indexed: 01/01/2023]
Abstract
OBJECTIVE To adapt and validate a chart-based delirium detection tool for use in critically ill adults. DESIGN Validation study. SETTING Medical-surgical intensive care unit (ICU) in an academic hospital. MEASUREMENTS A chart-based delirium detection tool (CHART-DEL) was adapted for use in critically ill adults (CHART-DEL-ICU) and compared with prospective delirium assessments (i.e., clinical assessments (reference standard) by a research nurse trained by a neuropsychiatrist and routine delirium screening tools Confusion Assessment Method (CAM-ICU)) and (Intensive Care Delirium Screening Checklist (ICDSC)). The original CHART-DEL tool was adapted to include physician-reported ICDSC score (for probable delirium) and Richmond-Agitation Sedation Scale score (for altered level of consciousness and agitation). Two trained chart abstractors blinded to all delirium assessments manually abstracted delirium-related information from medical charts and electronic medical records and rated if delirium was present (four levels: uncertain, possible, probable, definite) or absent (no evidence). RESULTS Charts were manually abstracted for delirium-related information for 213 patients who were included in a prospective cohort study that included prospective delirium assessments. The CHART-DEL-ICU tool had excellent interrater reliability (kappa = 0.90). Compared to the reference standard, the sensitivity was 66.0% (95% CI = 59.3-72.3%) and specificity was 82.1% (95% CI = 78.0-85.7%), with a cut-point that included definite, probable, possible, and uncertain delirium. The AUC of the CHART-DEL-ICU alone is 74.1% (95% CI = 70.4-77.8%) compared with the addition of the CAM-ICU and ICDSC (CAM-ICU/CHART-DEL-ICU: 80.9% (95% CI = 77.8-83.9%), P = .01; ICDSC/CHART-DEL-ICU: 79.2% (95% CI = 75.9-82.6%), P = .03). CONCLUSION A chart-based delirium detection tool has improved diagnostic accuracy when combined with routine delirium screening tools (CAM-ICU and ICDSC), compared to a chart-based method on its own. This presents a potential for retrospective detection of delirium from medical charts for research or to augment routine delirium screening methods to find missed cases of delirium.
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Affiliation(s)
- Karla D Krewulak
- Department of Critical Care Medicine, Alberta Health Services & University of Calgary, Calgary, Alberta, Canada
| | - Carmen Hiploylee
- Department of Critical Care Medicine, Alberta Health Services & University of Calgary, Calgary, Alberta, Canada
| | - E W Ely
- Tennessee Valley Veteran's Affairs Geriatric Research Education Clinical Center (VA GRECC), Critical Illness, Brain Dysfunction, and Survivorship (CIBS) Center, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Henry T Stelfox
- Department of Critical Care Medicine, Alberta Health Services & University of Calgary, Calgary, Alberta, Canada.,Department of Community Health Sciences & O'Brien Institute for Public Health, University of Calgary, Calgary, Alberta, Canada
| | - Sharon K Inouye
- Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA.,Aging Brain Center, Marcus Institute for Aging Research, Hebrew Senior Life, Boston, Massachusetts, USA
| | - Kirsten M Fiest
- Department of Critical Care Medicine, Alberta Health Services & University of Calgary, Calgary, Alberta, Canada.,Department of Community Health Sciences & O'Brien Institute for Public Health, University of Calgary, Calgary, Alberta, Canada.,Department of Psychiatry & Hotchkiss Brain Institute, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
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Wennberg R, Hiploylee C, Tator CH. Is concussion a risk factor for epilepsy? Br J Sports Med 2017. [DOI: 10.1136/bjsports-2016-097270.64] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
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Hiploylee C, Wennberg R, Tator CH. The financial toll of career-ending concussions in professional hockey. Concussion 2016; 1:CNC20. [PMID: 30202562 PMCID: PMC6093817 DOI: 10.2217/cnc-2016-0008] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2016] [Accepted: 07/04/2016] [Indexed: 11/21/2022] Open
Abstract
AIM Several high-profile professional hockey players have retired due to career-ending concussions sustained in the National Hockey League (NHL). We sought to determine the salary cost of career-ending concussions in the NHL. METHODS Concussion-induced retirements from 1995 to 2015 were identified using public media sources. The number of missed games due to a player's final concussion was multiplied by per game salary to determine cost. RESULTS In total, 35 players were identified: the total cost to teams and insurers of career-ending concussions was US$135,476,777. Half of the total consisted of salaries owing three players with contracts still active in 2015. CONCLUSION The financial impact of concussion-induced retirements provides another reason for professional leagues to take measures to better protect their players from concussion.
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Affiliation(s)
- Carmen Hiploylee
- Canadian Sports Concussion Project, Krembil Neuroscience Centre, University of Toronto, Toronto Western Hospital, 399 Bathurst Street, Toronto, ON M5T 2S8, Canada
| | - Richard Wennberg
- Canadian Sports Concussion Project, Krembil Neuroscience Centre, University of Toronto, Toronto Western Hospital, 399 Bathurst Street, Toronto, ON M5T 2S8, Canada
| | - Charles H Tator
- Canadian Sports Concussion Project, Krembil Neuroscience Centre, University of Toronto, Toronto Western Hospital, 399 Bathurst Street, Toronto, ON M5T 2S8, Canada
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Hiploylee C, Dufort PA, Davis HS, Wennberg RA, Tartaglia MC, Mikulis D, Hazrati LN, Tator CH. Longitudinal Study of Postconcussion Syndrome: Not Everyone Recovers. J Neurotrauma 2016; 34:1511-1523. [PMID: 27784191 DOI: 10.1089/neu.2016.4677] [Citation(s) in RCA: 167] [Impact Index Per Article: 20.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
We examined recovery from postconcussion syndrome (PCS) in a series of 285 patients diagnosed with concussion based on international sport concussion criteria who received a questionnaire regarding recovery. Of 141 respondents, those with postconcussion symptoms lasting less than 3 months, a positive computed tomography (CT) and/or magnetic resonance imaging (MRI), litigants, and known Test of Memory Malingering (TOMM)-positive cases were excluded, leaving 110 eligible respondents. We found that only 27% of our population eventually recovered and 67% of those who recovered did so within the first year. Notably, no eligible respondent recovered from PCS lasting 3 years or longer. Those who did not recover (n = 80) were more likely to be non-compliant with a do-not-return-to-play recommendation (p = 0.006) but did not differ from the recovered group (n = 30) in other demographic variables, including age and sex (p ≥ 0.05). Clustergram analysis revealed that symptoms tended to appear in a predictable order, such that symptoms later in the order were more likely to be present if those earlier in the order were already present. Cox proportional hazards model analysis showed that the more symptoms reported, the longer the time to recovery (p = 7.4 × 10-6), with each additional symptom reducing the recovery rate by approximately 20%. This is the first longitudinal PCS study to focus on PCS defined specifically as a minimum of 3 months of symptoms, negative CT and/or MRI, negative TOMM test, and no litigation. PCS may be permanent if recovery has not occurred by 3 years. Symptoms appear in a predictable order, and each additional PCS symptom reduces recovery rate by 20%. More long-term follow-up studies are needed to examine recovery from PCS.
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Affiliation(s)
- Carmen Hiploylee
- 1 Division of Neurosurgery, University of Toronto and Toronto Western Hospital , Toronto, Ontario, Canada .,2 Canadian Concussion Center , Toronto Western Hospital, Toronto, Canada
| | - Paul A Dufort
- 2 Canadian Concussion Center , Toronto Western Hospital, Toronto, Canada
| | - Hannah S Davis
- 1 Division of Neurosurgery, University of Toronto and Toronto Western Hospital , Toronto, Ontario, Canada .,2 Canadian Concussion Center , Toronto Western Hospital, Toronto, Canada
| | - Richard A Wennberg
- 2 Canadian Concussion Center , Toronto Western Hospital, Toronto, Canada .,3 Division of Neurology, University of Toronto and Toronto Western Hospital , Toronto, Ontario, Canada
| | - Maria Carmela Tartaglia
- 2 Canadian Concussion Center , Toronto Western Hospital, Toronto, Canada .,3 Division of Neurology, University of Toronto and Toronto Western Hospital , Toronto, Ontario, Canada
| | - David Mikulis
- 2 Canadian Concussion Center , Toronto Western Hospital, Toronto, Canada .,4 Division of Neuroradiology, University of Toronto and Toronto Western Hospital , Toronto, Ontario, Canada
| | - Lili-Naz Hazrati
- 2 Canadian Concussion Center , Toronto Western Hospital, Toronto, Canada .,5 Department of Laboratory Medicine and Pathobiology, University of Toronto , Toronto, Ontario, Canada
| | - Charles H Tator
- 1 Division of Neurosurgery, University of Toronto and Toronto Western Hospital , Toronto, Ontario, Canada .,2 Canadian Concussion Center , Toronto Western Hospital, Toronto, Canada
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Tator CH, Davis HS, Dufort PA, Tartaglia MC, Davis KD, Ebraheem A, Hiploylee C. Postconcussion syndrome: demographics and predictors in 221 patients. J Neurosurg 2016; 125:1206-1216. [PMID: 26918481 DOI: 10.3171/2015.6.jns15664] [Citation(s) in RCA: 86] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVE The objective of this study was to determine the demographics and predictors of postconcussion syndrome (PCS) in a large series of patients using a novel definition of PCS. METHODS The authors conducted a retrospective cohort study of 284 consecutive concussed patients, 221 of whom had PCS on the basis of at least 3 symptoms persisting at least 1 month. This definition of PCS was uniformly employed and is unique in accepting an expanded list of symptoms, in shortening the postconcussion interval to 1 month from 3 months, and in excluding those with focal injuries such as hemorrhages and contusions. RESULTS The 221 cases showed considerable heterogeneity in clinical features of PCS. They averaged 3.3 concussions, with a range of 0 to 12 or more concussions, and 62.4% occurred during sports and recreation. The median duration of PCS was 7 months at the time of examination, with 11.8% lasting more than 2 years, and 23.1% with PCS had only 1 concussion. The average patient age was 27 years (range 10-74 years). The average number of persistent symptoms was 8.1; 26.2% had a previous psychiatric condition, attention-deficit disorder/attention-deficit hyperactivity disorder, a learning disability, or previous migraine headaches. The prevalence of arachnoid cysts and Chiari malformation in PCS exceeded the general population. Additionally, involvement in litigation, presence of extracranial injuries, amnesia and/or loss of consciousness, and female sex were predictive of reporting a high number of symptoms. A prior history of psychiatric conditions or migraines, cause of injury, number of previous concussions, and age did not significantly predict symptom number. Only the number of symptoms reported predicted the duration of PCS. To predict the number of symptoms for those who fulfilled PCS criteria according to the International Classification of Diseases, 10th Revision (ICD-10), and the Diagnostic and Statistical Manual of Mental Disorders, 4th Edition (DSM-IV), the number of previous concussions was significant. CONCLUSIONS PCS is commonly associated with multiple concussions, but 23.1% in the present series occurred after only 1 concussion. Most patients with PCS had multiple symptoms persisting for months or years. The median duration of PCS was 7 months, with a range up to 26 years. In only 11.3%, the PCS had ended at the time of consultation. Not all predictors commonly cited in the literature align with the findings in this study. This is likely due to differences in the definitions of PCS used in research. These results suggest that the use of ICD-10 and DSM-IV to diagnose PCS may be biased toward those who are vulnerable to concussions or with more severe forms of PCS. It is thus important to redefine PCS based on evidence-based medicine.
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Affiliation(s)
- Charles H Tator
- Canadian Concussion Centre, Toronto Western Hospital; and.,Divisions of 2 Neurosurgery and
| | - Hannah S Davis
- Canadian Concussion Centre, Toronto Western Hospital; and
| | - Paul A Dufort
- Canadian Concussion Centre, Toronto Western Hospital; and
| | - Maria Carmella Tartaglia
- Canadian Concussion Centre, Toronto Western Hospital; and.,Neurology, University of Toronto and Toronto Western Hospital, Toronto, Ontario, Canada
| | - Karen D Davis
- Canadian Concussion Centre, Toronto Western Hospital; and.,Divisions of 2 Neurosurgery and.,Neurology, University of Toronto and Toronto Western Hospital, Toronto, Ontario, Canada
| | - Ahmed Ebraheem
- Canadian Concussion Centre, Toronto Western Hospital; and
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Hiploylee C, Colbourne F. Intracranial pressure measured in freely moving rats for days after intracerebral hemorrhage. Exp Neurol 2014; 255:49-55. [PMID: 24582611 DOI: 10.1016/j.expneurol.2014.02.017] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2014] [Revised: 02/09/2014] [Accepted: 02/20/2014] [Indexed: 10/25/2022]
Abstract
In some patients, intracerebral hemorrhage (ICH) causes life-threatening elevations in intracranial pressure (ICP) arising from mass effect of the hematoma and edema. Accordingly, edema is a common endpoint to gauge treatment efficacy in rodent ICH models. Despite widespread reliance on edema, its relationship with ICP and cerebral perfusion pressure (CPP) is unknown. Blood pressure (BP) and ICP were measured by telemetry devices in rats after collagenase ("severe" - 0.3U, and "moderate" - 0.15U doses) or blood infusion (100μL) into striatum (vs. saline infused shams). We compared epidural and intraparenchymal ICP readings (collagenase), evaluated CPP (collagenase), and compared models. Moderate (9.46mmHg±4.72 SD, 3day average) and severe collagenase ICHs (10.79±3.50) significantly increased ICP versus shams (4.02±2.09), whereas blood infusion did not (5.37±0.55). The two monitoring locations gave similar readings after severe collagenase ICH. Increased ICP reduced CPP by ~7.5mmHg for days after the larger collagenase infusion. CPP averaged from 103-112mmHg in shams. Edema occurred in all ICH models and predicted ICP. However, ICP and CPP were only modestly changed even after severe ICH and edema. Thus, small changes in edema typically reported in the literature, which often use smaller bleeds than presently used, likely minimally affects ICP and CPP. Further research into the face validity of these models, endpoints, and their ability to evaluate therapeutics is needed.
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Affiliation(s)
- Carmen Hiploylee
- Department of Psychology, University of Alberta, Edmonton, Alberta, Canada
| | - Frederick Colbourne
- Department of Psychology, University of Alberta, Edmonton, Alberta, Canada; Center for Neuroscience, University of Alberta, Edmonton, Alberta, Canada.
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Hiploylee C, Colbourne F. Drug-induced hypothermia: editorial commentary on katz et Al., 2012. Ther Hypothermia Temp Manag 2013; 3:11-2. [PMID: 24837634 DOI: 10.1089/ther.2013.1504] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- Carmen Hiploylee
- Department of Psychology, University of Alberta , Edmonton, Alberta, Canada
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