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Chesnut RM, Temkin N, Videtta W, Lujan S, Petroni G, Pridgeon J, Dikmen S, Chaddock K, Hendrix T, Barber J, Machamer J, Guadagnoli N, Hendrickson P, Alanis V, La Fuente G, Lavadenz A, Merida R, Sandi Lora F, Romero R, Pinillos O, Urbina Z, Figueroa J, Ochoa M, Davila R, Mora J, Bustamante L, Perez C, Leiva J, Carricondo C, Mazzola AM, Guerra J. The Roles of Protocols and Protocolization in Improving Outcome From Severe Traumatic Brain Injury. Neurosurgery 2023:00006123-990000000-00986. [PMID: 38051042 DOI: 10.1227/neu.0000000000002777] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2023] [Accepted: 10/02/2023] [Indexed: 12/07/2023] Open
Abstract
BACKGROUND AND OBJECTIVES Our Phase-I parallel-cohort study suggested that managing severe traumatic brain injury (sTBI) in the absence of intracranial pressure (ICP) monitoring using an ad hoc Imaging and Clinical Examination (ICE) treatment protocol was associated with superior outcome vs nonprotocolized management but could not differentiate the influence of protocolization from that of the specific protocol. Phase II investigates whether adopting the Consensus REVised Imaging and Clinical Examination (CREVICE) protocol improved outcome directly or indirectly via protocolization. METHODS We performed a Phase-II sequential parallel-cohort study examining adoption of the CREVICE protocol from no protocol vs a previous protocol in patients with sTBI older than 13 years presenting ≤24 hours after injury. Primary outcome was prespecified 6-month recovery. The study was done mostly at public South American centers managing sTBI without ICP monitoring. Fourteen Phase-I nonprotocol centers and 5 Phase-I protocol centers adopted CREVICE. Data were analyzed using generalized estimating equation regression adjusting for demographic imbalances. RESULTS A total of 501 patients (86% male, mean age 35.4 years) enrolled; 81% had 6 months of follow-up. Adopting CREVICE from no protocol was associated with significantly superior results for overall 6-month extended Glasgow Outcome Score (GOSE) (protocol effect = 0.53 [0.11, 0.95], P = .013), mortality (36% vs 21%, HR = 0.59 [0.46, 0.76], P < .001), and orientation (Galveston Orientation and Amnesia Test discharge protocol effect = 10.9 [6.0, 15.8], P < .001, 6-month protocol effect = 11.4 [4.1, 18.6], P < .005). Adopting CREVICE from ICE was associated with significant benefits to GOSE (protocol effect = 0.51 [0.04, 0.98], P = .033), 6-month mortality (25% vs 18%, HR = 0.55 [0.39, 0.77], P < .001), and orientation (Galveston Orientation and Amnesia Test 6-month protocol effect = 9.2 [3.6, 14.7], P = .004). Comparing both groups using CREVICE, those who had used ICE previously had significantly better GOSE (protocol effect = 1.15 [0.09, 2.20], P = .033). CONCLUSION Centers managing adult sTBI without ICP monitoring should strongly consider protocolization through adopting/adapting the CREVICE protocol. Protocolization is indirectly supported at sTBI centers regardless of resource availability.
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Affiliation(s)
- Randall M Chesnut
- Department of Neurological Surgery, University of Washington, Seattle, Washington, USA
- Department of Orthopaedic Surgery, University of Washington, Seattle, Washington, USA
- School of Global Health, University of Washington, Seattle, Washington, USA
- Harborview Medical Center, University of Washington, Seattle, Washington, USA
| | - Nancy Temkin
- Department of Neurological Surgery, University of Washington, Seattle, Washington, USA
- Department of Biostatistics, University of Washington, Seattle, Washington, USA
| | - Walter Videtta
- Terapia Intensiva, Hospital Nacional Professor Alejandro Posadas, Buenos Aires, Argentina
| | - Silvia Lujan
- Hospital Emergencia, Dr Clemente Alvarez, Rosario, Argentina
- Centro de Informatica e Investigacion Clinica, Rosario, Argentina
| | - Gustavo Petroni
- School of Global Health, University of Washington, Seattle, Washington, USA
| | - Jim Pridgeon
- Department of Neurological Surgery, University of Washington, Seattle, Washington, USA
| | - Sureyya Dikmen
- Department of Rehabilitation Medicine, University of Washington, Seattle, Washington, USA
| | - Kelley Chaddock
- Department of Neurological Surgery, University of Washington, Seattle, Washington, USA
| | | | - Jason Barber
- Department of Neurological Surgery, University of Washington, Seattle, Washington, USA
| | - Joan Machamer
- Department of Neurological Surgery, University of Washington, Seattle, Washington, USA
| | - Nahuel Guadagnoli
- Hospital Emergencia, Dr Clemente Alvarez, Rosario, Argentina
- Centro de Informatica e Investigacion Clinica, Rosario, Argentina
| | - Peter Hendrickson
- Department of Neurological Surgery, University of Washington, Seattle, Washington, USA
| | - Victor Alanis
- Terapia Intensiva, Hospital San Juan de Dios, Santa Cruz de la Sierra, Bolivia
| | - Gustavo La Fuente
- Terapia Intensiva, Hospital Japones, Santa Cruz de la Sierra, Bolivia
| | | | - Roberto Merida
- Terapia Intensiva, Hospital San Juan de Dios, Tarija, Bolivia
| | | | - Ricardo Romero
- Terapia Intensiva, Fundacion Clinica Campbell, Barranquilla, Colombia
| | - Oscar Pinillos
- Terapia Intensiva, Clinica Universitaria Rafael Uribe, Cali, Colombia
| | - Zulma Urbina
- Terapia Intensiva, Hospital Erasmo Meoz ICU No 1, Cucuta, Colombia
| | - Jairo Figueroa
- Terapia Intensiva, Hospital Erasmo Meoz ICU No 2, Cucuta, Colombia
| | - Marcelo Ochoa
- Terapia Intensiva, Hospital José Carrasco Artega, Cuenca, Ecuador
| | - Rafael Davila
- Terapia Intensiva, Hospital Luis Razetti, Barinas, Venezuela
| | - Jacobo Mora
- Terapia Intensiva, Hospital Luis Razetti, Barcelona, Venezuela
| | - Luis Bustamante
- Terapia Intensiva, Delicia Conception Hospital Masvernat, Concordia, Entre Ríos, Argentina
| | - Carlos Perez
- Terapia Intensiva, Hospital Justo José de Urquiza, Concepción del Uruguay, Entre Ríos, Argentina
| | - Jorge Leiva
- Terapia Intensiva, Hospital Córdoba, Córdoba, Argentina
| | | | | | - Juan Guerra
- Terapia Intensiva, Hospital COSSMIL Militar, Louisiana Paz, Bolivia
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Philipson EB, Machamer J, Dikmen S, Temkin N. Traumatic Brain Injuries Impact on School One Month and One Year After Injury. Neurotrauma Rep 2023; 4:507-514. [PMID: 37771425 PMCID: PMC10523406 DOI: 10.1089/neur.2022.0069] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [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: 09/30/2023] Open
Abstract
Traumatic brain injury (TBI) is a major cause of death and disability among the American population, but the impact TBIs have on the school experience of high school, and post-secondary students, is poorly understood. In this study, a cohort of 79 students, ages 15-22, with mild-to-severe TBIs, were retrospectively identified from the University of Washington Traumatic Brain Injury Database and Sample Repository. The Sickness Impact Profile (SIP) was used to determine the frequency at which schooling was impacted by a TBI and identify the most common self-reported issues students faced in their return to school. At 1 month post-injury, 70% of students either had not returned to school as a result of their TBI or had returned to school but experienced issues related to their TBI. The most-reported issues at 1 month were a difficulty keeping up with school work as a result of it taking longer to complete assignments, tiring easily, having to take frequent rests, and grades that were not as good as they used to be. At 1 year post-injury, the number of students whose TBIs were affecting their school situation dropped 20 percentage points to 49%. The most reported issues at 1 year were forgetting more quickly what was learned in class and having more difficulty understanding new concepts and material. These findings indicate that TBIs have a profound effect on a student's school experiences up to at least 1 year post-injury.
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Affiliation(s)
- Erik B. Philipson
- Harborview Injury Prevention and Research Center, University of Washington, Seattle, Washington, USA
| | - Joan Machamer
- Department of Neurological Surgery, University of Washington, Seattle, Washington, USA
| | - Sureyya Dikmen
- Department of Rehabilitation Medicine, University of Washington, Seattle, Washington, USA
| | - Nancy Temkin
- Department of Neurological Surgery, University of Washington, Seattle, Washington, USA
- Department of Biostatistics, University of Washington, Seattle, Washington, USA
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Chesnut RM, Temkin N, Videtta W, Lujan S, Petroni G, Pridgeon J, Dikmen S, Chaddock K, Hendrix T, Barber J, Machamer J, Guadagnoli N, Hendrickson P, Alanis V, La Fuente G, Lavadenz A, Merida R, Lora FS, Romero R, Pinillos O, Urbina Z, Figueroa J, Ochoa M, Davila R, Mora J, Bustamante L, Perez C, Leiva J, Carricondo C, Mazzola AM, Guerra J. Testing the Impact of Protocolized Care of Patients With Severe Traumatic Brain Injury Without Intracranial Pressure Monitoring: The Imaging and Clinical Examination Protocol. Neurosurgery 2023; 92:472-480. [PMID: 36790211 PMCID: PMC10158870 DOI: 10.1227/neu.0000000000002251] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2021] [Accepted: 08/30/2022] [Indexed: 02/16/2023] Open
Abstract
BACKGROUND Most patients with severe traumatic brain injury (sTBI) in low- or-middle-income countries and surprisingly many in high-income countries are managed without intracranial pressure (ICP) monitoring. The impact of the first published protocol (Imaging and Clinical Examination [ICE] protocol) is untested against nonprotocol management. OBJECTIVE To determine whether patients treated in intensive care units (ICUs) using the ICE protocol have lower mortality and better neurobehavioral functioning than those treated in ICUs using no protocol. METHODS This study involved nineteen mostly public South American hospitals. This is a prospective cohort study, enrolling patients older than 13 years with sTBI presenting within 24 h of injury (January 2014-July 2015) with 6-mo postinjury follow-up. Five hospitals treated all sTBI cases using the ICE protocol; 14 used no protocol. Primary outcome was prespecified composite of mortality, orientation, functional outcome, and neuropsychological measures. RESULTS A total of 414 patients (89% male, mean age 34.8 years) enrolled; 81% had 6 months of follow-up. All participants included in composite outcome analysis: average percentile (SD) = 46.8 (24.0) nonprotocol, 56.9 (24.5) protocol. Generalized estimating equation (GEE) used to account for center effects (confounder-adjusted difference [95% CI] = 12.2 [4.6, 19.8], P = .002). Kaplan-Meier 6-month mortality (95% CI) = 36% (30%, 43%) nonprotocol, 25% (19%, 31%) protocol (GEE and confounder-adjusted hazard ratio [95% CI] = .69 [.43, 1.10], P = .118). Six-month Extended Glasgow Outcome Scale for 332 participants: average Extended Glasgow Outcome Scale score (SD) = 3.6 (2.6) nonprotocol, 4.7 (2.8) protocol (GEE and confounder-adjusted and lost to follow-up-adjusted difference [95% CI] = 1.36 [.55, 2.17], P = .001). CONCLUSION ICUs managing patients with sTBI using the ICE protocol had better functional outcome than those not using a protocol. ICUs treating patients with sTBI without ICP monitoring should consider protocolization. The ICE protocol, tested here and previously, is 1 option.
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Affiliation(s)
- Randall M. Chesnut
- University of Washington, Harborview Medical Center, Seattle, Washington, USA
| | - Nancy Temkin
- University of Washington, Harborview Medical Center, Seattle, Washington, USA
| | - Walter Videtta
- Medicina Intensiva, Hospital Nacional Professor Alejandro Posadas, Buenos Aires, Argentina;
| | - Silvia Lujan
- Hospital Emergencia, Dr Clemente Alvarez, Rosario, Argentina;
| | - Gustavo Petroni
- Hospital Emergencia, Dr Clemente Alvarez, Rosario, Argentina;
| | - Jim Pridgeon
- University of Washington, Harborview Medical Center, Seattle, Washington, USA
| | - Sureyya Dikmen
- University of Washington, Harborview Medical Center, Seattle, Washington, USA
| | - Kelley Chaddock
- University of Washington, Harborview Medical Center, Seattle, Washington, USA
| | | | - Jason Barber
- University of Washington, Harborview Medical Center, Seattle, Washington, USA
| | - Joan Machamer
- University of Washington, Harborview Medical Center, Seattle, Washington, USA
| | | | - Peter Hendrickson
- University of Washington, Harborview Medical Center, Seattle, Washington, USA
| | - Victor Alanis
- Medicina Intensiva, Hospital San Juan de Dios, Santa Cruz de la Sierra, Bolivia;
| | - Gustavo La Fuente
- Medicina Intensiva, Hospital Japones, Santa Cruz de la Sierra, Bolivia;
| | | | - Roberto Merida
- Medicina Intensiva, Hospital San Juan de Dios, Tarija, Bolivia;
| | | | - Ricardo Romero
- Medicina Intensiva, Fundacion Clinica Campbell, Barranquilla, Colombia;
| | - Oscar Pinillos
- Medicina Intensiva, Clinica Universitaria Rafael Uribe, Cali, Colombia;
| | - Zulma Urbina
- Medicina Intensiva, Hospital Erasmo Meoz ICU No 1, Cucuta, Colombia;
| | - Jairo Figueroa
- Medicina Intensiva, Hospital Erasmo Meoz ICU No 2, Cucuta, Colombia;
| | - Marcelo Ochoa
- Medicina Intensiva, Hospital José Carrasco Artega, Cuenca, Ecuador;
| | - Rafael Davila
- Medicina Intensiva, Hospital Luis Razetti, Barinas, Venezuela;
| | - Jacobo Mora
- Medicina Intensiva, Hospital Luis Razetti, Barcelona, Venezuela;
| | - Luis Bustamante
- Medicina Intensiva, Delicia Conception Hospital Masvernat, Concordia, Entre Ríos, Argentina;
| | - Carlos Perez
- Medicina Intensiva, Hospital Justo José de Urquiza, Concepción del Uruguay, Entre Ríos, Argentina;
| | - Jorge Leiva
- Medicina Intensiva, Hospital Córdoba, Córdoba, Argentina;
| | | | - Ana Maria Mazzola
- Medicina Intensiva, Hospital San Felipe, San Nicolás, Buenos Aires, Argentina;
| | - Juan Guerra
- Medicina Intensiva, Hospital COSSMIL Militar, La Paz, Bolivia
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Bodien YG, Barber J, Taylor SR, Boase K, Corrigan JD, Dikmen S, Gardner RC, Kramer JH, Levin H, Machamer J, McAllister T, Nelson LD, Ngwenya LB, Sherer M, Stein MB, Vassar M, Whyte J, Yue JK, Markowitz A, McCrea MA, Manley GT, Temkin N, Giacino JT. Feasibility and Utility of a Flexible Outcome Assessment Battery for Longitudinal Traumatic Brain Injury Research: A TRACK-TBI Study. J Neurotrauma 2023; 40:337-348. [PMID: 36097759 PMCID: PMC9902043 DOI: 10.1089/neu.2022.0141] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023] Open
Abstract
The effects of traumatic brain injury (TBI) are difficult to measure in longitudinal cohort studies, because disparate pre-injury characteristics and injury mechanisms produce variable impairment profiles and recovery trajectories. In preparation for the Transforming Research and Clinical Knowledge in TBI (TRACK-TBI) study, which followed patients with injuries ranging from uncomplicated mild TBI to coma, we designed a multi-dimensional Flexible outcome Assessment Battery (FAB). The FAB relies on a decision-making algorithm that assigns participants to a Comprehensive (CAB) or Abbreviated Assessment Battery (AAB) and guides test selection across all phases of recovery. To assess feasibility of the FAB, we calculated the proportion of participants followed at 2 weeks (2w) and at 3, 6, and 12 months (3m, 6m, 12m) post-injury who completed the FAB and received valid scores. We evaluated utility of the FAB by examining differences in 6m and 12m Glasgow Outcome Scale-Extended (GOSE) scores between participant subgroups derived from the FAB-enabled versus traditional approach to outcome assessment applied at 2w. Among participants followed at 2w (n = 2094), 3m (n = 1871), 6m (n = 1736), and 12m (n = 1607) post-injury, 95-99% received valid completion scores on the FAB, in full or in part, either in person or by telephone. Level of function assessed by the FAB-enabled approach at 2w was associated with 6m and 12m GOSE scores (proportional odds p < 0.001). These findings suggest that the participant classification methodology afforded by the FAB may enable more effective data collection to improve detection of natural history changes and TBI treatment effects.
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Affiliation(s)
- Yelena G. Bodien
- Massachusetts General Hospital, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
- Spaulding Rehabilitation Hospital, Charlestown, Massachusetts, USA
| | - Jason Barber
- University of Washington, Seattle, Washington, USA
| | - Sabrina R. Taylor
- University of California, San Francisco, San Francisco, California, USA
| | - Kim Boase
- University of Washington, Seattle, Washington, USA
| | | | | | - Raquel C. Gardner
- University of California, San Francisco, San Francisco, California, USA
| | - Joel H. Kramer
- University of California, San Francisco, San Francisco, California, USA
| | | | | | - Thomas McAllister
- University of Indiana School of Medicine, Indianapolis, Indiana, USA
| | | | | | - Mark Sherer
- Baylor College of Medicine, Houston, Texas, USA
- TIRR Memorial Hermann, Houston, Texas, USA
| | - Murray B. Stein
- University of California San Diego, La Jolla, California, USA
| | - Mary Vassar
- University of California, San Francisco, San Francisco, California, USA
| | - John Whyte
- Moss Rehabilitation Research Institute, Elkins Park, Pennsylvania, USA
| | - John K. Yue
- University of California, San Francisco, San Francisco, California, USA
| | - Amy Markowitz
- University of California, San Francisco, San Francisco, California, USA
| | | | | | - Nancy Temkin
- University of Washington, Seattle, Washington, USA
| | - Joseph T. Giacino
- Massachusetts General Hospital, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
- Spaulding Rehabilitation Hospital, Charlestown, Massachusetts, USA
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5
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Temkin N, Machamer J, Dikmen S, Nelson LD, Barber J, Hwang PH, Boase K, Stein MB, Sun X, Giacino J, McCrea MA, Taylor SR, Jain S, Manley G. Risk Factors for High Symptom Burden Three Months after Traumatic Brain Injury and Implications for Clinical Trial Design: A Transforming Research and Clinical Knowledge in Traumatic Brain Injury Study. J Neurotrauma 2022; 39:1524-1532. [PMID: 35754333 PMCID: PMC9689769 DOI: 10.1089/neu.2022.0113] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
More than 75% of patients presenting to level I trauma centers in the United States with suspicion of TBI sufficient to require a clinical computed tomography scan report injury-related symptoms 3 months later. There are currently no approved treatments, and few clinical trials have evaluated possible treatments. Efficient trials will require subject inclusion and exclusion criteria that balance cost-effective recruitment with enrolling individuals with a higher chance of benefiting from the interventions. Using data from the Transforming Research and Clinical Knowledge in Traumatic Brain Injury (TRACK-TBI) study, we examined the relationship of 3-month symptoms to pre-injury, demographic, and acute characteristics as well as 2-week symptoms and blood-based biomarkers to identify and evaluate factors that may be used for sample enrichment for clinical trials. Many of the risk factors for TBI symptoms reported in the literature were supported, but the effect sizes of each were small or moderate (< 0.5). The only factors with large effect sizes when predicting 3-month symptom burden were TBI-related (i.e., post-concussive) and post-traumatic stress symptom levels at 2 weeks (respective effect sizes 1.13 and 1.34). TBI severity was not significantly associated with 3-month symptom burden (p = 0.37). Using simulated data to evaluate the effect of enrichment, we showed that including only people with high symptom burden at 2 weeks would permit trials to reduce the sample size by half, with minimal increase in screening, as compared with enrolling an unenriched sample. Clinical trials aimed at reducing symptoms after TBI can be efficiently conducted by enriching the included sample with people reporting a high early symptom burden.
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Affiliation(s)
- Nancy Temkin
- Department of Neurological Surgery, University of Washington, Seattle, Washington, USA
- Department of Biostatistics, University of Washington, Seattle, Washington, USA
| | - Joan Machamer
- Department of Neurological Surgery, University of Washington, Seattle, Washington, USA
| | - Sureyya Dikmen
- Department of Rehabilitation Medicine, University of Washington, Seattle, Washington, USA
| | - Lindsay D. Nelson
- Department of Neurosurgery, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Jason Barber
- Department of Neurological Surgery, University of Washington, Seattle, Washington, USA
| | - Phillip H. Hwang
- Department of Anatomy and Neurobiology, Boston University, Boston Massachusetts, USA
| | - Kim Boase
- Department of Neurological Surgery, University of Washington, Seattle, Washington, USA
| | - Murray B. Stein
- Department of Psychiatry and Herbert Wertheim School of Public Health, University of California, San Diego, California, USA
| | - Xiaoying Sun
- Biostatistics Research Center Herbert Wertheim School of Public Health, University of California, San Diego, California, USA
| | - Joseph Giacino
- Department of Rehabilitation Medicine, Spaulding Rehabilitation Hospital, Harvard Medical School, Charlestown, Massachusetts, USA
| | - Michael A. McCrea
- Department of Neurosurgery, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
- Department of Neurology, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Sabrina R. Taylor
- Brain and Spinal Injury Center, San Francisco California, USA
- Department of Neurological Surgery, University of California, San Francisco, California, USA
| | - Sonia Jain
- Biostatistics Research Center Herbert Wertheim School of Public Health, University of California, San Diego, California, USA
| | - Geoff Manley
- Brain and Spinal Injury Center, San Francisco California, USA
- Department of Neurological Surgery, University of California, San Francisco, California, USA
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Machamer J, Temkin N, Dikmen S, Nelson LD, Barber J, Hwang P, Boase K, Stein MB, Sun X, Giacino J, McCrea MA, Taylor SR, Jain S, Manley G. Symptom Frequency and Persistence in the First Year after Traumatic Brain Injury: A TRACK-TBI Study. J Neurotrauma 2022; 39:358-370. [PMID: 35078327 PMCID: PMC8892966 DOI: 10.1089/neu.2021.0348] [Citation(s) in RCA: 30] [Impact Index Per Article: 15.0] [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: 02/01/2023] Open
Abstract
Symptom endorsement after traumatic brain injury (TBI) is common acutely post-injury and is associated with other adverse outcomes. Prevalence of persistent symptoms has been debated, especially in mild TBI (mTBI). A cohort of participants ≥17 years with TBI (n = 2039), 257 orthopedic trauma controls (OTCs), and 300 friend controls (FCs) were enrolled in the TRACK-TBI study and evaluated at 2 weeks and 3, 6, and 12 months post-injury using the Rivermead Post-Concussion Symptoms Questionnaire (RPQ). TBI participants had significantly higher symptom burden than OTCs or FCs at all times, with average scores more than double. TBI cases showed significant decreases in RPQ score between each evaluation (p < 0.001), decreasing ∼1.7 points per month between 2 weeks and 3 months and 0.2 points per month after that. More than 50% of the TBI sample, including >50% of each of the mild and moderate/severe TBI subsamples, continued to endorse three or more symptoms as worse than pre-injury through 12 months post-injury. A majority of TBI participants who endorsed a symptom at 3 months or later did so at the next evaluation as well. Contrary to reviews that report symptom resolution by 3 months post-injury among those with mTBI, this study of participants treated at level 1 trauma centers and having a computed tomography ordered found that persistent symptoms are common to at least a year after TBI. Additionally, although symptom endorsement was not specific to TBI given that they were also reported by OTC and FC participants, TBI participants endorsed over twice the symptom burden compared with the other groups.
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Affiliation(s)
- Joan Machamer
- Department of Neurological Surgery, University of Washington, Seattle, Washington, USA
| | - Nancy Temkin
- Department of Neurological Surgery, University of Washington, Seattle, Washington, USA.,Department of Biostatistics, University of Washington, Seattle, Washington, USA
| | - Sureyya Dikmen
- Department of Rehabilitation Medicine, University of Washington, Seattle, Washington, USA
| | - Lindsay D Nelson
- Department of Neurosurgery, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Jason Barber
- Department of Neurological Surgery, University of Washington, Seattle, Washington, USA
| | - Phillip Hwang
- Department of Anatomy and Neurobiology, Boston University, Boston, Massachusetts, USA
| | - Kim Boase
- Department of Neurological Surgery, University of Washington, Seattle, Washington, USA
| | - Murray B Stein
- Department of Psychiatry and Herbert Wertheim School of Public Health, Herbert Wertheim School of Public Health, University of California San Diego, La Jolla, California, USA
| | - Xiaoying Sun
- Biostatistics Research Center, Herbert Wertheim School of Public Health, University of California San Diego, La Jolla, California, USA
| | - Joseph Giacino
- Department of Rehabilitation Medicine, Spaulding Rehabilitation Hospital, Harvard Medical School, Charlestown, Massachusetts, USA
| | - Michael A McCrea
- Department of Neurosurgery and Neurology, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Sabrina R Taylor
- Brain and Spinal Injury Center, San Francisco, California, USA.,Department of Neurological Surgery, University of California, San Francisco, San Francisco, California, USA
| | - Sonia Jain
- Biostatistics Research Center, Herbert Wertheim School of Public Health, University of California San Diego, La Jolla, California, USA
| | - Geoff Manley
- Brain and Spinal Injury Center, San Francisco, California, USA.,Department of Neurological Surgery, University of California, San Francisco, San Francisco, California, USA
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7
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Boase K, Machamer J, Temkin NR, Dikmen S, Wilson L, Nelson LD, Barber J, Bodien YG, Giacino JT, Markowitz AJ, McCrea MA, Satris G, Stein MB, Taylor SR, Manley GT. Central Curation of Glasgow Outcome Scale-Extended Data: Lessons Learned from TRACK-TBI. J Neurotrauma 2021; 38:2419-2434. [PMID: 33832330 PMCID: PMC8390785 DOI: 10.1089/neu.2020.7528] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
The Glasgow Outcome Scale (GOS) in its original or extended (GOSE) form is the most widely used assessment of global disability in traumatic brain injury (TBI) research. Several publications have reported concerns about assessor scoring inconsistencies, but without documentation of contributing factors. We reviewed 6801 GOSE assessments collected longitudinally, across 18 sites in the 5-year, observational Transforming Research and Clinical Knowledge in TBI (TRACK-TBI) study. We recorded error rates (i.e., corrections to a section or an overall rating) based on site assessor documentation and categorized scoring issues, which then informed further training. In cohort 1 (n = 1261; February 2014 to May 2016), 24% of GOSEs had errors identified by central review. In cohort 2 (n = 1130; June 2016 to July 2018), acquired after curation of cohort 1 data, feedback, and further training of site assessors, the error rate was reduced to 10%. GOSE sections associated with the most frequent interpretation and scoring difficulties included whether current functioning represented a change from pre-injury (466 corrected ratings in cohort 1; 62 in cohort 2), defining dependency in the home and community (163 corrections in cohort 1; three in cohort 2) and return to work/school (72 corrections in cohort 1; 35 in cohort 2). These results highlight the importance of central review in improving consistency across sites and over time. Establishing clear scoring criteria, coupled with ongoing guidance and feedback to data collectors, is essential to avoid scoring errors and resultant misclassification, which carry potential to result in "failure" of clinical trials that rely on the GOSE as their primary outcome measure.
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Affiliation(s)
- Kim Boase
- Department of Neurological Surgery, Harborview Medical Center, University of Washington, Seattle, Washington, USA
| | - Joan Machamer
- Department of Neurological Surgery, Harborview Medical Center, University of Washington, Seattle, Washington, USA
| | - Nancy R. Temkin
- Department of Neurological Surgery, Harborview Medical Center, University of Washington, Seattle, Washington, USA
| | - Sureyya Dikmen
- Department of Neurological Surgery, Harborview Medical Center, University of Washington, Seattle, Washington, USA
| | - Lindsay Wilson
- Division of Psychology, School of Natural Sciences, University of Stirling, Stirling, United Kingdom
| | - Lindsay D. Nelson
- Department of Neurological Surgery, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Jason Barber
- Department of Neurological Surgery, Harborview Medical Center, University of Washington, Seattle, Washington, USA
| | - Yelena G. Bodien
- Spaulding Rehabilitation Hospital Massachusetts General Hospital, Charlestown, Massachusetts, USA
| | - Joseph T. Giacino
- Spaulding Rehabilitation Hospital Massachusetts General Hospital, Charlestown, Massachusetts, USA
| | - Amy J. Markowitz
- Brain and Spinal Injury Center, University of California, San Francisco, San Francisco, California, USA
| | - Michael A. McCrea
- Department of Neurological Surgery, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Gabriela Satris
- Brain and Spinal Injury Center, University of California, San Francisco, San Francisco, California, USA
| | - Murray B. Stein
- Department of Psychiatry, University of California, San Diego, La Jolla, California, USA
| | - Sabrina R. Taylor
- Brain and Spinal Injury Center, University of California, San Francisco, San Francisco, California, USA
| | - Geoffrey T. Manley
- Brain and Spinal Injury Center, University of California, San Francisco, San Francisco, California, USA
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8
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McCrea MA, Giacino JT, Barber J, Temkin NR, Nelson LD, Levin HS, Dikmen S, Stein M, Bodien YG, Boase K, Taylor SR, Vassar M, Mukherjee P, Robertson C, Diaz-Arrastia R, Okonkwo DO, Markowitz AJ, Manley GT, Adeoye O, Badjatia N, Bullock MR, Chesnut R, Corrigan JD, Crawford K, Duhaime AC, Ellenbogen R, Feeser VR, Ferguson AR, Foreman B, Gardner R, Gaudette E, Goldman D, Gonzalez L, Gopinath S, Gullapalli R, Hemphill JC, Hotz G, Jain S, Keene CD, Korley FK, Kramer J, Kreitzer N, Lindsell C, Machamer J, Madden C, Martin A, McAllister T, Merchant R, Ngwenya LB, Noel F, Nolan A, Palacios E, Perl D, Puccio A, Rabinowitz M, Rosand J, Sander A, Satris G, Schnyer D, Seabury S, Sherer M, Toga A, Valadka A, Wang K, Yue JK, Yuh E, Zafonte R. Functional Outcomes Over the First Year After Moderate to Severe Traumatic Brain Injury in the Prospective, Longitudinal TRACK-TBI Study. JAMA Neurol 2021; 78:982-992. [PMID: 34228047 DOI: 10.1001/jamaneurol.2021.2043] [Citation(s) in RCA: 90] [Impact Index Per Article: 30.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
Importance Moderate to severe traumatic brain injury (msTBI) is a major cause of death and disability in the US and worldwide. Few studies have enabled prospective, longitudinal outcome data collection from the acute to chronic phases of recovery after msTBI. Objective To prospectively assess outcomes in major areas of life function at 2 weeks and 3, 6, and 12 months after msTBI. Design, Setting, and Participants This cohort study, as part of the Transforming Research and Clinical Knowledge in TBI (TRACK-TBI) study, was conducted at 18 level 1 trauma centers in the US from February 2014 to August 2018 and prospectively assessed longitudinal outcomes, with follow-up to 12 months postinjury. Participants were patients with msTBI (Glasgow Coma Scale scores 3-12) extracted from a larger group of patients with mild, moderate, or severe TBI who were enrolled in TRACK-TBI. Data analysis took place from October 2019 to April 2021. Exposures Moderate or severe TBI. Main Outcomes and Measures The Glasgow Outcome Scale-Extended (GOSE) and Disability Rating Scale (DRS) were used to assess global functional status 2 weeks and 3, 6, and 12 months postinjury. Scores on the GOSE were dichotomized to determine favorable (scores 4-8) vs unfavorable (scores 1-3) outcomes. Neurocognitive testing and patient reported outcomes at 12 months postinjury were analyzed. Results A total of 484 eligible patients were included from the 2679 individuals in the TRACK-TBI study. Participants with severe TBI (n = 362; 283 men [78.2%]; median [interquartile range] age, 35.5 [25-53] years) and moderate TBI (n = 122; 98 men [80.3%]; median [interquartile range] age, 38 [25-53] years) were comparable on demographic and premorbid variables. At 2 weeks postinjury, 36 of 290 participants with severe TBI (12.4%) and 38 of 93 participants with moderate TBI (41%) had favorable outcomes (GOSE scores 4-8); 301 of 322 in the severe TBI group (93.5%) and 81 of 103 in the moderate TBI group (78.6%) had moderate disability or worse on the DRS (total score ≥4). By 12 months postinjury, 142 of 271 with severe TBI (52.4%) and 54 of 72 with moderate TBI (75%) achieved favorable outcomes. Nearly 1 in 5 participants with severe TBI (52 of 270 [19.3%]) and 1 in 3 with moderate TBI (23 of 71 [32%]) reported no disability (DRS score 0) at 12 months. Among participants in a vegetative state at 2 weeks, 62 of 79 (78%) regained consciousness and 14 of 56 with available data (25%) regained orientation by 12 months. Conclusions and Relevance In this study, patients with msTBI frequently demonstrated major functional gains, including recovery of independence, between 2 weeks and 12 months postinjury. Severe impairment in the short term did not portend poor outcomes in a substantial minority of patients with msTBI. When discussing prognosis during the first 2 weeks after injury, clinicians should be particularly cautious about making early, definitive prognostic statements suggesting poor outcomes and withdrawal of life-sustaining treatment in patients with msTBI.
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Affiliation(s)
- Michael A McCrea
- Department of Neurosurgery, Medical College of Wisconsin, Milwaukee
| | - Joseph T Giacino
- Department of Physical Medicine and Rehabilitation, Spaulding Rehabilitation Hospital, Charlestown, Massachusetts.,Department of Physical Medicine and Rehabilitation, Massachusetts General Hospital, Boston.,Department of Physical Medicine and Rehabilitation, Harvard Medical School, Boston, Massachusetts
| | - Jason Barber
- Department of Neurological Surgery, University of Washington, Seattle
| | - Nancy R Temkin
- Department of Neurological Surgery, University of Washington, Seattle
| | - Lindsay D Nelson
- Department of Neurosurgery, Medical College of Wisconsin, Milwaukee
| | - Harvey S Levin
- Physical Medicine and Rehabilitation, Baylor College of Medicine, Houston, Texas
| | - Sureyya Dikmen
- Department of Neurological Surgery, University of Washington, Seattle
| | - Murray Stein
- Department of Family Medicine and Public Health, University of California, San Diego, San Diego
| | - Yelena G Bodien
- Department of Physical Medicine and Rehabilitation, Spaulding Rehabilitation Hospital, Charlestown, Massachusetts.,Department of Physical Medicine and Rehabilitation, Massachusetts General Hospital, Boston.,Department of Physical Medicine and Rehabilitation, Harvard Medical School, Boston, Massachusetts
| | - Kim Boase
- Department of Neurological Surgery, University of Washington, Seattle
| | - Sabrina R Taylor
- Neurological Surgery, University of California, San Francisco, San Francisco
| | - Mary Vassar
- Neurological Surgery, University of California, San Francisco, San Francisco
| | - Pratik Mukherjee
- Neurological Surgery, University of California, San Francisco, San Francisco
| | - Claudia Robertson
- Physical Medicine and Rehabilitation, Baylor College of Medicine, Houston, Texas
| | | | - David O Okonkwo
- Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Amy J Markowitz
- Neurological Surgery, University of California, San Francisco, San Francisco
| | - Geoffrey T Manley
- Neurological Surgery, University of California, San Francisco, San Francisco
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | - Sonia Jain
- University of California, San Diego, La Jolla
| | | | | | - Joel Kramer
- University of California, San Francisco, San Francisco
| | | | | | | | | | | | | | | | | | | | - Amber Nolan
- University of California, San Francisco, San Francisco
| | - Eva Palacios
- University of California, San Francisco, San Francisco
| | - Daniel Perl
- Uniformed Services University, Bethesda, Maryland
| | - Ava Puccio
- University of Pittsburgh, Pittsburgh, Pennsylvania
| | | | | | | | | | | | | | | | - Arthur Toga
- University of Southern California, Los Angeles
| | | | | | - John K Yue
- University of California, San Francisco, San Francisco
| | - Esther Yuh
- University of California, San Francisco, San Francisco
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9
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Yuh EL, Jain S, Sun X, Pisica D, Harris MH, Taylor SR, Markowitz AJ, Mukherjee P, Verheyden J, Giacino JT, Levin HS, McCrea M, Stein MB, Temkin NR, Diaz-Arrastia R, Robertson CS, Lingsma HF, Okonkwo DO, Maas AIR, Manley GT, Adeoye O, Badjatia N, Boase K, Bodien Y, Corrigan JD, Crawford K, Dikmen S, Duhaime AC, Ellenbogen R, Feeser VR, Ferguson AR, Foreman B, Gardner R, Gaudette E, Gonzalez L, Gopinath S, Gullapalli R, Hemphill JC, Hotz G, Keene CD, Kramer J, Kreitzer N, Lindsell C, Machamer J, Madden C, Martin A, McAllister T, Merchant R, Nelson L, Ngwenya LB, Noel F, Nolan A, Palacios E, Perl D, Rabinowitz M, Rosand J, Sander A, Satris G, Schnyer D, Seabury S, Toga A, Valadka A, Vassar M, Zafonte R. Pathological Computed Tomography Features Associated With Adverse Outcomes After Mild Traumatic Brain Injury: A TRACK-TBI Study With External Validation in CENTER-TBI. JAMA Neurol 2021; 78:1137-1148. [PMID: 34279565 PMCID: PMC8290344 DOI: 10.1001/jamaneurol.2021.2120] [Citation(s) in RCA: 39] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Question Are different patterns of intracranial injury on head computed tomography associated with prognosis after mild traumatic brain injury (mTBI)? Findings In this cohort study, subarachnoid hemorrhage, subdural hematoma, and contusion often co-occurred and were associated with both incomplete recovery and more severe impairment out to 12 months after injury, while intraventricular and/or petechial hemorrhage co-occurred and were associated with more severe impairment up to 12 months after injury; epidural hematoma was associated with incomplete recovery at some points but not with more severe impairment. Some intracranial hemorrhage patterns were more strongly associated with outcomes than previously validated demographic and clinical variables. Meaning In this study, different pathological features on head computed tomography carried different implications for mild traumatic brain injury prognosis to 1 year. Importance A head computed tomography (CT) with positive results for acute intracranial hemorrhage is the gold-standard diagnostic biomarker for acute traumatic brain injury (TBI). In moderate to severe TBI (Glasgow Coma Scale [GCS] scores 3-12), some CT features have been shown to be associated with outcomes. In mild TBI (mTBI; GCS scores 13-15), distribution and co-occurrence of pathological CT features and their prognostic importance are not well understood. Objective To identify pathological CT features associated with adverse outcomes after mTBI. Design, Setting, and Participants The longitudinal, observational Transforming Research and Clinical Knowledge in Traumatic Brain Injury (TRACK-TBI) study enrolled patients with TBI, including those 17 years and older with GCS scores of 13 to 15 who presented to emergency departments at 18 US level 1 trauma centers between February 26, 2014, and August 8, 2018, and underwent head CT imaging within 24 hours of TBI. Evaluations of CT imaging used TBI Common Data Elements. Glasgow Outcome Scale–Extended (GOSE) scores were assessed at 2 weeks and 3, 6, and 12 months postinjury. External validation of results was performed via the Collaborative European NeuroTrauma Effectiveness Research in Traumatic Brain Injury (CENTER-TBI) study. Data analyses were completed from February 2020 to February 2021. Exposures Acute nonpenetrating head trauma. Main Outcomes and Measures Frequency, co-occurrence, and clustering of CT features; incomplete recovery (GOSE scores <8 vs 8); and an unfavorable outcome (GOSE scores <5 vs ≥5) at 2 weeks and 3, 6, and 12 months. Results In 1935 patients with mTBI (mean [SD] age, 41.5 [17.6] years; 1286 men [66.5%]) in the TRACK-TBI cohort and 2594 patients with mTBI (mean [SD] age, 51.8 [20.3] years; 1658 men [63.9%]) in an external validation cohort, hierarchical cluster analysis identified 3 major clusters of CT features: contusion, subarachnoid hemorrhage, and/or subdural hematoma; intraventricular and/or petechial hemorrhage; and epidural hematoma. Contusion, subarachnoid hemorrhage, and/or subdural hematoma features were associated with incomplete recovery (odds ratios [ORs] for GOSE scores <8 at 1 year: TRACK-TBI, 1.80 [95% CI, 1.39-2.33]; CENTER-TBI, 2.73 [95% CI, 2.18-3.41]) and greater degrees of unfavorable outcomes (ORs for GOSE scores <5 at 1 year: TRACK-TBI, 3.23 [95% CI, 1.59-6.58]; CENTER-TBI, 1.68 [95% CI, 1.13-2.49]) out to 12 months after injury, but epidural hematoma was not. Intraventricular and/or petechial hemorrhage was associated with greater degrees of unfavorable outcomes up to 12 months after injury (eg, OR for GOSE scores <5 at 1 year in TRACK-TBI: 3.47 [95% CI, 1.66-7.26]). Some CT features were more strongly associated with outcomes than previously validated variables (eg, ORs for GOSE scores <5 at 1 year in TRACK-TBI: neuropsychiatric history, 1.43 [95% CI .98-2.10] vs contusion, subarachnoid hemorrhage, and/or subdural hematoma, 3.23 [95% CI 1.59-6.58]). Findings were externally validated in 2594 patients with mTBI enrolled in the CENTER-TBI study. Conclusions and Relevance In this study, pathological CT features carried different prognostic implications after mTBI to 1 year postinjury. Some patterns of injury were associated with worse outcomes than others. These results support that patients with mTBI and these CT features need TBI-specific education and systematic follow-up.
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Affiliation(s)
- Esther L Yuh
- Brain and Spinal Injury Center, San Francisco, California.,Department of Radiology and Biomedical Imaging, University of California, San Francisco, San Francisco
| | - Sonia Jain
- Biostatistics Research Center, Herbert Wertheim School of Public Health and Human Longevity Science, University of California, San Diego, La Jolla
| | - Xiaoying Sun
- Biostatistics Research Center, Herbert Wertheim School of Public Health and Human Longevity Science, University of California, San Diego, La Jolla
| | - Dana Pisica
- Department of Neurosurgery, Erasmus Medical Center, Rotterdam, the Netherlands.,Department of Public Health, Erasmus Medical Center, Rotterdam, the Netherlands
| | - Mark H Harris
- Brain and Spinal Injury Center, San Francisco, California.,Department of Neurological Surgery, University of California, San Francisco, San Francisco
| | - Sabrina R Taylor
- Brain and Spinal Injury Center, San Francisco, California.,Department of Neurological Surgery, University of California, San Francisco, San Francisco
| | - Amy J Markowitz
- Brain and Spinal Injury Center, San Francisco, California.,Department of Neurological Surgery, University of California, San Francisco, San Francisco
| | - Pratik Mukherjee
- Brain and Spinal Injury Center, San Francisco, California.,Department of Radiology and Biomedical Imaging, University of California, San Francisco, San Francisco
| | - Jan Verheyden
- Research and Development, Icometrix, Leuven, Belgium
| | - Joseph T Giacino
- Department of Physical Medicine and Rehabilitation, Spaulding Rehabilitation Hospital, Charlestown, Massachusetts.,Department of Physical Medicine and Rehabilitation, Harvard Medical School, Boston, Massachusetts
| | - Harvey S Levin
- Department of Physical Medicine and Rehabilitation, Baylor College of Medicine, Houston, Texas
| | - Michael McCrea
- Department of Neurosurgery, Medical College of Wisconsin, Milwaukee
| | - Murray B Stein
- Department of Psychiatry, University of California San Diego, La Jolla.,Veterans Affairs San Diego Healthcare System, San Diego, California
| | - Nancy R Temkin
- Department of Neurological Surgery, University of Washington, Seattle
| | | | | | - Hester F Lingsma
- Department of Public Health, Erasmus Medical Center, Rotterdam, the Netherlands
| | - David O Okonkwo
- Department of Neurological Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Andrew I R Maas
- Department of Neurosurgery, Antwerp University Hospital and University of Antwerp, Edegem, Belgium
| | - Geoffrey T Manley
- Brain and Spinal Injury Center, San Francisco, California.,Department of Neurological Surgery, University of California, San Francisco, San Francisco
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | - Joel Kramer
- University of California, San Francisco, San Francisco
| | | | | | | | | | | | | | | | | | | | | | - Amber Nolan
- University of California, San Francisco, San Francisco
| | - Eva Palacios
- University of California, San Francisco, San Francisco
| | - Daniel Perl
- Uniformed Services University, Bethesda, Maryland
| | | | | | | | | | | | | | - Arthur Toga
- University of Southern California, Los Angeles
| | | | - Mary Vassar
- University of California, San Francisco, San Francisco
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Mashaqi S, Patel SI, Combs D, Estep L, Helmick S, Machamer J, Parthasarathy S. The Hypoglossal Nerve Stimulation as a Novel Therapy for Treating Obstructive Sleep Apnea-A Literature Review. Int J Environ Res Public Health 2021; 18:ijerph18041642. [PMID: 33572156 PMCID: PMC7914469 DOI: 10.3390/ijerph18041642] [Citation(s) in RCA: 25] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/25/2020] [Revised: 01/12/2021] [Accepted: 02/04/2021] [Indexed: 12/17/2022]
Abstract
Obstructive sleep apnea (OSA) is a common sleep disorder that affects all age groups and is associated with many co-morbid diseases (especially cardiovascular diseases). Continuous positive airway pressure (CPAP) is the gold standard for treating OSA. However, adherence to PAP therapy has been a major challenge with an estimated adherence between 20% and 80%. Mandibular advancement devices (MAD) are a good alternative option if used in the appropriate patient. MAD are most effective in mild and moderate OSA but not severe OSA. Surgical options are invasive, not appropriate for severe OSA, and associated with pain and long healing time. Hypoglossal nerve stimulation (HGNS), or upper airway stimulation (UAS), is a novel therapy in treating moderate and severe degrees of OSA in patients who cannot tolerate CPAP therapy. We reviewed the MEDLINE (PubMed) database. The search process yielded 303 articles; 31 met the inclusion and exclusion criteria and were included. We concluded that hypoglossal nerve stimulation is a very effective and novel alternative therapy for moderate and severe OSA in patients who cannot tolerate CPAP therapy. Adherence to HGNS is superior to CPAP. However, more developments are needed to ensure the highest safety profile.
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Affiliation(s)
- Saif Mashaqi
- UAHS Center for Sleep & Circadian Sciences and Division of Pulmonary, Allergy, Critical Care and Sleep Medicine, Department of Medicine, University of Arizona College of Medicine, Tucson, AZ 85724, USA; (S.I.P.); (L.E.); (S.H.); (J.M.); (S.P.)
- Correspondence: ; Tel.: +1-(304)-690-0586
| | - Salma Imran Patel
- UAHS Center for Sleep & Circadian Sciences and Division of Pulmonary, Allergy, Critical Care and Sleep Medicine, Department of Medicine, University of Arizona College of Medicine, Tucson, AZ 85724, USA; (S.I.P.); (L.E.); (S.H.); (J.M.); (S.P.)
| | - Daniel Combs
- UAHS Center for Sleep & Circadian Sciences and Division of Pulmonary and Sleep Medicine, Department of Pediatrics, University of Arizona, Tucson, AZ 85724, USA;
| | - Lauren Estep
- UAHS Center for Sleep & Circadian Sciences and Division of Pulmonary, Allergy, Critical Care and Sleep Medicine, Department of Medicine, University of Arizona College of Medicine, Tucson, AZ 85724, USA; (S.I.P.); (L.E.); (S.H.); (J.M.); (S.P.)
| | - Sonia Helmick
- UAHS Center for Sleep & Circadian Sciences and Division of Pulmonary, Allergy, Critical Care and Sleep Medicine, Department of Medicine, University of Arizona College of Medicine, Tucson, AZ 85724, USA; (S.I.P.); (L.E.); (S.H.); (J.M.); (S.P.)
| | - Joan Machamer
- UAHS Center for Sleep & Circadian Sciences and Division of Pulmonary, Allergy, Critical Care and Sleep Medicine, Department of Medicine, University of Arizona College of Medicine, Tucson, AZ 85724, USA; (S.I.P.); (L.E.); (S.H.); (J.M.); (S.P.)
| | - Sairam Parthasarathy
- UAHS Center for Sleep & Circadian Sciences and Division of Pulmonary, Allergy, Critical Care and Sleep Medicine, Department of Medicine, University of Arizona College of Medicine, Tucson, AZ 85724, USA; (S.I.P.); (L.E.); (S.H.); (J.M.); (S.P.)
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Bodien Y, Sherer M, Taylor S, Dikmen S, Yue J, Stein M, Corrigan J, Levin H, Temkin N, Machamer J, Boase K, Vassar M, McCrea M, McAllister T, Whyte J, Barber J, Gardner R, Kramer J, Nelson L, Manley G, Giacino J. Feasibility and Utility of a Flexible Outcome Assessment Battery for Use in Longitudinal Traumatic Brain Injury Research. Arch Phys Med Rehabil 2020. [DOI: 10.1016/j.apmr.2020.09.028] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Chesnut RM, Temkin N, Videtta W, Petroni G, Lujan S, Pridgeon J, Dikmen S, Chaddock K, Barber J, Machamer J, Guadagnoli N, Hendrickson P, Aguilera S, Alanis V, Bello Quezada ME, Bautista Coronel E, Bustamante LA, Cacciatori AC, Carricondo CJ, Carvajal F, Davila R, Dominguez M, Figueroa Melgarejo JA, Fillipi MM, Godoy DA, Gomez DC, Lacerda Gallardo AJ, Guerra Garcia JA, Zerain GLF, Lavadenz Cuientas LA, Lequipe C, Grajales Yuca GV, Jibaja Vega M, Kessler ME, López Delgado HJ, Sandi Lora F, Mazzola AM, Maldonado RM, Mezquia de Pedro N, Martínez Zubieta JR, Mijangos Méndez JC, Mora J, Ochoa Parra JM, Pahnke PB, Paranhos J, Piñero GR, Rivadeneira Pilacuán FA, Mendez Rivera MN, Romero Figueroa RL, Rubiano AM, Saraguro Orozco AM, Silesky Jiménez JI, Silva Naranjo L, Soler Morejon C, Urbina Z. Consensus-Based Management Protocol (CREVICE Protocol) for the Treatment of Severe Traumatic Brain Injury Based on Imaging and Clinical Examination for Use When Intracranial Pressure Monitoring Is Not Employed. J Neurotrauma 2020; 37:1291-1299. [PMID: 32013721 DOI: 10.1089/neu.2017.5599] [Citation(s) in RCA: 38] [Impact Index Per Article: 9.5] [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: 02/03/2023] Open
Abstract
Globally, intracranial pressure (ICP) monitoring use in severe traumatic brain injury (sTBI) is inconsistent and susceptible to resource limitations and clinical philosophies. For situations without monitoring, there is no published comprehensive management algorithm specific to identifying and treating suspected intracranial hypertension (SICH) outside of the one ad hoc Imaging and Clinical Examination (ICE) protocol in the Benchmark Evidence from South American Trials: Treatment of Intracranial Pressure (BEST:TRIP) trial. As part of an ongoing National Institutes of Health (NIH)-supported project, a consensus conference involving 43 experienced Latin American Intensivists and Neurosurgeons who routinely care for sTBI patients without ICP monitoring, refined, revised, and augmented the original BEST:TRIP algorithm. Based on BEST:TRIP trial data and pre-meeting polling, 11 issues were targeted for development. We used Delphi-based methodology to codify individual statements and the final algorithm, using a group agreement threshold of 80%. The resulting CREVICE (Consensus REVised ICE) algorithm defines SICH and addresses both general management and specific treatment. SICH treatment modalities are organized into tiers to guide treatment escalation and tapering. Treatment schedules were developed to facilitate targeted management of disease severity. A decision-support model, based on the group's combined practices, is provided to guide this process. This algorithm provides the first comprehensive management algorithm for treating sTBI patients when ICP monitoring is not available. It is intended to provide a framework to guide clinical care and direct future research toward sTBI management. Because of the dearth of relevant literature, it is explicitly consensus based, and is provided solely as a resource (a "consensus-based curbside consult") to assist in treating sTBI in general intensive care units in resource-limited environments.
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Affiliation(s)
- Randall M Chesnut
- University of Washington, Harborview Medical Center, Seattle, Washington, USA
| | - Nancy Temkin
- University of Washington, Harborview Medical Center, Seattle, Washington, USA
| | - Walter Videtta
- Hospital Nacional Professor Alejandro Posadas, Buenos Aires, Argentina
| | - Gustavo Petroni
- Hospital Emergencia, Dr. Clemente Alvarez, Rosario, Argentina
| | - Silvia Lujan
- Hospital Emergencia, Dr. Clemente Alvarez, Rosario, Argentina
| | - Jim Pridgeon
- University of Washington, Harborview Medical Center, Seattle, Washington, USA
| | - Sureyya Dikmen
- University of Washington, Harborview Medical Center, Seattle, Washington, USA
| | - Kelley Chaddock
- University of Washington, Harborview Medical Center, Seattle, Washington, USA
| | - Jason Barber
- University of Washington, Harborview Medical Center, Seattle, Washington, USA
| | - Joan Machamer
- University of Washington, Harborview Medical Center, Seattle, Washington, USA
| | | | - Peter Hendrickson
- University of Washington, Harborview Medical Center, Seattle, Washington, USA
| | | | - Victor Alanis
- Hospital San Juan de Dios, Santa Cruz de la Sierra, Bolivia
| | | | | | | | | | | | - Felipe Carvajal
- Hospital Municipal Eva Peron de Merlo, Provincia Buenos Aires, Argentina
| | - Rafael Davila
- Hospital Universitario Luis Razetti, Barcelona, Venezuela
| | - Mario Dominguez
- Hospital Universitario Provincial "Arnaldo Milián Castro," Santa Clara, Cuba
| | | | | | | | | | | | | | | | | | | | | | | | | | - Hubiel J López Delgado
- Neurosurgery, Critical Care Medicine, CEDIMAT, Plaza de la Salud Juan, Santo Domingo, Dominican Republic
| | | | | | | | | | | | | | - Jacobo Mora
- Hospital Universitario Luis Razetti, Barcelona, Venezuela
| | - Johnny Marcelo Ochoa Parra
- Hospital José Carrasco Arteaga. IESS. Cuenca Facultad de Medicina, Universidad del Azuay, Cuenca, Ecuador
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Zahniser E, Temkin NR, Machamer J, Barber J, Manley GT, Markowitz AJ, Dikmen SS. The Functional Status Examination in Mild Traumatic Brain Injury: A TRACK-TBI Sub-Study. Arch Clin Neuropsychol 2019; 34:1165-1174. [PMID: 30608522 PMCID: PMC10576412 DOI: 10.1093/arclin/acy103] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2018] [Revised: 08/11/2018] [Accepted: 12/26/2018] [Indexed: 08/06/2023] Open
Abstract
OBJECTIVE The Functional Status Examination (FSE) is a comprehensive measure of functional status post-traumatic brain injury (TBI) that has primarily been used in studies of moderate-to-severe TBI. The present observational study examines functional status using the FSE among patients who sustained mild TBIs (mTBIs; defined as Glasgow Coma Scale [GCS] = 13-15 at admission) seen in a Level 1 trauma center. Study aims included examining the course of functional status following mTBI, as well as exploring relationships of the FSE and other relevant constructs among those with GCS = 13-15. METHOD Participants were assessed at 2 weeks (n = 112), 3 months (n = 113), 6 months (n = 106), and 12 months (n = 88) post-injury for changes in functional status resulting both (a) from all injuries and (b) from TBI only. RESULTS Among seven domains of day-to-day functioning, participants generally experienced the greatest disruption in their primary activity (work or school) and in leisure and recreation. Subjects' overall functional status tended to improve over time, with sharpest increases in functionality occurring in the first 3 months post-injury. However, some subjects continued to report functional limitations even at 12 months post-injury. Functional status was largely unrelated to neurocognitive functioning, but related strongly to post-traumatic symptoms, life satisfaction, and emotional well-being, particularly at 3 months post-injury and beyond. CONCLUSION Findings indicate that functional impairments related to mTBI may be more likely to persist than widely believed, with those who experience lingering functional deficits at particular risk for emotional health difficulties.
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Affiliation(s)
- Evan Zahniser
- Department of Neurological Surgery, University of Washington, Seattle, WA, USA
| | - Nancy R Temkin
- Department of Neurological Surgery, University of Washington, Seattle, WA, USA
- Department of Biostatistics, University of Washington, Seattle, WA, USA
| | - Joan Machamer
- Department of Rehabilitation Medicine, University of Washington, Seattle, WA, USA
| | - Jason Barber
- Department of Neurological Surgery, University of Washington, Seattle, WA, USA
| | - Geoffrey T Manley
- Department of Neurological Surgery, University of California San Francisco, San Francisco, CA, USA
| | - Amy J Markowitz
- Department of Neurological Surgery, University of California San Francisco, San Francisco, CA, USA
| | - Sureyya S Dikmen
- Department of Rehabilitation Medicine, University of Washington, Seattle, WA, USA
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Nelson LD, Temkin NR, Dikmen S, Barber J, Giacino JT, Yuh E, Levin HS, McCrea MA, Stein MB, Mukherjee P, Okonkwo DO, Robertson CS, Diaz-Arrastia R, Manley GT, Adeoye O, Badjatia N, Boase K, Bodien Y, Bullock MR, Chesnut R, Corrigan JD, Crawford K, Duhaime AC, Ellenbogen R, Feeser VR, Ferguson A, Foreman B, Gardner R, Gaudette E, Gonzalez L, Gopinath S, Gullapalli R, Hemphill JC, Hotz G, Jain S, Korley F, Kramer J, Kreitzer N, Lindsell C, Machamer J, Madden C, Martin A, McAllister T, Merchant R, Noel F, Palacios E, Perl D, Puccio A, Rabinowitz M, Rosand J, Sander A, Satris G, Schnyer D, Seabury S, Sherer M, Taylor S, Toga A, Valadka A, Vassar MJ, Vespa P, Wang K, Yue JK, Zafonte R. Recovery After Mild Traumatic Brain Injury in Patients Presenting to US Level I Trauma Centers: A Transforming Research and Clinical Knowledge in Traumatic Brain Injury (TRACK-TBI) Study. JAMA Neurol 2019; 76:1049-1059. [PMID: 31157856 DOI: 10.1001/jamaneurol.2019.1313] [Citation(s) in RCA: 210] [Impact Index Per Article: 42.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
Importance Most traumatic brain injuries (TBIs) are classified as mild (mTBI) based on admission Glasgow Coma Scale (GCS) scores of 13 to 15. The prevalence of persistent functional limitations for these patients is unclear. Objectives To characterize the natural history of recovery of daily function following mTBI vs peripheral orthopedic traumatic injury in the first 12 months postinjury using data from the Transforming Research and Clinical Knowledge in Traumatic Brain Injury (TRACK-TBI) study, and, using clinical computed tomographic (CT) scans, examine whether the presence (CT+) or absence (CT-) of acute intracranial findings in the mTBI group was associated with outcomes. Design, Setting, and Participants TRACK-TBI, a cohort study of patients with mTBI presenting to US level I trauma centers, enrolled patients from February 26, 2014, to August 8, 2018, and followed up for 12 months. A total of 1453 patients at 11 level I trauma center emergency departments or inpatient units met inclusion criteria (ie, mTBI [n = 1154] or peripheral orthopedic traumatic injury [n = 299]) and were enrolled within 24 hours of injury; mTBI participants had admission GCS scores of 13 to 15 and clinical head CT scans. Patients with peripheral orthopedic trauma injury served as the control (OTC) group. Exposures Participants with mTBI or OTC. Main Outcomes and Measures The Glasgow Outcome Scale Extended (GOSE) scale score, reflecting injury-related functional limitations across broad life domains at 2 weeks and 3, 6, and 12 months postinjury was the primary outcome. The possible score range of the GOSE score is 1 (dead) to 8 (upper good recovery), with a score less than 8 indicating some degree of functional impairment. Results Of the 1453 participants, 953 (65.6%) were men; mean (SD) age was 40.9 (17.1) years in the mTBI group and 40.9 (15.4) years in the OTC group. Most participants (mTBI, 87%; OTC, 93%) reported functional limitations (GOSE <8) at 2 weeks postinjury. At 12 months, the percentage of mTBI participants reporting functional limitations was 53% (95% CI, 49%-56%) vs 38% (95% CI, 30%-45%) for OTCs. A higher percentage of CT+ patients reported impairment (61%) compared with the mTBI CT- group (49%; relative risk [RR], 1.24; 95% CI, 1.08-1.43) and a higher percentage in the mTBI CT-group compared with the OTC group (RR, 1.28; 95% CI, 1.02-1.60). Conclusions and Relevance Most patients with mTBI presenting to US level I trauma centers report persistent, injury-related life difficulties at 1 year postinjury, suggesting the need for more systematic follow-up of patients with mTBI to provide treatments and reduce the risk of chronic problems after mTBI.
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Affiliation(s)
| | | | | | | | - Joseph T Giacino
- Spaulding Rehabilitation Hospital, Harvard Medical School, Boston, Massachusetts.,Massachusetts General Hospital, Boston
| | | | | | | | - Murray B Stein
- University of California, San Diego, La Jolla.,Veterans Affairs San Diego Healthcare System, San Diego, California
| | | | | | - Claudia S Robertson
- Department of Physical Medicine and Rehabilitation, Baylor College of Medicine, Houston, Texas
| | | | | | | | | | | | - Kim Boase
- Department of Rehabilitation Medicine, University of Washington, Seattle
| | | | | | - Randall Chesnut
- Department of Neurological Surgery, University of Washington, Seattle
| | | | | | | | | | - V Ramana Feeser
- Department of Emergency Medicine, Virginia Commonwealth University, Richmond
| | - Adam Ferguson
- Department of Neurological Surgery, University of California, San Francisco
| | | | - Raquel Gardner
- Department of Neurology, University of California, San Francisco
| | | | | | - Shankar Gopinath
- Department of Neurosurgery, Baylor College of Medicine, Houston, Texas
| | | | | | | | - Sonia Jain
- University of California, San Diego, La Jolla
| | - Frederick Korley
- Department of Emergency Medicine, University of Michigan Medical School, Ann Arbor
| | - Joel Kramer
- Department of Neurology, University of California, San Francisco
| | | | - Chris Lindsell
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Joan Machamer
- Department of Rehabilitation Medicine, University of Washington, Seattle
| | - Christopher Madden
- Department of Neurological Surgery, UT Southwestern Medical Center, Dallas, Texas
| | - Alastair Martin
- Department of Radiology & Biomedical Imaging, University of California, San Francisco
| | - Thomas McAllister
- Department of Psychiatry, Indiana University School of Medicine, Indianapolis
| | - Randall Merchant
- Department of Anatomy and Neurobiology, Virginia Commonwealth University, Richmond
| | - Florence Noel
- Dan L. Duncan Institute for Clinical and Translational Research, Baylor College of Medicine, Houston, Texas
| | - Eva Palacios
- Department of Radiology & Biomedical Imaging, University of California, San Francisco
| | - Daniel Perl
- Department of Pathology, Uniformed Services University, Bethesda, Maryland
| | - Ava Puccio
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Miri Rabinowitz
- Department of Neurology, University of Pennsylvania, Philadelphia
| | | | - Angelle Sander
- Department of Physical Medicine and Rehabilitation, Baylor College of Medicine, Houston, Texas
| | - Gabriela Satris
- Brain and Spinal Cord Injury Center, Zuckerberg San Francisco General Hospital and Trauma Center, San Francisco, California
| | - David Schnyer
- Department of Psychology, University of Texas at Austin, Austin
| | | | | | - Sabrina Taylor
- Department of Neurological Surgery, University of California, San Francisco
| | - Arthur Toga
- University of Southern California, Los Angeles
| | - Alex Valadka
- Department of Neurosurgery, Virginia Commonwealth University, Richmond
| | - Mary J Vassar
- Department of Neurological Surgery, University of California, San Francisco.,Brain and Spinal Cord Injury Center, Zuckerberg San Francisco General Hospital and Trauma Center, San Francisco, California
| | - Paul Vespa
- Department of Neurology, University of California Los Angeles School of Medicine, Los Angeles
| | - Kevin Wang
- Department of Psychiatry, University of Florida, Gainesville
| | - John K Yue
- Brain and Spinal Cord Injury Center, Zuckerberg San Francisco General Hospital and Trauma Center, San Francisco, California
| | - Ross Zafonte
- Department of Physical Medicine and Rehabilitation, Harvard Medical School, Boston, Massachusetts
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15
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Dikmen S, Machamer J, Manley GT, Yuh EL, Nelson LD, Temkin NR. Functional Status Examination versus Glasgow Outcome Scale Extended as Outcome Measures in Traumatic Brain Injuries: How Do They Compare? J Neurotrauma 2019; 36:2423-2429. [PMID: 30827167 DOI: 10.1089/neu.2018.6198] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [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: 11/13/2022] Open
Abstract
Outcome measures are essential components of natural history studies of recovery and treatment effects after traumatic brain injury (TBI). The Glasgow Outcome Scale (GOS) and its revised version, the Glasgow Outcome Scale Extended (GOSE), are well accepted and widely used for both observational and intervention studies, but there are concerns about their psychometric properties and aptness as outcome measures for TBI. The present study compares the Functional Status Examination (FSE) with the GOSE to assess outcome after TBI in a sample of 533 participants with TBI from the Magnesium Sulfate study and the Transforming Research and Clinical Knowledge in Traumatic Brain Injury (TRACK-TBI) study by evaluating the sensitivity of each measure to severity of brain injury and recovery of function over time. The results indicate that both measures are strongly correlated with TBI severity. At three months, the correlation strengths between injury severity and each outcome measure do not differ (p = 0.88 for Glasgow Coma Scale [GCS], p = 0.13 for computed tomography [CT] abnormalities) but at six months, the FSE is more strongly related to TBI severity indices than is the GOSE (p = 0.045 for GCS, p = 0.014 for CT abnormalities). In addition, the FSE generally shows significantly more improvement over time than the GOSE (p < 0.001). Detailed, structured administration rules and a wider score range of the FSE likely yields more sensitive and precise assessment of functional level than the GOSE. The FSE may be a valuable alternative to the GOSE for assessing functional outcome after TBI.
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Affiliation(s)
- Sureyya Dikmen
- 1Department of Rehabilitation Medicine, University of Washington, Seattle, Washington.,2Department of Neurological Surgery, University of Washington, Seattle, Washington.,3Department of Psychiatry & Behavioral Sciences, and University of Washington, Seattle, Washington
| | - Joan Machamer
- 1Department of Rehabilitation Medicine, University of Washington, Seattle, Washington
| | - Geoffrey T Manley
- 4Department of Neurosurgery, Brain and Spinal Injury Center, University of California San Francisco, and Zuckerberg San Francisco General Hospital, San Francisco, California
| | - Esther L Yuh
- 4Department of Neurosurgery, Brain and Spinal Injury Center, University of California San Francisco, and Zuckerberg San Francisco General Hospital, San Francisco, California.,5Department of Radiology & Biomedical Imaging, University of California San Francisco, San Francisco, California
| | - Lindsay D Nelson
- 6Departments of Neurosurgery and Neurology, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Nancy R Temkin
- 1Department of Rehabilitation Medicine, University of Washington, Seattle, Washington.,2Department of Neurological Surgery, University of Washington, Seattle, Washington.,7Department of Biostatistics, University of Washington, Seattle, Washington
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16
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Stein MB, Jain S, Giacino JT, Levin H, Dikmen S, Nelson LD, Vassar MJ, Okonkwo DO, Diaz-Arrastia R, Robertson CS, Mukherjee P, McCrea M, Mac Donald CL, Yue JK, Yuh E, Sun X, Campbell-Sills L, Temkin N, Manley GT, Adeoye O, Badjatia N, Boase K, Bodien Y, Bullock MR, Chesnut R, Corrigan JD, Crawford K, Diaz-Arrastia R, Dikmen S, Duhaime AC, Ellenbogen R, Feeser VR, Ferguson A, Foreman B, Gardner R, Gaudette E, Giacino JT, Gonzalez L, Gopinath S, Gullapalli R, Hemphill JC, Hotz G, Jain S, Korley F, Kramer J, Kreitzer N, Levin H, Lindsell C, Machamer J, Madden C, Martin A, McAllister T, McCrea M, Merchant R, Mukherjee P, Nelson LD, Noel F, Okonkwo DO, Palacios E, Perl D, Puccio A, Rabinowitz M, Robertson CS, Rosand J, Sander A, Satris G, Schnyer D, Seabury S, Sherer M, Stein MB, Taylor S, Toga A, Temkin N, Valadka A, Vassar MJ, Vespa P, Wang K, Yue JK, Yuh E, Zafonte R. Risk of Posttraumatic Stress Disorder and Major Depression in Civilian Patients After Mild Traumatic Brain Injury: A TRACK-TBI Study. JAMA Psychiatry 2019; 76:249-258. [PMID: 30698636 PMCID: PMC6439818 DOI: 10.1001/jamapsychiatry.2018.4288] [Citation(s) in RCA: 160] [Impact Index Per Article: 32.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
IMPORTANCE Traumatic brain injury (TBI) has been associated with adverse mental health outcomes, such as posttraumatic stress disorder (PTSD) and major depressive disorder (MDD), but little is known about factors that modify risk for these psychiatric sequelae, particularly in the civilian sector. OBJECTIVE To ascertain prevalence of and risk factors for PTSD and MDD among patients evaluated in the emergency department for mild TBI (mTBI). DESIGN, SETTING, AND PARTICIPANTS Prospective longitudinal cohort study (February 2014 to May 2018). Posttraumatic stress disorder and MDD symptoms were assessed using the PTSD Checklist for DSM-5 and the Patient Health Questionnaire-9 Item. Risk factors evaluated included preinjury and injury characteristics. Propensity score weights-adjusted multivariable logistic regression models were performed to assess associations with PTSD and MDD. A total of 1155 patients with mTBI (Glasgow Coma Scale score, 13-15) and 230 patients with nonhead orthopedic trauma injuries 17 years and older seen in 11 US hospitals with level 1 trauma centers were included in this study. MAIN OUTCOMES AND MEASURES Probable PTSD (PTSD Checklist for DSM-5 score, ≥33) and MDD (Patient Health Questionnaire-9 Item score, ≥15) at 3, 6, and 12 months postinjury. RESULTS Participants were 1155 patients (752 men [65.1%]; mean [SD] age, 40.5 [17.2] years) with mTBI and 230 patients (155 men [67.4%]; mean [SD] age, 40.4 [15.6] years) with nonhead orthopedic trauma injuries. Weights-adjusted prevalence of PTSD and/or MDD in the mTBI vs orthopedic trauma comparison groups at 3 months was 20.0% (SE, 1.4%) vs 8.7% (SE, 2.2%) (P < .001) and at 6 months was 21.2% (SE, 1.5%) vs 12.1% (SE, 3.2%) (P = .03). Risk factors for probable PTSD at 6 months after mTBI included less education (adjusted odds ratio, 0.89; 95% CI, 0.82-0.97 per year), being black (adjusted odds ratio, 5.11; 95% CI, 2.89-9.05), self-reported psychiatric history (adjusted odds ratio, 3.57; 95% CI, 2.09-6.09), and injury resulting from assault or other violence (adjusted odds ratio, 3.43; 95% CI, 1.56-7.54). Risk factors for probable MDD after mTBI were similar with the exception that cause of injury was not associated with increased risk. CONCLUSIONS AND RELEVANCE After mTBI, some individuals, on the basis of education, race/ethnicity, history of mental health problems, and cause of injury were at substantially increased risk of PTSD and/or MDD. These findings should influence recognition of at-risk individuals and inform efforts at surveillance, follow-up, and intervention.
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Affiliation(s)
- Murray B. Stein
- Department of Psychiatry, University of California San Diego, La Jolla,Department of Family Medicine & Public Health, University of California San Diego, La Jolla,VA San Diego Healthcare System, San Diego, California
| | - Sonia Jain
- Department of Family Medicine & Public Health, University of California San Diego, La Jolla
| | - Joseph T. Giacino
- Department of Physical Medicine and Rehabilitation, Harvard Medical School, Boston, Massachusetts,Spaulding Rehabilitation Hospital, Charlestown, Massachusetts
| | - Harvey Levin
- Department of Physical Medicine and Rehabilitation, Baylor College of Medicine, Houston, Texas
| | - Sureyya Dikmen
- Department of Rehabilitation Medicine, University of Washington, Seattle
| | - Lindsay D. Nelson
- Departments of Neurosurgery and Neurology, Medical College of Wisconsin, Milwaukee
| | - Mary J. Vassar
- Brain and Spinal Cord Injury Center, Zuckerberg San Francisco General Hospital and Trauma Center, San Francisco, California,Department of Neurological Surgery, University of California, San Francisco
| | - David O. Okonkwo
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | | | - Claudia S. Robertson
- Department of Physical Medicine and Rehabilitation, Baylor College of Medicine, Houston, Texas
| | - Pratik Mukherjee
- Brain and Spinal Cord Injury Center, Zuckerberg San Francisco General Hospital and Trauma Center, San Francisco, California,Department of Radiology & Biomedical Imaging, University of California, San Francisco,Department of Bioengineering & Therapeutic Sciences, University of California, San Francisco
| | - Michael McCrea
- Departments of Neurosurgery and Neurology, Medical College of Wisconsin, Milwaukee
| | | | - John K. Yue
- Brain and Spinal Cord Injury Center, Zuckerberg San Francisco General Hospital and Trauma Center, San Francisco, California
| | - Esther Yuh
- Brain and Spinal Cord Injury Center, Zuckerberg San Francisco General Hospital and Trauma Center, San Francisco, California,Department of Radiology & Biomedical Imaging, University of California, San Francisco,Department of Bioengineering & Therapeutic Sciences, University of California, San Francisco
| | - Xiaoying Sun
- Department of Family Medicine & Public Health, University of California San Diego, La Jolla
| | | | - Nancy Temkin
- Department of Neurological Surgery, University of Washington, Seattle,Department of Biostatistics, University of Washington, Seattle
| | - Geoffrey T. Manley
- Brain and Spinal Cord Injury Center, Zuckerberg San Francisco General Hospital and Trauma Center, San Francisco, California,Department of Neurological Surgery, University of California, San Francisco
| | | | | | | | - Kim Boase
- Department of Rehabilitation Medicine, University of Washington, Seattle
| | | | | | - Randall Chesnut
- Department of Neurological Surgery, University of Washington, Seattle
| | | | | | | | - Sureyya Dikmen
- Department of Rehabilitation Medicine, University of Washington, Seattle
| | | | | | - V Ramana Feeser
- Department of Emergency Medicine, Virginia Commonwealth University, Richmond
| | - Adam Ferguson
- Department of Neurological Surgery, University of California, San Francisco
| | | | - Raquel Gardner
- Department of Neurology, University of California, San Francisco
| | | | - Joseph T Giacino
- Department of Physical Medicine and Rehabilitation, Harvard Medical School, Boston, Massachusetts.,Spaulding Rehabilitation Hospital, Charlestown, Massachusetts
| | | | - Shankar Gopinath
- Department of Neurosurgery, Baylor College of Medicine, Houston, Texas
| | | | | | | | - Sonia Jain
- Department of Family Medicine & Public Health, University of California San Diego, La Jolla
| | - Frederick Korley
- Department of Emergency Medicine, University of Michigan Medical School, Ann Arbor
| | - Joel Kramer
- Department of Neurology, University of California, San Francisco
| | | | - Harvey Levin
- Department of Physical Medicine and Rehabilitation, Baylor College of Medicine, Houston, Texas
| | - Chris Lindsell
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Joan Machamer
- Department of Rehabilitation Medicine, University of Washington, Seattle
| | - Christopher Madden
- Department of Neurological Surgery, UT Southwestern Medical Center, Dallas, Texas
| | - Alastair Martin
- Department of Radiology & Biomedical Imaging, University of California, San Francisco
| | - Thomas McAllister
- Department of Psychiatry, Indiana University School of Medicine, Indianapolis
| | - Michael McCrea
- Departments of Neurosurgery and Neurology, Medical College of Wisconsin, Milwaukee
| | - Randall Merchant
- Department of Anatomy and Neurobiology, Virginia Commonwealth University, Richmond
| | - Pratik Mukherjee
- Brain and Spinal Cord Injury Center, Zuckerberg San Francisco General Hospital and Trauma Center, San Francisco, California.,Department of Radiology & Biomedical Imaging, University of California, San Francisco.,Department of Bioengineering & Therapeutic Sciences, University of California, San Francisco
| | - Lindsay D Nelson
- Departments of Neurosurgery and Neurology, Medical College of Wisconsin, Milwaukee
| | - Florence Noel
- Dan L. Duncan Institute for Clinical and Translational Research, Baylor College of Medicine, Houston, Texas
| | - David O Okonkwo
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Eva Palacios
- Department of Radiology & Biomedical Imaging, University of California, San Francisco
| | - Daniel Perl
- Department of Pathology, Uniformed Services University, Bethesda, Maryland
| | - Ava Puccio
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Miri Rabinowitz
- Department of Neurology, University of Pennsylvania, Philadelphia
| | - Claudia S Robertson
- Department of Physical Medicine and Rehabilitation, Baylor College of Medicine, Houston, Texas
| | | | - Angelle Sander
- Department of Physical Medicine and Rehabilitation, Baylor College of Medicine, Houston, Texas
| | - Gabriela Satris
- Brain and Spinal Cord Injury Center, Zuckerberg San Francisco General Hospital and Trauma Center, San Francisco, California
| | - David Schnyer
- Department of Psychology, University of Texas at Austin, Austin
| | | | | | - Murray B Stein
- Department of Psychiatry, University of California San Diego, La Jolla.,Department of Family Medicine & Public Health, University of California San Diego, La Jolla.,VA San Diego Healthcare System, San Diego, California
| | - Sabrina Taylor
- Department of Neurological Surgery, University of California, San Francisco
| | - Arthur Toga
- University of Southern California, Los Angeles
| | - Nancy Temkin
- Department of Neurological Surgery, University of Washington, Seattle.,Department of Biostatistics, University of Washington, Seattle
| | - Alex Valadka
- Department of Neurosurgery, Virginia Commonwealth University, Richmond
| | - Mary J Vassar
- Brain and Spinal Cord Injury Center, Zuckerberg San Francisco General Hospital and Trauma Center, San Francisco, California.,Department of Neurological Surgery, University of California, San Francisco
| | - Paul Vespa
- Department of Neurology, University of California Los Angeles School of Medicine, Los Angeles
| | - Kevin Wang
- Department of Psychiatry, University of Florida, Gainesville
| | - John K Yue
- Brain and Spinal Cord Injury Center, Zuckerberg San Francisco General Hospital and Trauma Center, San Francisco, California
| | - Esther Yuh
- Brain and Spinal Cord Injury Center, Zuckerberg San Francisco General Hospital and Trauma Center, San Francisco, California.,Department of Radiology & Biomedical Imaging, University of California, San Francisco.,Department of Bioengineering & Therapeutic Sciences, University of California, San Francisco
| | - Ross Zafonte
- Department of Physical Medicine and Rehabilitation, Harvard Medical School, Boston, Massachusetts
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17
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Machamer J, Temkin NR, Manley GT, Dikmen S. Functional Status Examination in Patients with Moderate-to-Severe Traumatic Brain Injuries. J Neurotrauma 2018; 35:1132-1137. [PMID: 29415608 DOI: 10.1089/neu.2017.5460] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [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: 10/18/2022] Open
Abstract
The assessment of functional status after traumatic brain injury (TBI) is important. The Glasgow Outcome Scale (GOS) and its revised version, the Glasgow Outcome Scale Extended (GOSE), have been used most frequently in TBI research, but there are concerns about the sensitivity of these measures. The current study evaluated the psychometric properties of the Functional Status Examination (FSE) using a sample of 448 moderately to severely injured subjects with TBI. It was shown that the FSE is significantly related to other measures of functional status including the GOSE, Short Form Health Survey, and European Quality of Life Checklist (p < 0.001), is sensitive to TBI severity (p < 0.001), and is responsive to recovery from 3 to 6 months post-injury (p < 0.001). In addition, there was a significant agreement (r = 0.817, p < 0.001) between the patient and significant other's assessment of functional status on the FSE at 6 months post-injury. The FSE may be a valuable measure of functional status after TBI given its strong psychometric properties, including validity, sensitivity to brain injury severity, and recovery over time.
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Affiliation(s)
- Joan Machamer
- 1 Department of Rehabilitation Medicine, University of Washington , Seattle, Washington
| | - Nancy R Temkin
- 1 Department of Rehabilitation Medicine, University of Washington , Seattle, Washington.,2 Department of Neurological Surgery, University of Washington , Seattle, Washington.,3 Department of Biostatistics, University of Washington , Seattle, Washington
| | - Geoffrey T Manley
- 4 Department of Neurosurgery, Brain and Spinal Injury Center, University of California San Francisco; Zuckerberg San Francisco General Hospital , San Francisco, California
| | - Sureyya Dikmen
- 1 Department of Rehabilitation Medicine, University of Washington , Seattle, Washington.,2 Department of Neurological Surgery, University of Washington , Seattle, Washington.,5 Department of Psychiatry and Behavioral Sciences, University of Washington , Seattle, Washington
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18
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Chesnut RM, Temkin N, Dikmen S, Rondina C, Videtta W, Petroni G, Lujan S, Alanis V, Falcao A, de la Fuenta G, Gonzalez L, Jibaja M, Lavarden A, Sandi F, Mérida R, Romero R, Pridgeon J, Barber J, Machamer J, Chaddock K. A Method of Managing Severe Traumatic Brain Injury in the Absence of Intracranial Pressure Monitoring: The Imaging and Clinical Examination Protocol. J Neurotrauma 2017; 35:54-63. [PMID: 28726590 DOI: 10.1089/neu.2016.4472] [Citation(s) in RCA: 45] [Impact Index Per Article: 6.4] [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: 11/13/2022] Open
Abstract
The imaging and clinical examination (ICE) algorithm used in the Benchmark Evidence from South American Trials: Treatment of Intracranial Pressure (BEST TRIP) randomized controlled trial is the only prospectively investigated clinical protocol for traumatic brain injury management without intracranial pressure (ICP) monitoring. As the default literature standard, it warrants careful evaluation. We present the ICE protocol in detail and analyze the demographics, outcome, treatment intensity, frequency of intervention usage, and related adverse events in the ICE-protocol cohort. The 167 ICE protocol patients were young (median 29 years) with a median Glasgow Coma Scale motor score of 4 but with anisocoria or abnormal pupillary reactivity in 40%. This protocol produced outcomes not significantly different from those randomized to the monitor-based protocol (favorable 6-month extended Glasgow Outcome Score in 39%; 41% mortality rate). Agents commonly employed to treat suspected intracranial hypertension included low-/moderate-dose hypertonic saline (72%) and mannitol (57%), mild hyperventilation (adjusted partial pressure of carbon dioxide 30-35 mm Hg in 73%), and pressors to maintain cerebral perfusion (62%). High-dose hyperosmotics or barbiturates were uncommonly used. Adverse event incidence was low and comparable to the BEST TRIP monitored group. Although this protocol should produce similar/acceptable results under circumstances comparable to those in the trial, influences such as longer pre-hospital times and non-specialist transport personnel, plus an intensive care unit model of aggressive physician-intensive care by small groups of neurotrauma-focused intensivists, which differs from most high-resource models, support caution in expecting the same results in dissimilar settings. Finally, this protocol's ICP-titration approach to suspected intracranial hypertension (vs. crisis management for monitored ICP) warrants further study.
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Affiliation(s)
- Randall M Chesnut
- 1 University of Washington , Harborview Medical Center, Seattle, Washington
| | - Nancy Temkin
- 1 University of Washington , Harborview Medical Center, Seattle, Washington
| | - Sureyya Dikmen
- 1 University of Washington , Harborview Medical Center, Seattle, Washington
| | - Carlos Rondina
- 2 Hospital Emergencia , Dr. Clemente Alvarez, Rosario, Argentina
| | - Walter Videtta
- 3 Hospital Nacional Professor Alejandro Posadas , Buenos Aires, Argentina
| | - Gustavo Petroni
- 2 Hospital Emergencia , Dr. Clemente Alvarez, Rosario, Argentina
| | - Silvia Lujan
- 2 Hospital Emergencia , Dr. Clemente Alvarez, Rosario, Argentina
| | - Victor Alanis
- 4 Hospital San Juan de Dios , Santa Cruz de la Sierra, Bolivia
| | | | | | | | | | | | - Freddy Sandi
- 10 Hospital Obrero No 1 de La Paz , La Paz, Bolivia
| | | | | | - Jim Pridgeon
- 1 University of Washington , Harborview Medical Center, Seattle, Washington
| | - Jason Barber
- 1 University of Washington , Harborview Medical Center, Seattle, Washington
| | - Joan Machamer
- 1 University of Washington , Harborview Medical Center, Seattle, Washington
| | - Kelley Chaddock
- 1 University of Washington , Harborview Medical Center, Seattle, Washington
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19
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Dikmen S, Machamer J, Temkin N. Mild Traumatic Brain Injury: Longitudinal Study of Cognition, Functional Status, and Post-Traumatic Symptoms. J Neurotrauma 2016; 34:1524-1530. [PMID: 27785968 DOI: 10.1089/neu.2016.4618] [Citation(s) in RCA: 109] [Impact Index Per Article: 13.6] [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: 01/23/2023] Open
Abstract
More than 75% of traumatic brain injuries (TBIs) seeking medical attention are mild, and outcome in that group is heterogeneous. Until sensitive and valid biomarkers are identified, methods are needed to classify mild TBI into more homogeneous subgroups. Four hundred twenty-one adults with mild TBI were divided into groups based on Glasgow Coma Scale (GCS) 13-15 without computed tomography (CT) abnormalities, GCS 15 with CT abnormalities, and GCS 13-14 with CT abnormalities, and were compared with 120 trauma controls on 1-month and 1-year outcomes. At 1 month post-injury, almost all neuropsychological variables differed significantly among the groups. Compared with trauma controls, the GCS 13-15 CT normal group showed no significant differences on any neuropsychological measure or Glasgow Outcome Scale (GOS). The GCS 15 CT abnormal group performed significantly worse on only a measure of episodic memory and learning (Selective Reminding Recall [SRCL]) and GOS, and the GCS 13-14 CT abnormal group performed significantly worse on most neuropsychological measures and GOS. At 1 year post-injury, except for an isolated difficulty on SRCL in the GCS 13-14 CT abnormal group, no differences were observed on any neuropsychological measures nor on GOS. Mean percent of total post-traumatic symptoms endorsed as new or worse and percent endorsing three or more symptoms differed significantly (p < 0.001), with each TBI subgroup reporting significantly more symptoms than the trauma controls at both 1 month and 1 year. In conclusion, this subgrouping improves granularity within mild TBI. While most neuropsychological and functional differences abate by 1 year, reporting three or more post-traumatic symptoms remain for about half of individuals.
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Affiliation(s)
- Sureyya Dikmen
- 1 Department of Rehabilitation Medicine, University of Washington , Seattle, Washington.,2 Department of Psychiatry and Behavioral Sciences, University of Washington , Seattle, Washington.,3 Department of Neurological Surgery, University of Washington , Seattle, Washington
| | - Joan Machamer
- 1 Department of Rehabilitation Medicine, University of Washington , Seattle, Washington
| | - Nancy Temkin
- 1 Department of Rehabilitation Medicine, University of Washington , Seattle, Washington.,3 Department of Neurological Surgery, University of Washington , Seattle, Washington.,4 Department of Biostatistics, University of Washington , Seattle, Washington
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Bell KR, Fann JR, Brockway JA, Cole WR, Bush NE, Dikmen S, Hart T, Lang AJ, Grant G, Gahm G, Reger MA, St De Lore J, Machamer J, Ernstrom K, Raman R, Jain S, Stein MB, Temkin N. Telephone Problem Solving for Service Members with Mild Traumatic Brain Injury: A Randomized, Clinical Trial. J Neurotrauma 2016; 34:313-321. [PMID: 27579992 DOI: 10.1089/neu.2016.4444] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.8] [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: 11/12/2022] Open
Abstract
Mild traumatic brain injury (mTBI) is a common injury for service members in recent military conflicts. There is insufficient evidence of how best to treat the consequences of mTBI. In a randomized, clinical trial, we evaluated the efficacy of telephone-delivered problem-solving treatment (PST) on psychological and physical symptoms in 356 post-deployment active duty service members from Joint Base Lewis McChord, Washington, and Fort Bragg, North Carolina. Members with medically confirmed mTBI sustained during deployment to Iraq and Afghanistan within the previous 24 months received PST or education-only (EO) interventions. The PST group received up to 12 biweekly telephone calls from a counselor for subject-selected problems. Both groups received 12 educational brochures describing common mTBI and post-deployment problems, with follow-up for all at 6 months (end of PST), and at 12 months. At 6 months, the PST group significantly improved on a measure of psychological distress (Brief Symptom Inventory; BSI-18) compared to the EO group (p = 0.005), but not on post-concussion symptoms (Rivermead Post-Concussion Symptoms Questionnaire [RPQ]; p = 0.19), the two primary endpoints. However, these effects did not persist at 12-month follow-up (BSI, p = 0.54; RPQ, p = 0.45). The PST group also had significant short-term improvement on secondary endpoints, including sleep (p = 0.01), depression (p = 0.03), post-traumatic stress disorder (p = 0.04), and physical functioning (p = 0.03). Participants preferred PST over EO (p < 0.001). Telephone-delivered PST appears to be a well-accepted treatment that offers promise for reducing psychological distress after combat-related mTBI and could be a useful adjunct treatment post-mTBI. Further studies are required to determine how to sustain its effects. (Trial registration: ClinicalTrials.gov Identifier: NCT01387490 https://clinicaltrials.gov ).
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Affiliation(s)
- Kathleen R Bell
- 1 Department of Rehabilitation Medicine, University of Washington , Seattle, Washington
| | - Jesse R Fann
- 1 Department of Rehabilitation Medicine, University of Washington , Seattle, Washington.,2 Department of Psychiatry and Behavioral Sciences, University of Washington , Seattle, Washington
| | - Jo Ann Brockway
- 1 Department of Rehabilitation Medicine, University of Washington , Seattle, Washington
| | - Wesley R Cole
- 3 Defense and Veterans Brain Injury Center, Intrepid Spirit, Womack Army Medical Center , Fort Bragg, North Carolina
| | - Nigel E Bush
- 4 National Center for Telehealth and Technology , Joint Base Lewis McChord, Tacoma, Washington
| | - Sureyya Dikmen
- 1 Department of Rehabilitation Medicine, University of Washington , Seattle, Washington.,5 Department of Neurological Surgery, University of Washington , Seattle, Washington
| | - Tessa Hart
- 6 Moss Rehabilitation Research Institute , Elkins Park, Pennsylvania
| | - Ariel J Lang
- 7 Department of Psychiatry, University California San Diego and VA San Diego Healthcare System Center of Excellence for Stress and Mental Health , La Jolla, California
| | - Gerald Grant
- 8 Department of Surgery, Duke University , Durham, North Carolina
| | - Gregory Gahm
- 4 National Center for Telehealth and Technology , Joint Base Lewis McChord, Tacoma, Washington
| | - Mark A Reger
- 4 National Center for Telehealth and Technology , Joint Base Lewis McChord, Tacoma, Washington
| | - Jef St De Lore
- 5 Department of Neurological Surgery, University of Washington , Seattle, Washington
| | - Joan Machamer
- 1 Department of Rehabilitation Medicine, University of Washington , Seattle, Washington
| | - Karin Ernstrom
- 9 Department of Family Medicine and Public Health, University of California San Diego , La Jolla, California
| | - Rema Raman
- 9 Department of Family Medicine and Public Health, University of California San Diego , La Jolla, California
| | - Sonia Jain
- 9 Department of Family Medicine and Public Health, University of California San Diego , La Jolla, California
| | - Murray B Stein
- 7 Department of Psychiatry, University California San Diego and VA San Diego Healthcare System Center of Excellence for Stress and Mental Health , La Jolla, California.,9 Department of Family Medicine and Public Health, University of California San Diego , La Jolla, California
| | - Nancy Temkin
- 1 Department of Rehabilitation Medicine, University of Washington , Seattle, Washington.,5 Department of Neurological Surgery, University of Washington , Seattle, Washington.,10 Department of Biostatistics, University of Washington , Seattle, Washington
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21
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Chesnut RM, Temkin N, Dikmen S, Rondina C, Videtta W, Lujan S, Petroni G, Pridgeon J, Barber J, Machamer J, Chaddock K, Celix JM, Cherner M, Hendrix T. Ethical and methodological considerations on conducting clinical research in poor and low-income countries: Viewpoint of the authors of the BEST TRIP ICP randomized trial in Latin America. Surg Neurol Int 2015; 6:116. [PMID: 26229731 PMCID: PMC4513298 DOI: 10.4103/2152-7806.159841] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2014] [Accepted: 10/08/2014] [Indexed: 11/04/2022] Open
Affiliation(s)
- Randall M. Chesnut
- Department of Neurological Surgery and Orthopaedics and Sports Medicine, Harborview Medical Center, University of Washington, Seattle, USA
| | - Nancy Temkin
- Department of Neurological Surgery and Biostatistics, Harborview Medical Center, University of Washington, Seattle, USA
| | - Sureyya Dikmen
- Department of Rehabilitation Medicine and Neurological Surgery, Harborview Medical Center, University of Washington, Seattle, USA
| | - Carlos Rondina
- President Fundacion ALAS, Hospital de Emergencias, “Dr. Clemente Alvarez,” University of California, San Diego, California, USA
| | - Walter Videtta
- President Latin American Brain Injury Consortium, Hospital Nacional Professor Alejandro Posadas, University of California, San Diego, California, USA
| | - Silvia Lujan
- Latin American Outcomes Examiner/Trainer/Coordinator/Data monitor, Hospital de Emergencias, “Dr. Clemente Alvarez,” CIIC, University of California, San Diego, California, USA
| | - Gustavo Petroni
- Latin American Outcomes Examiner/Trainer/Coordinator/Data monitor, Hospital de Emergencias, “Dr. Clemente Alvarez,” CIIC, University of California, San Diego, California, USA
| | - James Pridgeon
- Department of Neurological Surgery, Harborview Medical Center, University of Washington, Seattle, USA
| | - Jason Barber
- Department of Neurological Surgery, Harborview Medical Center, University of Washington, Seattle, USA
| | - Joan Machamer
- Department of Rehabilitation Medicine, Harborview Medical Center, University of Washington, Seattle, USA
| | - Kelley Chaddock
- Department of Neurological Surgery, Harborview Medical Center, University of Washington, Seattle, USA
| | - Juanita M. Celix
- Department of Neurological Surgery, Harborview Medical Center, University of Washington, Seattle, USA
| | - Marianna Cherner
- Department of Psychiatry, Neuropsychologist, Outcome measures consultant (Spanish), University of California, San Diego, California, USA
| | - Terence Hendrix
- Latin America Site Outcomes Coordinator, Clinical Research Study Coordinator, HIV Neurobehavioral Research Programs (HNRP), University of California, San Diego, California, USA
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Abstract
Despite its importance to care, clinicians and researchers often discount patient-reported outcomes in favor of proxy reports, in persons with traumatic brain injury (TBI). The rationale relates to concerns about lack of awareness of patients regarding their functioning. However, although lack of awareness occurs in some patients with severe TBI, or in TBI involving certain lesion locations, or very soon after injury, this conclusion has been overgeneralized. The objective of this study is to determine the validity of patient-reported health-related quality of life by evaluating its relationship to injury severity and more objective indices of outcome, in a representative series of adults with TBI. A consecutive sample of 374 persons with TBI at least 14 years old, and having a post-resuscitation Glasgow Coma Scale score ≤12, an acute seizure, or a CT scan showing TBI- related findings. Seventy-six percent (374/491) of the eligible survivors were assessed at 6 months post-injury on the Life Satisfaction Survey. The greatest decrease in satisfaction was in the ability to think and remember, work, receive adequate income, and participate in leisure and recreational activities. Dissatisfaction significantly related to the functional limitation in that area as judged by the patients themselves (p<0.001) or by someone who knew them well (p≤0.001). The most severely injured group reported the most dissatisfaction for 13 out of 17 areas assessed. Patients with TBI, in general, do not need a proxy to report on their behalf regarding their functional limitations or health-related quality of life.
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Affiliation(s)
- Joan Machamer
- 1 Department of Rehabilitation Medicine, University of Washington , Seattle, Washington
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23
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Chesnut RM, Temkin N, Carney N, Dikmen S, Rondina C, Videtta W, Petroni G, Lujan S, Pridgeon J, Barber J, Machamer J, Chaddock K, Celix JM, Cherner M, Hendrix T. A trial of intracranial-pressure monitoring in traumatic brain injury. N Engl J Med 2012; 367:2471-81. [PMID: 23234472 PMCID: PMC3565432 DOI: 10.1056/nejmoa1207363] [Citation(s) in RCA: 761] [Impact Index Per Article: 63.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
BACKGROUND Intracranial-pressure monitoring is considered the standard of care for severe traumatic brain injury and is used frequently, but the efficacy of treatment based on monitoring in improving the outcome has not been rigorously assessed. METHODS We conducted a multicenter, controlled trial in which 324 patients 13 years of age or older who had severe traumatic brain injury and were being treated in intensive care units (ICUs) in Bolivia or Ecuador were randomly assigned to one of two specific protocols: guidelines-based management in which a protocol for monitoring intraparenchymal intracranial pressure was used (pressure-monitoring group) or a protocol in which treatment was based on imaging and clinical examination (imaging-clinical examination group). The primary outcome was a composite of survival time, impaired consciousness, and functional status at 3 months and 6 months and neuropsychological status at 6 months; neuropsychological status was assessed by an examiner who was unaware of protocol assignment. This composite measure was based on performance across 21 measures of functional and cognitive status and calculated as a percentile (with 0 indicating the worst performance, and 100 the best performance). RESULTS There was no significant between-group difference in the primary outcome, a composite measure based on percentile performance across 21 measures of functional and cognitive status (score, 56 in the pressure-monitoring group vs. 53 in the imaging-clinical examination group; P=0.49). Six-month mortality was 39% in the pressure-monitoring group and 41% in the imaging-clinical examination group (P=0.60). The median length of stay in the ICU was similar in the two groups (12 days in the pressure-monitoring group and 9 days in the imaging-clinical examination group; P=0.25), although the number of days of brain-specific treatments (e.g., administration of hyperosmolar fluids and the use of hyperventilation) in the ICU was higher in the imaging-clinical examination group than in the pressure-monitoring group (4.8 vs. 3.4, P=0.002). The distribution of serious adverse events was similar in the two groups. CONCLUSIONS For patients with severe traumatic brain injury, care focused on maintaining monitored intracranial pressure at 20 mm Hg or less was not shown to be superior to care based on imaging and clinical examination. (Funded by the National Institutes of Health and others; ClinicalTrials.gov number, NCT01068522.).
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Affiliation(s)
- Randall M Chesnut
- Department of Neurological Surgery, University of Washington, Harborview Medical Center, Seattle, WA 98104, USA.
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24
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Chesnut RM, Temkin N, Carney N, Dikmen S, Pridgeon J, Barber J, Celix JM, Chaddock K, Cherner M, Hendrix T, Lujan S, Machamer J, Petroni G, Rondina C, Videtta W. Traumatic brain injury in Latin America: lifespan analysis randomized control trial protocol*. Neurosurgery 2012; 71:1055-63. [PMID: 22986600 PMCID: PMC3549327 DOI: 10.1227/neu.0b013e31827276b7] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Although in the developed world the intracranial pressure (ICP) monitor is considered the standard of care for patients with severe traumatic brain injury (TBI), its usefulness to direct treatment decisions has never been tested rigorously. OBJECTIVE The primary focus was to conduct a high-quality, randomized, controlled trial to determine whether ICP monitoring used to direct TBI treatment improves patient outcomes. By providing education, equipment, and structure, the project will enhance the research capacity of the collaborating investigators and will foster the collaborations established during earlier studies. METHODS Study centers were selected that routinely treated ICP based on clinical examination and computed tomography imaging using internal protocols. We randomized patients to either an ICP monitor group or an imaging and clinical examination group. Treatment decisions for the ICP monitor group are guided by ICP monitoring based on established guidelines. Treatment decisions for the imaging and clinical examination group are made using a single protocol derived from those previously being used at those centers. EXPECTED OUTCOMES There are 2 study hypotheses: (1) patients with severe TBI whose acute care treatment is managed using ICP monitors will have improved outcomes and 2) incorporating ICP monitoring in the care of patients with severe TBI will minimize complications and decrease length of intensive care unit stay. DISCUSSION This clinical trial tests the effectiveness of a management protocol based on technology considered pivotal to brain trauma treatment in the developed world: the ICP monitor. A randomized, controlled trial of ICP monitoring has never been performed-a critical gap in the evidence base that supports the role of ICP monitoring in TBI care. As such, the results of this randomized, controlled trial will have global implications regardless of the level of development of the trauma system.
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Affiliation(s)
- Randall M. Chesnut
- University of Washington, Harborview Medical Center, Departments of Neurological Surgery & Orthopaedics and Sports Medicine, 325 Ninth Ave, Box 359766, Seattle, WA 98104, Phone: 206-744-9322, Fax: 206-744-9943
| | - Nancy Temkin
- University of Washington, Harborview Medical Center, Departments of Neurological Surgery & Biostatistics, 325 Ninth Ave, Box 359766, Seattle, WA 98104, Phone: 206-744-9322, Fax: 206-744-9943
| | - Nancy Carney
- Oregon Health & Science University, Department of Medical Informatics and Clinical Epidemiology, 3181 SW Sam Jackson Park Road, Portland, OR 97239, Phone: 503-494-0663, Fax: 503-494-4551
| | - Sureyya Dikmen
- University of Washington, Harborview Medical Center, Departments of Rehabilitation Medicine & Neurological Surgery, 325 Ninth Ave, Box 359766, Seattle, WA 98104, Phone: 206-744-9322, Fax: 206-744-9943
| | - Jim Pridgeon
- University of Washington, Harborview Medical Center, Department of Neurological Surgery, 325 Ninth Ave, Box 359766, Seattle, WA 98104, Phone: 206-744-9322, Fax: 206-744-9943
| | - Jason Barber
- University of Washington, Harborview Medical Center, Department of Neurological Surgery, 325 Ninth Ave, Box 359766, Seattle, WA 98104, Phone: 206-744-9322, Fax: 206-744-9943
| | - Juanita M. Celix
- University of Washington, Harborview Medical Center, Department of Neurological Surgery, 325 Ninth Ave, Box 359766, Seattle, WA 98104, Phone: 206-744-9322, Fax: 206-744-9943
| | - Kelley Chaddock
- University of Washington, Harborview Medical Center, Department of Neurological Surgery, 325 Ninth Ave, Box 359766, Seattle, WA 98104, Phone: 206-744-9322, Fax: 206-744-9943
| | - Marianna Cherner
- University of California, San Diego, Department of Psychiatry, 9500 Gilman Drive, MC: 0603, La Jolla, CA 92093-0603, Phone: 619-543-5048 Fax: 619-543-1235
| | - Terence Hendrix
- Clinical Research Study Coordinator, HIV Neurobehavioral Research Programs (HNRP), University of California, San Diego, 220 Dickinson St., Suite B MC 8231, San Diego, CA 92103-8231, Phone: 619-543-8873, Fax: 619-543-1235
| | - Silvia Lujan
- Hospital de Emergencias, “Dr. Clemente Alvarez”, Pellegrini 3205, Rosario, Santa Fe, Argentina, Phone: 54-341-4808111, Fax: 54-341-4231087
| | - Joan Machamer
- University of Washington, Harborview Medical Center, Department of Rehabilitation Medicine, 325 Ninth Ave, Box 359766, Seattle, WA 98104, Phone: 206-744-9322, Fax: 206-744-9943
| | - Gustavo Petroni
- Hospital de Emergencias, “Dr. Clemente Alvarez”, Pellegrini 3205, Rosario, Santa Fe, Argentina, Phone: 54-341-4808111, Fax: 54-341-4231087
| | - Carlos Rondina
- Hospital de Emergencias, “Dr. Clemente Alvarez”, Pellegrini 3205, Rosario, Santa Fe, Argentina, Phone: 54-341-4808111, Fax: 54-341-4231087
| | - Walter Videtta
- Hospital Nacional Professor Alejandro Posadas, Acda. Illia y Marconi, El Palomar, Buenos Aires, Argentina, Phone: 54-114-4699290, Fax: 54-114-4699290
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25
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Carney N, Lujan S, Dikmen S, Temkin N, Petroni G, Pridgeon J, Barber J, Machamer J, Cherner M, Chaddock K, Hendrix T, Rondina C, Videtta W, Celix JM, Chesnut R. Intracranial pressure monitoring in severe traumatic brain injury in latin america: process and methods for a multi-center randomized controlled trial. J Neurotrauma 2012; 29:2022-9. [PMID: 22435793 DOI: 10.1089/neu.2011.2019] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
In patients with severe traumatic brain injury (TBI), the influence on important outcomes of the use of information from intracranial pressure (ICP) monitoring to direct treatment has never been tested in a randomized controlled trial (RCT). We are conducting an RCT in six trauma centers in Latin America to test this question. We hypothesize that patients randomized to ICP monitoring will have lower mortality and better outcomes at 6-months post-trauma than patients treated without ICP monitoring. We selected three centers in Bolivia to participate in the trial, based on (1) the absence of ICP monitoring, (2) adequate patient accession and data collection during the pilot phase, (3) preliminary institutional review board approval, and (4) the presence of equipoise about the value of ICP monitoring. We conducted extensive training of site personnel, and initiated the trial on September 1, 2008. Subsequently, we included three additional centers. A total of 176 patients were entered into the trial as of August 31, 2010. Current enrollment is 81% of that expected. The trial is expected to reach its enrollment goal of 324 patients by September of 2011. We are conducting a high-quality RCT to answer a question that is important globally. In addition, we are establishing the capacity to conduct strong research in Latin America, where TBI is a serious epidemic. Finally, we are demonstrating the feasibility and utility of international collaborations that share resources and unique patient populations to conduct strong research about global public health concerns.
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Affiliation(s)
- Nancy Carney
- Department of Medical Informatics and Clinical Epidemiology, Oregon Health and Science University, Portland, Oregon 97239, USA.
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26
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Affiliation(s)
| | - Sureyya Dikmen
- Department of Rehabilitation Medicine, University of Washington, Seattle, WA
- Department of Neurological Surgery, University of Washington, Seattle, WA
| | - Joan Machamer
- Department of Rehabilitation Medicine, University of Washington, Seattle, WA
| | | | - Nancy Temkin
- Department of Rehabilitation Medicine, University of Washington, Seattle, WA
- Department of Neurological Surgery, University of Washington, Seattle, WA
- Department of Biostatistics, University of Washington, Seattle, WA
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27
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Watson NF, Dikmen S, Machamer J, Doherty M, Temkin N. Hypersomnia following traumatic brain injury. J Clin Sleep Med 2007; 3:363-8. [PMID: 17694724 PMCID: PMC1978314] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/16/2023]
Abstract
STUDY OBJECTIVES To evaluate the prevalence and natural history of sleepiness following traumatic brain injury. METHODS This prospective cohort study used the Sickness Impact Profile to evaluate sleepiness in 514 consecutive subjects with traumatic brain injury (TBI), 132 non-cranial trauma controls, and 102 trauma-free controls 1 month and 1 year after injury. RESULTS Fifty-five percent of TBI subjects, 41% of non-cranial trauma controls, and 3% of trauma-free controls endorsed 1 or more sleepiness items 1 month following injury (p < .001). One year following injury, 27% of TBI subjects, 23% of non-cranial trauma controls, and 1% of trauma-free controls endorsed 1 or more sleepiness items (p < .001). Patients with TBI were sleepier than non-cranial trauma controls at 1 month (p < .02) but not 1 year after injury. Brain-injured subjects were divided into injury-severity groups based on time to follow commands (TFC). At 1 month, the non-cranial trauma controls were less sleepy than the 1- to 6-day (p < .05), 7- to 13-day (p < .01), and 14-day or longer (p < .01) TFC groups. In addition, the < or = 24-hour group was less sleepy then the 7- to 13-day and 14-day or longer groups (each p < .05). At 1 year, the non-cranial trauma control group (p < .05) and the < or = 24-hour TFC group (p < .01) were less sleepy than the 14-day or longer TFC group. Sleepiness improved in 84% to 100% of subjects in the TBI TFC groups, as compared with 78% of the non-cranial trauma control group (p < .01). CONCLUSIONS Sleepiness is common following traumatic injury, particularly TBI, with more severe injuries resulting in greater sleepiness. Sleepiness improves in many patients, particularly those with TBI. However, about a quarter of TBI subjects and non-cranial trauma control subjects remained sleepy 1 year after injury.
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Affiliation(s)
- Nathaniel F Watson
- Department of Neurology, University of Washington, Seattle, WA 98104-2499, USA.
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28
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Chaytor N, Temkin N, Machamer J, Dikmen S. The ecological validity of neuropsychological assessment and the role of depressive symptoms in moderate to severe traumatic brain injury. J Int Neuropsychol Soc 2007; 13:377-85. [PMID: 17445285 DOI: 10.1017/s1355617707070592] [Citation(s) in RCA: 39] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/26/2006] [Revised: 12/11/2006] [Accepted: 12/12/2006] [Indexed: 11/06/2022]
Abstract
Evaluating the ecological validity of neuropsychological tests has become an increasingly important topic. Previous research suggests that neuropsychological tests have a moderate level of ecological validity when predicting everyday functioning. The presence of depressive symptoms, however, may impact the relationship between neuropsychological tests and real world performance. The current study empirically tests this hypothesis in a sample of 216 participants with moderate to severe traumatic brain injury (TBI) who completed neuropsychological testing, self-report of mood symptoms, and report of everyday functioning six months post-injury. Contrary to some previous research and clinical lore, results indicated that depression was weakly related to neuropsychological test performance, although it was more strongly related to everyday functioning. Neuropsychological test performance was also significantly related to everyday functioning. The ecological validity of the neuropsychological tests together was not impacted by depressive symptoms, when predicting significant other ratings of functional status. However, patient self-report seems somewhat less related to neuropsychological performance in those with significant depressive symptoms. Neuropsychological test performance was equally related to self and other report of everyday functioning in patients without significant depressive symptoms.
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Affiliation(s)
- Naomi Chaytor
- Regional Epilepsy Center, Harborview Medical Center, Seattle, Washington 98104-2499, USA.
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Pagulayan KF, Temkin NR, Machamer J, Dikmen SS. A Longitudinal Study of Health-Related Quality of Life After Traumatic Brain Injury. Arch Phys Med Rehabil 2006; 87:611-8. [PMID: 16635622 DOI: 10.1016/j.apmr.2006.01.018] [Citation(s) in RCA: 97] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2005] [Revised: 01/13/2006] [Accepted: 01/17/2006] [Indexed: 11/18/2022]
Abstract
OBJECTIVE To examine the longitudinal course of health-related quality of life from 1 month to 3 to 5 years after traumatic brain injury (TBI). DESIGN Longitudinal cohort study with 4 evaluation points. SETTING Level I trauma center. PARTICIPANTS Consecutive hospital admissions of 133 adolescents and adults with complicated mild to severe TBI who completed the outcome measure at all 4 time points, 111 general trauma patients, and 87 healthy friend controls. INTERVENTIONS Not applicable. MAIN OUTCOME MEASURE Sickness Impact Profile. RESULTS TBI patients reported significant limitations at 1 month postinjury, with substantial improvement occurring by 6 months, especially in the physical domain. Psychosocial improvement was smaller, and perceived cognitive, emotional, and communication difficulties did not change over the time period assessed. Persons with TBI had clear difficulties relative to healthy peers, but their reported level of difficulties was very similar to that of the persons who had sustained a general trauma by 1 year postinjury. CONCLUSIONS In this sample, TBI was associated with significant early limitations in most aspects of everyday life. Considerable improvement was noted over the first 6 months postinjury, especially in physical domains. Some aspects of psychosocial functioning also improved, although reported limitations in communication, cognitive, and emotional domains remained constant over time. These findings highlight the persistence of injury-related difficulties that compromise quality of life.
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Affiliation(s)
- Kathleen F Pagulayan
- Department of Rehabilitation Medicine, University of Washington, Seattle, WA 98195, USA.
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30
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Abstract
Although substantial information exists about factors related to who returns to work and time taken to return to work after traumatic brain injury (TBI), less is known about the stability of the work experience after the injury. One hundred sixty-five workers with complicated mild to severe traumatic brain injury were followed for 3 to 5 years postinjury. Work stability definitions included amount of time worked (amount of time worked divided by time observed postinjury) and maintenance of uninterrupted employment once a person returned to work. Amount of time worked was significantly and systematically related to brain injury severity, neuropsychological functioning at l-month postinjury, and preinjury characteristics such as prior work stability and earnings. However, once persons returned to work, the ability to maintain uninterrupted employment was largely related to premorbid characteristics such as being older, higher income before the injury, or a preinjury job with benefits. It was also related to higher neuropsychological functioning at 1-month postinjury (reflecting the combined effects of premorbid functioning and traumatic brain injury severity), but not related to neurologic indices of severity.
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Affiliation(s)
- Joan Machamer
- Department of Rehabilitation Medicine, Box 356490, University of Washington, Seattle, WA 98195-6490, USA.
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31
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Abstract
OBJECTIVES To describe changes in drinking from before traumatic brain injury (TBI) to 1 year after TBI. DESIGN Inception cohort with 1-year follow-up. SETTING Level I trauma center. PARTICIPANTS Adults (N=197) hospitalized with a broad range of head injury severity. INTERVENTIONS Not applicable. MAIN OUTCOME MEASURES Alcohol consumption and alcohol-related problems. RESULTS Drinking and alcohol-related problems decreased substantially from preinjury to 1 year after TBI. However, about one quarter of the sample reported heavy drinking, significant problems, or both during the first year after TBI. Preinjury alcohol use and problems were highly predictive of heavy use and problems after TBI. CONCLUSION Although drinking and alcohol-related problems decreased after TBI, there appears to be an ongoing need for prevention and intervention efforts. Screening for preinjury alcohol problems can be used to identify the vast majority of persons who will develop alcohol-related problems within 1 year after injury.
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Affiliation(s)
- Charles H Bombardier
- Department of Rehabilitation Medicine, University of Washington School of Medicine, Seattle, WA, USA.
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32
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Abstract
Feelings of burden and factors related to it were examined in a sample of 180 relatives of moderately to severely traumatically brain injured (TBI) subjects 6 months postinjury. Relatives were enrolled onto the study based on their family member's head injury and not on outcome. The results indicate that although both positive and negative experiences were common, the majority of the relatives reported an overall positive experience. The significant other's (SO's) experience was significantly and systematically related to many factors with overall negative experience associated with increased brain injury severity, worse neuropsychological functioning, increased dependency on others, SO's report of changes in the TBI subject, changes in the SO's life as a result of caregiving and SO depression.
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Affiliation(s)
- Joan Machamer
- Department of Rehabilitation Medicine, University of Washington, Seattle 98195-6490, USA.
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33
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Abstract
While most would agree that mild traumatic brain injury (TBI) is associated with early neuropsychological problems, disagreement exists regarding their persistence and whether they are the cause of the disabilities experienced by some people. The aim of this study was to examine how the criteria used to define mild TBI and how the pre-injury characteristics of people affect their neuropsychological outcome. A total of 157 unselected hospitalized cases with Glasgow Coma Scale scores of 13-15 and 109 trauma controls were prospectively recruited and administered a number of cognitive measures at 1 month and 12 months after injury. The results indicated early impairments that decreased with time and the stringency of the definition of 'mild' TBI. The contribution of demographics was usually significant and often stronger than the mild TBI effect. Subtle variation of the demographics of the brain injured or the comparison subjects can be sufficient to mimic or mask mild brain injury effects.
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Affiliation(s)
- S Dikmen
- Department of Rehabilitation Medicine, University of Washington, Seattle, WA 98195, USA.
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Dikmen S, Machamer J, Miller B, Doctor J, Temkin N. Functional status examination: a new instrument for assessing outcome in traumatic brain injury. J Neurotrauma 2001; 18:127-40. [PMID: 11229707 DOI: 10.1089/08977150150502578] [Citation(s) in RCA: 83] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
The Functional Status Examination (FSE) is a new measure designed to evaluate change in activities of everyday life as a function of an event or illness, including traumatic brain injury. The measure covers physical, social, and psychological domains. The FSE is based on a structured interview and includes levels of functioning that accommodate the full spectrum of possible outcomes, from death through recovery to preinjury functioning. Based on 133 prospectively studied patients with moderate to severe traumatic brain injury, the FSE has favorable psychometric properties including good test-retest reliability (r = 0.80) and close correspondence of assessments provided by the patient and their significant other (SO; r = 0.80). The FSE correlated significantly with each of three severity indices with closest relationships occurring between the FSE assessed by the SO and posttraumatic amnesia (r = 0.76). The FSE assessed by the SO was significantly (p < 0.05) more closely related to each severity index than the Glasgow Outcome Scale (GOS) or Sickness Impact Profile and, for two of the three indices, than the SF-36. All measures showed significant change from 1 to 6 months after injury with the FSE showing the largest effect sizes. The FSE is significantly related to important constructs such as family burden, SO depression, and sacrifices the family makes, as well as overall indices of recovery and satisfaction with level of functioning. The latter relationships are significantly stronger than for the GOS. The FSE has demonstrated good reliability, validity, and sensitivity, and appears to be a promising instrument for monitoring recovery and assessing functional status in clinical trials.
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Affiliation(s)
- S Dikmen
- Department of Rehabilitation Medicine, University of Washington, Seattle 98195-6490, USA.
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Abstract
OBJECTIVES To examine emotional and behavioral adjustment and recovery over 1 year after traumatic brain injury (TBI), and to determine whether the difficulties, if present, are due to neurologic insult. DESIGN Longitudinal evaluation of adjustment from 1 month to 1 year after injury. SETTING Level I trauma center at a university hospital. PATIENTS One hundred fifty-seven consecutively hospitalized adults with TBI and 125 trauma controls with other system injuries evaluated at 1 and 12 months after injury. MAIN OUTCOME MEASURES Katz Adjustment Scale (KAS). RESULTS The TBI group at 1 year follow-up demonstrated significant emotional and behavioral maladjustment, but such difficulties did not appear to be mediated by the brain injury, since the KAS scores for the TBI and trauma control groups were not significantly different. Those with moderate TBI reported greater difficulties than those with mild or severe injuries. Changes in adjustment over 1 year were common for both groups. Within the TBI group there was differential recovery: improvement in cognitive clarity, dysphoric mood, and emotional stability, but increased difficulties with anger management, antisocial behaviors, and self-monitoring. CONCLUSIONS These results raise questions about commonly held beliefs that those with mild TBI report greater distress, and clarify some misconceptions regarding change in emotional and behavioral functioning over time.
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Affiliation(s)
- R A Hanks
- Department of Rehabilitation Medicine, University of Washington, Seattle, USA
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Abstract
Psychosocial outcome and recovery of a group of 31 consecutive adult patients with moderate to severe head injuries were prospectively investigated over a 2-year period. A friend control group was used for comparison purposes. We conclude that moderate and severe head injuries have a significant long-term impact on psychosocial functioning. More specifically, although there is an increase over time in the number of subjects who resume former levels of activity, many moderate to severely head-injured people remain unable to work, support themselves financially, live independently and participate in pre-injury leisure activities at least up to 2 years post-injury. Initially, self-perceived limitations in everyday functioning are widespread, with physical functioning being of primary concern. Over time, there is improvement in both physical and psychosocial areas. However, in spite of improvement, difficulties in psychosocial functioning become dominant later due to greater improvement in the physical area. This study gives no evidence of general increase in emotional distress with increasing time since injury.
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Affiliation(s)
- S Dikmen
- Department of Rehabilitation Medicine, University of Washington, Seattle 98195
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Dikmen SS, Temkin NR, Miller B, Machamer J, Winn HR. Neurobehavioral effects of phenytoin prophylaxis of posttraumatic seizures. JAMA 1991; 265:1271-7. [PMID: 1995974] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
In order to determine potential negative neurobehavioral effects of phenytoin given to prevent the development of posttraumatic seizures, 244 subjects were randomized to phenytoin or placebo. They received neurobehavioral assessments at 1 and 12 months postinjury while receiving their assigned drug and at 24 months while receiving no drugs. In the severely injured, phenytoin significantly impaired performance at 1 month. No significant differences were found as a function of phenytoin in the moderately injured patients at 1 month or in either severity group at 1 year. Patients who stopped receiving phenytoin according to protocol between 1 and 2 years improved more than corresponding placebo cases on several measures. We conclude that phenytoin has negative cognitive effects. This, combined with lack of evidence for its effectiveness in preventing posttraumatic seizures beyond the first week, raises questions regarding its use for long-term prophylaxis. Our findings do not negate phenytoin's proven efficacy in controlling established seizures nor do they indicate that its cognitive effects are worse than other anticonvulsant drugs.
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Affiliation(s)
- S S Dikmen
- Department of Rehabilitation Medicine, University of Washington, Seattle 98195
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Abstract
Neuropsychological outcome and recovery of a group of 31 consecutive adult patients with moderate to severe head injuries were prospectively investigated over a 2-year period. A friend control group was used for comparison purposes. Based on the results we conclude: (1) there is marked impairment of a broad spectrum of neuropsychological functions at 1, 12, and 24 months postinjury; (2) coma length is significantly related to neuropsychological status at all three time periods, although the relationship is weaker at 12 and 24 months; (3) marked improvement in all functions occurs in the first year, while recovery in the second year appears more specific and may depend on the severity of the injury and type of function; (4) practice effects and variability over repeated measures cause difficulties in determining recovery and need to be addressed with larger samples.
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Affiliation(s)
- S Dikmen
- Department of Rehabilitation Medicine, University of Washington, Seattle 98195
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Temkin NR, Dikmen S, Machamer J, McLean A. General versus disease-specific measures. Further work on the Sickness Impact Profile for head injury. Med Care 1989; 27:S44-53. [PMID: 2921886] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
Three modifications devised to make the Sickness Impact Profile more sensitive to head injury are evaluated in 202 head-injured and 132 general trauma patients 1 month and 12 months after injury. The modifications consist of adding items, deleting nonapplicable items, and reweighting areas of function. Each of the modifications, and especially all three combined, slightly but significantly improve discrimination of head-injured and comparison subjects and increase correlations with neurologic and neuropsychologic severity indexes. These slight improvements occur more often at 12 months than at 1 month and among those without rather than with pre-existing conditions. No improvements are found in the ability to classify patients into subgroups. The modifications fail to make improvements sufficiently large or consistent to provide a practical advantage over the SIP. The standard SIP provides a reasonable measure of psychosocial functioning following head injury. It relates to head injury and other system injury severity and reflects recovery with time. The SIP score relates to emotional functioning even after injury severity has been taken into account. Until other factors, such as emotional status and responses style, are better controlled, little benefit is likely to be obtained from creating disease-specific psychosocial measures.
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Affiliation(s)
- N R Temkin
- Department of Neurological Surgery, University of Washington, Seattle 98104
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Abstract
One hundred and two consecutive head injured patients were studied at 1 and 12 months after injury. Their performances were compared with a group of uninjured friends. The results indicate that impairment in memory depends on the type of task used, time from injury to testing, and on the severity of head injury (that is, degree of impaired consciousness). Head injury severity indices are more closely related to behavioural outcome early as compared with later after injury. At 1 year, only those with deep or prolonged impaired consciousness (as represented by greater than 1 day of coma, Glasgow Coma Scale of 8 or less, and post traumatic amnesia of 2 weeks or greater) are performing significantly worse than comparison subjects.
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Affiliation(s)
- S Dikmen
- Department of Rehabilitation Medicine, University of Washington, Seattle 98195
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