Potential for recovery between 4 and 8 years after a severe traumatic brain injury. Data from the PariS-TBI longitudinal study

BACKGROUND

Severe traumatic brain injury (TBI) is a leading cause of complex and persistent disability. Yet, long-term change in global functioning and determinants of this change remain unclear.

OBJECTIVES

This study aimed to assess change in global functioning in the long-term after severe TBI and factors associated with the change.

METHODS

This was a prospective observational study of an inception cohort of adults with severe TBI in the Paris area (PariS-TBI). Outcome was assessed at 1, 4 and 8 years post-injury. For the included participants (n=257), change in global outcome between 4 and 8 years was evaluated with the Glasgow Outcome Scale Extended (GOSE) score, and its association with pre-injury, injury-related and post-injury variables was tested with univariate and multivariable analyses.

RESULTS

More than half of the 73 participants evaluated at both 4 and 8 years showed global improvement (of at least one point) in GOSE score and an improvement in mood, executive function, and subjective complaints. On univariate analysis, none of the pre-injury, injury or post-injury variables were associated with GOSE score change between 4 and 8 years, except for GOSE score at 4 years (rho=-0.24, P=0.04). On multivariable analysis, probability of increased GOSE score was associated with more years of education (odds ratio 1.18 [95% confidence interval 1.02-1.37], P=0.03). The change in GOSE score was significantly correlated with change in Hospital Anxiety Depression Scale score between 4 and 8 years (rho=-0.42, P<0.001).

CONCLUSIONS

Most participants with severe TBI in the present sample showed a late improvement (4 to 8 years post-injury) in global functioning. Of the socio-demographic and injury-related factors, only more years of education was associated with improvement in global functioning. Decreased anxiety and depression symptoms were associated with improved global functioning. Targeting interventions to enhance resilience may be the most effective in the long-term after severe TBI.

Effect of Systematic Intensive Care Unit Triage on Long-term Mortality Among Critically Ill Elderly Patients in France: A Randomized Clinical Trial

IMPORTANCE

The high mortality rate in critically ill elderly patients has led to questioning of the beneficial effect of intensive care unit (ICU) admission and to a variable ICU use among this population.

OBJECTIVE

To determine whether a recommendation for systematic ICU admission in critically ill elderly patients reduces 6-month mortality compared with usual practice.

DESIGN, SETTING, AND PARTICIPANTS

Multicenter, cluster-randomized clinical trial of 3037 critically ill patients aged 75 years or older, free of cancer, with preserved functional status (Index of Independence in Activities of Daily Living ≥4) and nutritional status (absence of cachexia) who arrived at the emergency department of one of 24 hospitals in France between January 2012 and April 2015 and were followed up until November 2015.

INTERVENTIONS

Centers were randomly assigned either to use a program to promote systematic ICU admission of patients (n=1519 participants) or to follow standard practice (n=1518 participants).

MAIN OUTCOMES AND MEASURES

The primary outcome was death at 6 months. Secondary outcomes included ICU admission rate, in-hospital death, functional status, and quality of life (12-Item Short Form Health Survey, ranging from 0 to 100, with higher score representing better self-reported health) at 6 months.

RESULTS

One patient withdrew consent, leaving 3036 patients included in the trial (median age, 85 [interquartile range, 81-89] years; 1361 [45%] men). Patients in the systematic strategy group had an increased risk of death at 6 months (45% vs 39%; relative risk [RR], 1.16; 95% CI, 1.07-1.26) despite an increased ICU admission rate (61% vs 34%; RR, 1.80; 95% CI, 1.66-1.95). After adjustments for baseline characteristics, patients in the systematic strategy group were more likely to be admitted to an ICU (RR, 1.68; 95% CI, 1.54-1.82) and had a higher risk of in-hospital death (RR, 1.18; 95% CI, 1.03-1.33) but had no significant increase in risk of death at 6 months (RR, 1.05; 95% CI, 0.96-1.14). Functional status and physical quality of life at 6 months were not significantly different between groups.

CONCLUSIONS AND RELEVANCE

Among critically ill elderly patients in France, a program to promote systematic ICU admission increased ICU use but did not reduce 6-month mortality. Additional research is needed to understand the decision to admit elderly patients to the ICU.

TRIAL REGISTRATION

clinicaltrials.gov Identifier: NCT01508819.

Self-awareness four years after severe traumatic brain injury: discordance between the patient’s and relative’s complaints. Results from the PariS-TBI study

Objective:

To evaluate the patient’s awareness of his or her difficulties in the chronic phase of severe traumatic brain injury (TBI) and to determine the factors related to poor awareness.

Design/Setting/Subjects:

This study was part of a larger prospective inception cohort study of patients with severe TBI in the Parisian region (PariS-TBI study).

Intervention/Main measures:

Evaluation was carried out at four years and included the Brain Injury Complaint Questionnaire (BICoQ) completed by the patient and his or her relative as well as the evaluation of impairments, disability and quality of life.

Results:

A total of 90 patient-relative pairs were included. Lack of awareness was measured using the unawareness index that corresponded to the number of discordant results between the patient and relative in the direction of under evaluation of difficulties by the patient. The only significant relationship found with lack of awareness was the subjective burden perceived by the relative (Zarit Burden Inventory) ( r = 0.5; P < 0.00001). There was no significant relationship between lack of awareness and injury severity, pre-injury socio-demographic data, cognitive impairments, mood disorders, functional independence (Barthel index), global disability (Glasgow Outcome Scale), return to work at four years or quality of life (Quality Of Life after Brain Injury scale (QOLIBRI)).

Conclusion:

Lack of awareness four years post severe TBI was not related to the severity of the initial trauma, sociodemographic data, the severity of impairments, limitations of activity and participation, or the patient’s quality of life. However, poor awareness did significantly influence the weight of the burden perceived by the relative.

Employment outcome four years after a severe traumatic brain injury: results of the Paris severe traumatic brain injury study

OBJECTIVE

To describe employment outcome four years after a severe traumatic brain injury by the assessment of individual patients' preinjury sociodemographic data, injury-related and postinjury factors.

DESIGN

A prospective, multicenter inception cohort of 133 adult patients in the Paris area (France) who had received a severe traumatic brain injury were followed up postinjury at one and four years. Sociodemographic data, factors related to injury severity and one-year functional and cognitive outcomes were prospectively collected.

METHODS

The main outcome measure was employment status. Potential predictors of employment status were assessed by univariate and multivariate analysis.

RESULTS

At the four-year follow-up, 38% of patients were in paid employment. The following factors were independent predictors of unemployment: being unemployed or studying before traumatic brain injury, traumatic brain injury severity (i.e., a lower Glasgow Coma Scale score upon admission and a longer stay in intensive care) and a lower one-year Glasgow Outcome Scale-Extended score.

CONCLUSION

This study confirmed the low rate of long-term employment amongst patients after a severe traumatic brain injury. The results illustrated the multiple determinants of employment outcome and suggested that students who had received a traumatic brain injury were particularly likely to be unemployed, thus we propose that they may require specific support to help them find work. Implications for rehabilitation Traumatic brain injury is a leading cause of persistent disablity and can associate cognitive, emotional, physical and sensory impairments, which often result in quality-of-life reduction and job loss. Predictors of post-traumatic brain injury unemployment and job loss remains unclear in the particular population of severe traumatic brain injury patients. The present study highlights the post-traumatic brain injury student population require a close follow-up and vocational rehabilitation. The study suggests that return to work post-severe traumatic brain injury is frequently unstable and workers often experience difficulties that caregivers have to consider.

Designing and conducting a cluster-randomized trial of ICU admission for the elderly patients: the ICE-CUB 2 study

Background

The benefit of ICU admission for elderly patients remains controversial. This report highlights the methodology, the feasibility of and the ethical and logistical constraints in designing and conducting a cluster-randomized trial of intensive care unit (ICU) admission for critically ill elderly patients.

Methods

We designed an interventional open-label cluster-randomized controlled trial in 24 centres in France. Clusters were healthcare centres with at least one emergency department (ED) and one ICU. Healthcare centres were randomly assigned either to recommend a systematic ICU admission (intervention group) or to follow standard practices regarding ICU admission (control group). Clusters were stratified by the number of ED annual visits (<44,616 or >44,616 visits), the presence or absence of a geriatric ward and the geographical area (Paris area vs other regions in France). All elderly patients (≥75 years of age) who got to the ED were assessed for eligibility. Patients were included if they had one of the pre-established critical conditions, a preserved functional status as assessed by an ADL scale ≥4 (0 = very dependent, 6 = independent), a preserved nutritional status (subjectively assessed by physicians) and without active cancer. Exclusion criteria were an ED stay >24 h, a secondary referral to the ED and refusal to participate. The primary outcome was the mortality at 6 months calculated at the individual patient level. Secondary outcomes were ICU and hospital mortality, as well as ADL scale and quality of life (as assessed by the SF-12 Health Survey) at 6 months.

Results

Between January 2012 and April 2015, 3036 patients were included in the trial, 1518 patients in 11 clusters allocated to intervention group and 1518 patients in 13 clusters allocated to standard care. There were 51 protocol violations.

Conclusions

The ICE-CUB 2 trial was deemed feasible and ethically acceptable. The ICE-CUB 2 trial will be the first cluster-randomized trial to assess the benefits of ICU admission for selected elderly patients on long-term mortality.

Trial registration Clinical trials.gov identifier: NCT01508819

Electronic supplementary material

The online version of this article (doi:10.1186/s13613-016-0161-5) contains supplementary material, which is available to authorized users.

Referral to Rehabilitation After Severe Traumatic Brain Injury

Background. After a severe traumatic brain injury (TBI), some patients are discharged home without rehabilitation, although rehabilitation is assumed to improve outcome. Objective. To assess factors that predict referral to rehabilitation following acute care. This study is part of a larger inception cohort study assessing the care network in the Parisian area (France). Methods. Between July 2005 and April 2007, 504 adults with severe TBI (Glasgow Coma Scale score ≤8) were prospectively recruited by mobile emergency services. This study included 254 acute care survivors (80% male, median age 32 years). Data regarding demographics, injury severity, and acute care pathway were collected. The first analysis compared patients referred to a rehabilitation facility with patients discharged to a living place. The second analysis compared patients referred to a specialized neurorehabilitation (NR) facility with patients referred to nonspecialized rehabilitation. Univariate and multivariate statistics were computed. Results. In all, 162 patients (64%) were referred to rehabilitation, 115 (45%) of which were referred to NR and 47 (19%) to nonspecialized rehabilitation. The following factors were significantly predictive of nonreferral to rehabilitation: living alone, a lower income professional category, pretraumatic alcohol abuse, lower TBI severity, and transfer through a nonspecialized medical ward before discharge. Patients referred to specialized NR were significantly younger and from a higher income professional category. Conclusions. These results raise concern regarding care pathways because many patients were discharged to living places, probably without adequate assessment and management of rehabilitation needs. Injury severity and social characteristics influenced discharge destination.