Patient costs and patient flow after implementation of S100B in Scandinavian head trauma guidelines

INTRODUCTION

The serum biomarker S100B has been implemented in the Scandinavian Neurotrauma Committee (SNC) 2013 Head Injury Guidelines for patients classified with mild head injury (MHI). Patients with a serum S100B level less-than 0.10 μg/l sampled within six hours after trauma can be discharged without further observation or investigation. The aim of this study was to examine the influence of S100B implementation on patient costs and patient flow in an emergency department.

METHODS

In this retrospective study, we included MHI patients (≥ 18 years) admitted to Rigshospitalet, Copenhagen, Denmark, between 1 February 2013 and 31 January 2014. Medical records were examined for the time of trauma, time of S100B sampling, serum S100B level, the severity of the head injury, clinical symptoms, radiological examinations, hospitalisation, discharge, surgical intervention, readmission and mortality.

RESULTS

Among 2,033 patients screened for potential study candidates, 227 patients met the inclusion criteria and were enrolled in the study. Among these patients, 119 (52%) were not treated according to SNC 2013 Head Injury Guidelines, leaving 108 (48%) with full guideline adherence. Compared with MHI management without S100B, implementation of S100B produced an additional cost of €1.26 per patient. Overall, the addition of S100B did not affect the waiting time for examination with S100B sampling or CT.

CONCLUSION

The use of S100B in the SNC 2013 Head Injury Guidelines did not reduce patient costs, nor did it cause substantial additional patient costs or delayed patient flow.

FUNDING

none.

TRIAL REGISTRATION

The Danish Data Protection Agency (journal number 2012-58-0004 and I-suite number RH-2017-164).

Copenhagen Head Injury Ciclosporin Study: A Phase IIa Safety, Pharmacokinetics, and Biomarker Study of Ciclosporin in Severe Traumatic Brain Injury Patients

Traumatic brain injury (TBI) contributes to almost one third of all trauma-related deaths, and those that survive often suffer from long-term physical and cognitive deficits. Ciclosporin (cyclosporine, cyclosporin A) has shown promising neuroprotective properties in pre-clinical TBI models. The Copenhagen Head Injury Ciclosporin (CHIC) study was initiated to establish the safety profile and pharmacokinetics of ciclosporin in patients with severe TBI, using a novel parenteral lipid emulsion formulation. Exploratory pharmacodynamic study measures included microdialysis in brain parenchyma and protein biomarkers of brain injury in the cerebrospinal fluid (CSF). Sixteen adult patients with severe TBI (Glasgow Coma Scale 4–8) were included, and all patients received an initial loading dose of 2.5 mg/kg followed by a continuous infusion for 5 days. The first 10 patients received an infusion dosage of 5 mg/kg/day whereas the subsequent 6 patients received 10 mg/kg/day. No mortality was registered within the study duration, and the distribution of adverse events was similar between the two treatment groups. Pharmacokinetic analysis of CSF confirmed dose-dependent brain exposure. Between- and within-patient variability in blood concentrations was limited, whereas CSF concentrations were more variable. The four biomarkers, glial fibrillary acidic protein, neurofilament light, tau, and ubiquitin carboxy-terminal hydrolase L1, showed consistent trends to decrease during the 5-day treatment period, whereas the samples taken on the days after the treatment period showed higher values in the majority of patients. In conclusion, ciclosporin, as administered in this study, is safe and well tolerated. The study confirmed that ciclosporin is able to pass the blood–brain barrier in a TBI population and provided an initial biomarker-based signal of efficacy.

[A Scandinavian guideline for initial management of minimal, mild and moderate head trauma in children]

The Scandinavian Neurotrauma Committee has recently published an evidence- and consensus-based guideline for the management of minor and moderate head trauma in children. They aim is to select children for computed tomography (CT) scan, observation or early discharge, with the attempt to reduce the number of CT scans in children without missing any significant intracranial injury in need for treatment. A flow chart of the guidelines and a help sheet has been developed for clinical use. Suggestions for in-hospital observation and parental information are also presented. We present the guideline in Danish.

Anticoagulation therapy a risk factor for the development of chronic subdural hematoma

OBJECTIVE

Chronic subdural hematoma (CSDH) is a common disease among the elderly and with increasing incidence we have chosen to focus on associations between development and recurrence of CSDH and anticoagulation and/or antiplatelet agent therapy.

METHODS

We conducted a retrospective review of 239 patients undergoing surgery for CSDH over a period of six years (2006-2011). Risk factors such as age, head trauma, anticoagulant and/or antiplatelet agent therapy and co-morbidity were investigated along with gender, coagulation status, laterality, surgical method and recurrence.

RESULTS

Seventy-two percent of the patients were male and the mean age was 71.8 years (range 28-97 years). Previous fall with head trauma was reported in 60% of the patients while 16% were certain of no previous head trauma. The majority of patients (63%) in the non-trauma group were receiving anticoagulants and/or antiplatelet agent therapy prior to CSDH presentation, compared to 42% in the trauma group. Twenty-four percent experienced recurrence of the CSDH. There was no association between recurrence and anticoagulant and/or antiplatelet agent therapy.

CONCLUSION

Anticoagulant and/or antiplatelet aggregation agent therapy is more prevalent among non-traumatic CSDH patients but does not seem to influence the rate of CSDH recurrence.

Protein S100B in Traumatic Brain Injury

Protein S100B is a small calcium-binding protein expressed in astroglial cells in the central nervous system. Its concentration increases in cerebrospinal fluid and blood after traumatic brain injury. There are several commercially available methods for analyzing serum S100B. The clinical use of serum S100B is mainly in minor head injury, as a complement to existing guidelines in order to help clinicians to determine who could safely be discharged without a previous CT scan. S100B in severe TBI is still being studied as a marker for secondary neurological complications, but has not yet had an impact in this specific area. Recent research on the clinical use of S100B in pediatric TBI has shown promising results, and the introduction of S100B in minor head injuries could have even greater impact than for adults. However, more research needs to be done before a biomarker can be clinically used in pediatric TBI.

Cognitive Impairment Questionnaire (CIMP-QUEST): reported topographic symptoms in MCI and dementia

OBJECTIVE

The Cognitive Impairment Questionnaire (CIMP-QUEST) is an instrument based on information obtained by key informants to identify symptoms of dementia and dementia-like disorders. The questionnaire consists of three subscales reflecting impairment in parietal-temporal (PT), frontal (F) and subcortical (SC) brain regions. The questionnaire includes a memory scale and lists non-cognitive symptoms. The reliability and validity of the questionnaire were examined in 131 patients with mild cognitive impairment (MCI) or mild dementia at a university-based memory unit.

METHODS/RESULTS

Cronbach alpha for all subscales was calculated at r = 0.90. Factor analysis supported the tri-dimensionality of CIMP-QUEST's brain region-oriented construct. Test-retest reliability for a subgroup of cognitively stable MCI-patients (n = 25) was found to be r = 0.83 (P = 0.0005). The correlation between the score on the cognitive subscales (PT + F + M) and Informant Questionnaire on Cognitive Decline in the Elderly was r = 0.83 (P = 0.0005, n = 123). The memory subscale correlated significantly with episodic memory tests, the PT subscale with visuospatial and language-oriented tests, and the SC and F subscales with tests of attention, psychomotor tempo and executive function.

CONCLUSIONS

CIMP-QUEST has high reliability and validity, and provides information about cognitive impairment and brain region-oriented symptomatology in patients with MCI and mild dementia.