Consensus-Based Development of a Global Registry for Traumatic Brain Injury: Establishment, Protocol, and Implementation

BACKGROUND AND OBJECTIVES

Global disparity exists in the demographics, pathology, management, and outcomes of surgically treated traumatic brain injury (TBI). However, the factors underlying these differences, including intervention effectiveness, remain unclear. Establishing a more accurate global picture of the burden of TBI represents a challenging task requiring systematic and ongoing data collection of patients with TBI across all management modalities. The objective of this study was to establish a global registry that would enable local service benchmarking against a global standard, identification of unmet need in TBI management, and its evidence-based prioritization in policymaking.

METHODS

The registry was developed in an iterative consensus-based manner by a panel of neurotrauma professionals. Proposed registry objectives, structure, and data points were established in 2 international multidisciplinary neurotrauma meetings, after which a survey consisting of the same data points was circulated within the global neurotrauma community. The survey results were disseminated in a final meeting to reach a consensus on the most pertinent registry variables.

RESULTS

A total of 156 professionals from 53 countries, including both high-income countries and low- and middle-income countries, responded to the survey. The final consensus-based registry includes patients with TBI who required neurosurgical admission, a neurosurgical procedure, or a critical care admission. The data set comprised clinically pertinent information on demographics, injury characteristics, imaging, treatments, and short-term outcomes. Based on the consensus, the Global Epidemiology and Outcomes following Traumatic Brain Injury (GEO-TBI) registry was established.

CONCLUSION

The GEO-TBI registry will enable high-quality data collection, clinical auditing, and research activity, and it is supported by the World Federation of Neurosurgical Societies and the National Institute of Health Research Global Health Program. The GEO-TBI registry ( https://geotbi.org ) is now open for participant site recruitment. Any center involved in TBI management is welcome to join the collaboration to access the registry.

An international, prospective observational study on traumatic brain injury epidemiology study protocol: GEO-TBI: Incidence

Background

The epidemiology of traumatic brain injury (TBI) is unclear - it is estimated to affect 27-69 million individuals yearly with the bulk of the TBI burden in low-to-middle income countries (LMICs). Research has highlighted significant between-hospital variability in TBI outcomes following emergency surgery, but the overall incidence and epidemiology of TBI remains unclear. To address this need, we established the Global Epidemiology and Outcomes following Traumatic Brain Injury (GEO-TBI) registry, enabling recording of all TBI cases requiring admission irrespective of surgical treatment.

Objective

The GEO-TBI: Incidence study aims to describe TBI epidemiology and outcomes according to development indices, and to highlight best practices to facilitate further comparative research.

Design

Multi-centre, international, registry-based, prospective cohort study.

Subjects

Any unit managing TBI and participating in the GEO-TBI registry will be eligible to join the study. Each unit will select a 90-day study period. All TBI patients meeting the registry inclusion criteria (neurosurgical/ICU admission or neurosurgical operation) during the selected study period will be included in the GEO-TBI: Incidence.

Methods

All units will form a study team, that will gain local approval, identify eligible patients and input data. Data will be collected via the secure registry platform and validated after collection. Identifiers may be collected if required for local utility in accordance with the GEO-TBI protocol.

Data

Data related to initial presentation, interventions and short-term outcomes will be collected in line with the GEO-TBI core dataset, developed following consensus from an iterative survey and feedback process. Patient demographics, injury details, timing and nature of interventions and post-injury care will be collected alongside associated complications. The primary outcome measures for the study will be the Glasgow Outcome at Discharge Scale (GODS) and 14-day mortality. Secondary outcome measures will be mortality and extended Glasgow Outcome Scale (GOSE) at the most recent follow-up timepoint.

Effect of high-flow nasal oxygen on hypoxaemia during procedural sedation: a systematic review and meta-analysis

We conducted a systematic review to evaluate the effect of high-flow nasal oxygen and conventional oxygen therapy during procedural sedation amongst adults and children. We searched MEDLINE, EMBASE and CINAHL for randomised controlled trials that reported the effects of high-flow nasal oxygen during procedural sedation. The primary outcome measure was hypoxaemia and the secondary outcomes were minimum oxygen saturation; hypercarbia; requirement for airway manoeuvres; and procedure interruptions. The quality of evidence was assessed using the revised Cochrane risk-of bias tool and grading of recommendations, assessment, development and evaluation (GRADE). Nineteen randomised controlled trials (4121 patients) including three in children were included. Administration of high-flow nasal oxygen reduced hypoxaemia, risk ratio (95%CI) 0.37 (0.24-0.56), p < 0.001; minor airway manoeuvre requirements, risk ratio (95%CI) 0.26 (0.11-0.59), p < 0.001; procedural interruptions, risk ratio (95%CI) 0.17 (0.05-0.53), p = 0.002; and increased minimum oxygen saturation, mean difference (95%CI) 4.1 (2.70-5.50), p < 0.001; as compared with the control group. High-flow nasal oxygen had no impact on hypercarbia, risk ratio (95%CI) 1.24 (0.97-1.58), p = 0.09, I²  = 0%. High-flow nasal oxygen reduced the incidence of hypoxaemia regardless of the procedure involved, degree of fractional inspired oxygen, risk-profile of patients and mode of propofol administration. The evidence was ascertained as moderate for all outcomes except for procedure interruptions. In summary, high-flow nasal oxygen compared with conventional oxygenation techniques reduced the risk of hypoxaemia, increased minimum oxygen saturation and reduced the requirement for airway manoeuvres. High-flow nasal oxygen should be considered in patients at risk of hypoxaemia during procedural sedation.

Pesticide induced changes of nitric oxide synthase in rat brain in vitro

Organic insecticides are well known neurotoxicants. Nitric oxide (NO) is a neurotransmitter formed stoicheometrically with citrulline from L-arqinine through mediation of the enzyme nitric oxide synthase (NOS). We measured NOS activity in rat brain in vitro in the presence of selected organic insecticides such as, 10-200 microM conc carbaryl, kepone and malathion. All these three compounds inhibited NOS activity of rat brain in vitro in a concentration dependent manner. In most cases the changes observed were statistically significant. The order of potency, based on IC50 values of these insecticides, to inhibit NOS activity of rat brain, is carbaryl (105 microM) > Kepone (144 microM) > malathion (170 microM). We further demonstrated that these insecticides inhibit calmodulin (CaM)-stimulated NOS activity without affecting the basal enzyme activity. It is reported that the observed inhibition of NOS by selected insecticides may be due to interaction of these insecticides with Ca2+/CaM on which the NOS activity is well known to be dependent. This ultimately may lead to neurotoxicity of rat brain.

Inhibition of rat brain nitric oxide synthase activity by cyclosporin-A

Cyclosporin-A, a potent immunosuppressive agent is known to induce cellular toxic side effects by way of altering calcium homeostasis, including calcium/calmodulin mediated events. We studied the in vitro and in vivo effects of cyclosporin-A on rat brain nitric oxide synthase activity (the enzyme that mediates the conversion of L-arginine to citrulline and NO). CsA in concentrations of 22-4400 nM inhibited rat brain NOS activity in vitro and in 10 or 25 mg/kg wt/4 weeks of CsA treated rat brains in vivo. We report here that CsA by way of interfering with rat brain Ca2+/CaM mediated events may inhibit its NOS activity which ultimately may result in neurotoxicity.

Cercal sensory regulation of ganglionic protein metabolism in the field cricket, Gryllotalpa africana

The effect of cercal deafferentation (cercectomy) on the ganglionic protein metabolism of the cricket, Gryllotalpa africana was studied. Significant changes in the activities of the enzymes acetylcholinesterase, glutamate dehydrogenase, alanine aminotransferase and aspartate aminotransferase were observed in the terminal ganglion following unilateral and bilateral cercectomy.

Cercal sensory regulation of acetylcholinesterase in nervous system of the cockroach, Periplaneta americana

Cercal ablation caused a significant loss in acetylcholinesterase (AChE) activity of the cercal nerves and terminal ganglion within 12 hr while a similar reduction in enzyme activity of connectives was noticed at least one day after cercectomy. The decrease in AChE activity of the nervous tissues showed a recovery toward control levels from 20 days of unilateral cercectomy whereas the bilateral cercectomy produced a continuous and irreversible decline in enzyme activity. These localized changes in AChE activity of the abdominal nervous system of the cockroach were attributed to be regulated by the cercal sensory innervation.

Nuclear magnetic resonance spectroscopy of plasma for the detection of head and neck cancer

The plasma of 15 normal volunteers, four patients with benign head and neck disease, and 12 patients with biopsy proven head and neck malignancies were evaluated using water-suppressed nuclear magnetic resonance (NMR) spectroscopy. While the mean full width at half height (HHLW) of the NMR spectra showed a significant difference between groups (P less than .05), the predictive value of a positive test was only 57% the sensitivity was only 33%, and individual values in all groups demonstrated considerable overlap. The mean HHLW of the control group was 38.5 Hz +/- 3.5 compared with 35.2 Hz +/- 4.7 for the cancer group and 35.0 Hz +/- 10 for the benign disease group. This method was not able to distinguish patients with malignancy from those with benign disease or controls. Its use as a specific screening method for head and neck malignancy cannot be recommended.