Clinical Epidemiology of Extracranial Injuries in Severe Pediatric Traumatic Brain Injury in South America

BACKGROUND

Severe traumatic brain injury (TBI) is a leading cause of pediatric mortality, with a disproportionate burden on low- and middle-income countries. The impact of concomitant extracranial injury (ECI) on these patients remains unclear. This study is the first to characterize the epidemiology and clinical course of severe pediatric TBI with extracranial injuries in any South American country.

METHODS

We conducted a secondary analysis of baseline data collected prior to implementation of a clinical trial on TBI care in Argentina, Paraguay, and Chile from September 2019 to July 2020. Patients ≤18 years with CT evidence of TBI, and a Glasgow coma scale (GCS) score ≤8 were recruited. Patients were initially stratified by highest non-head abbreviated injury scale (AIS): isolated TBI (AIS=0), minor extracranial injury (MEI; AIS=1-2), and serious extracranial injury (SEI; AIS≥3). Patients were subsequently stratified by mechanism of injury. Intergroup differences were compared using ANOVA, two-tailed unpaired t-tests, and chi-square tests.

RESULTS

Among the 116 children included, 33 % (n = 38) had an isolated TBI, 34 % (n = 39) had MEI, and 34 % (n = 39) had SEI. Facial (n = 53), thoracic (n = 44), and abdominal (n = 31) injuries were the most common ECIs. At discharge, there were no significant differences in median GCS, GOS, or GOS-extended between groups. Patients with SEI had a longer hospital LOS than those with isolated TBI (median 28.0 (IQR 10.6-40.1) vs 11.9 (IQR 8.7-20.7) days, p = 0.013). The most common mechanisms of injury were road traffic injuries (RTIs) (n = 50, 43 %) and falls (n = 35, 30 %). Patients with RTI-associated TBIs were more likely to be older (median 11.0 (IQR 3.0-14.0) vs 2.0 (IQR 0.8-7.0) years, p<0.001) and more likely to have an ECI (86% vs 54 %, respectively; p = 0.003). ICU and Hospital LOS for RTI patients (median 10.5 (IQR 6.1-21.1) and 24.1 (IQR 11.5-40.4) days) were longer than those of fall patients (median 6.1 (IQR 2.6-8.9) and 13.7 (IQR 7.7-24.5) days).

CONCLUSIONS

Extracranial injuries are common in South American patients with severe TBI. Severe ECI is more frequently associated with RTIs and can result in a higher rate of surgical procedures and LOS. Further strategies are needed to characterize the prevention and treatment of severe pediatric TBI in the South American context.

Fatigue and health-related quality of life in paroxysmal nocturnal haemoglobinuria: a post-hoc analysis of the pegcetacoplan PEGASUS trial data

OBJECTIVES

Paroxysmal nocturnal haemoglobinuria (PNH) is a rare, non-malignant haematological disorder associated with disabling fatigue and reduced health-related quality of life. Post-hoc analysis of PEGASUS phase 3 trial (NCT03500549) characterised improvements in patient-reported fatigue measured by Functional Assessment of Chronic Illness Therapy-Fatigue (FACIT-fatigue) instrument item-level ratings for pegcetacoplan and eculizumab for the treatment of PNH.

METHODS

Item-level responder analysis was conducted on a ≥2-level change from baseline (CFB) clinically important response (CIR) for the FACIT-fatigue 13 individual items rated on a 5-level Likert scale. We evaluated ≥2-level change against the minimal clinically important difference (MCID) of the FACIT-fatigue total score (≥5 points) and clinical parameters, haemoglobin (Hb; ≥1 g/dL) and normalised absolute reticulocyte count (ARC; 30-100 pg/cells). Logistic regressions estimated baseline-to-Week-16 FACIT-fatigue item-level transitional probabilities; Kaplan-Meier analysis estimated time to FACIT-fatigue item CIR.

RESULTS

Pegcetacoplan versus eculizumab was associated with significantly greater odds of Week 16 CIR across 8/13 items and on total score MCID (OR=11.19 [3.73:33.57]) and faster times to responses. The item-level CIR threshold also showed clinical relevance on Hb level and ARC normalization.

CONCLUSIONS

Compared with eculizumab, pegcetacoplan was associated with clinically meaningful greater improvements on a majority of FACIT-fatigue items. This article is protected by copyright. All rights reserved.

PEGASUS: the Design of an Intervention to Facilitate Shared Decision-making in Breast Reconstruction

Studies have found varying levels of satisfaction after breast reconstruction surgery with a substantial group of patients reporting some level of regret about their decision. The variable outcomes reported by women undergoing breast reconstruction surgery suggest a role for improved pre-operative communication and shared decision-making (SDM) between patient and health professional. Pragmatic approaches such as decision aids have been evaluated, but the aim of the Patient Expectations and Goals Assisting Shared Understanding of Surgery (PEGASUS) intervention is to facilitate closer interaction between the patient and clinical team. PEGASUS is a standardised two-stage process, in which patients' goals are first elicited, ranked in importance and recorded before being used to frame discussion and decision-making with the surgeon managing care. Following the Medical Research Council (MRC) model, feasibility and acceptability studies have already been reported and a 4-year multicentre randomised controlled trial of 180 participants is underway, (completion 2020). This paper therefore focuses on the design of the intervention itself, in line with recent advice that interventions, in comparison with evaluations, commonly lack a theoretical base and are often under reported. We report a retrospective application of the Capability, Opportunity, Motivation-Behaviour (COM-B) model to provide explicit detail of each step in the intervention design. This is intended to facilitate replication by other clinicians and to provide systematic guidance for others wishing to develop PEGASUS as a strategy for implementing SDM in other clinical populations. Trial Registration: ISRCTN 18000391 (DOI 10.1186/ISRCTN18000391) 27/01/2016.

Functional decomposition-A contribution to overcome the parameter space explosion during validation of highly automated driving

Objective: Particular testing by functional decomposition of the automated driving function can potentially contribute to reducing the effort of validating highly automated driving functions. In this study, the required size of test suites for scenario-based testing and the potential to reduce it by functional decomposition are quantified for the first time. Methods: The required size of test suites for scenario-based approval of a so-called Autobahn-Chauffeur (SAE Level 3) is analyzed for an exemplary set of scenarios. Based on studies of data from failure analyses in other domains, the possible range for the required test coverage is narrowed down and suitable discretization steps, as well as ranges for the influence parameters, are assumed. Based on those assumptions, the size of the test suites for testing the complete system is quantified. The effects that lead to a reduction in the parameter space for particular testing of the decomposed driving function are analyzed and the potential to reduce the validation effort is estimated by comparing the resulting test suite sizes for both methods. Results: The combination of all effects leads to a reduction in the test suites' size by a factor between 20 and 130, depending on the required test coverage. This means that the size of the required test suite can be reduced by 95-99% by particular testing compared to scenario-based testing of the complete system. Conclusions: The reduction potential is a valuable contribution to overcome the parameter space explosion during the validation of highly automated driving. However, this study is based on assumptions and only a small set of exemplary scenarios. Thus, the findings have to be validated in further studies.

Facilitating shared decision-making with breast augmentation patients: Acceptability of the PEGASUS intervention

BACKGROUND

PEGASUS is an intervention to facilitate shared decision-making by helping prospective patients consider their expectations of surgery, so that surgeons have a clear understanding of their individual goals. To date, shared decision-making interventions within aesthetic surgery are lacking. The present mixed methods study therefore explored the acceptability of implementing PEGASUS into routine private practice with breast augmentation patients and aesthetic providers.

METHOD

Seventeen women presenting for breast augmentation surgery from three practices received the PEGASUS intervention pre-operatively and completed a process evaluation post-operatively. Semi-structured interviews exploring 3 aesthetic providers' experiences of using PEGASUS were subjected to a thematic analysis, whilst a content analysis was conducted on the 77 goals identified by patients.

RESULTS

The majority of patients reported that the PEGASUS intervention was relevant, helpful and useful, and they felt comfortable during it. Qualitatively, patients and aesthetic providers found that PEGASUS enabled them to reflect on and discuss about their expectations from surgery. Aesthetic providers discussed some of the issues and barriers associated with implementing PEGASUS in routine private practice, factors that must be considered prior to further evaluation.

CONCLUSION

This study provides preliminary support for the acceptability of PEGASUS to breast augmentation patients and to aesthetic providers working in the private sector.

The acceptability of PEGASUS: an intervention to facilitate shared decision-making with women contemplating breast reconstruction

Good practice guidelines recommend that women who undergo mastectomy are offered reconstructive surgery. However, many who choose this option report a degree of decisional regret and dissatisfaction because their pre-surgical expectations were not met. This paper reports an acceptability study of a new intervention (PEGASUS) that aims to support shared decision-making by eliciting women's pre-surgical expectations and setting patient-centred goals. Eighteen women contemplating breast reconstruction completed the PEGASUS intervention. Semi-structured interviews were conducted with 12 women and 3 health professionals to explore their experiences of using PEGASUS. Interview transcripts were subjected to a thematic analysis, and a content analysis was conducted on 79 goals that the 18 women identified. Feedback was extremely positive--women found that completing PEGASUS alongside a discussion with a specially trained health professional helped them prepare for the surgical consultation and increased their trust in their surgeon. Staff reported that PEGASUS facilitated patient-centred discussions and informed the decisions made about potential surgery. This preliminary study suggests that this novel intervention is acceptable to patients and health professionals alike. Further work is needed to evaluate its efficacy and then its effectiveness with a larger sample of women, and its potential use with other patient groups.