1
|
Sinha AK, Moye L, Piller LB, Yamal JM, Barcenas CH, Song J, Davis BR. Simultaneous population enrichment and endpoint selection in phase 3 randomized controlled trials: An adaptive group sequential design with two binary alternative primary endpoints. COMMUN STAT-THEOR M 2023. [DOI: 10.1080/03610926.2022.2163180] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Affiliation(s)
- Arup K. Sinha
- Department of Biostatistics, The University of Texas School of Public Health, Houston, Texas, USA
| | - Lemuel Moye
- Department of Biostatistics, The University of Texas School of Public Health, Houston, Texas, USA
| | - Linda B. Piller
- Division of Epidemiology, Human Genetics and Environmental Sciences, The University of Texas School of Public Health, Houston, Texas, USA
| | - Jose-Miguel Yamal
- Department of Biostatistics, The University of Texas School of Public Health, Houston, Texas, USA
| | - Carlos H. Barcenas
- Department of Breast Medical Oncology, Division of Cancer Medicine, MD Anderson Cancer Center, Houston, Texas, USA
| | - Jaejoon Song
- Department of Biostatistics, MD Anderson Cancer Center, Houston, Texas, USA
| | - Barry R. Davis
- Department of Biostatistics, The University of Texas School of Public Health, Houston, Texas, USA
| |
Collapse
|
2
|
Sinha AK, Moye L, Piller LB, Yamal J, Barcenas CH, Lin J, Davis BR. Adaptive group‐sequential design with population enrichment in phase 3 randomized controlled trials with two binary co‐primary endpoints. Stat Med 2019; 38:3985-3996. [DOI: 10.1002/sim.8216] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2018] [Revised: 04/28/2019] [Accepted: 05/09/2019] [Indexed: 11/11/2022]
Affiliation(s)
- Arup K. Sinha
- Department of Biostatistics, School of Public HealthYale University New Haven Connecticut
| | - Lemuel Moye
- Department of Biostatistics, School of Public HealthThe University of Texas Health Science Center at Houston Houston Texas
| | - Linda B. Piller
- Department of Epidemiology, Human Genetics, and Environmental Sciences, School of Public HealthThe University of Texas Health Science Center at Houston Houston Texas
| | - Jose‐Miguel Yamal
- Department of Biostatistics, School of Public HealthThe University of Texas Health Science Center at Houston Houston Texas
| | - Carlos H. Barcenas
- Department of Breast Medical Oncology, Division of Cancer MedicineThe University of Texas MD Anderson Cancer Center Houston Texas
| | | | - Barry R. Davis
- Department of Biostatistics, School of Public HealthThe University of Texas Health Science Center at Houston Houston Texas
| |
Collapse
|
3
|
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] [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.
Collapse
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
| |
Collapse
|
4
|
Allanson F, Pestell C, Gignac GE, Yeo YX, Weinborn M. Neuropsychological Predictors of Outcome Following Traumatic Brain Injury in Adults: a Meta-Analysis. Neuropsychol Rev 2017; 27:187-201. [DOI: 10.1007/s11065-017-9353-5] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2016] [Accepted: 06/06/2017] [Indexed: 11/29/2022]
|
5
|
Abstract
Objective measurement and quantification of injury severity are necessary for triage, performance evaluation and research. In order to evaluate interventions, outcomes must also be compared. While this can be done using hospital stay or mortality, these will fail to detect subtle differences. Impact of injury on health can be quantified using a variety of scoring systems. Trauma scoring and outcome measurement have grown increasingly complex in recent years and are likely to become more so in the future.
Collapse
Affiliation(s)
- MP Revell
- Royal Orthopaedic Hospital, Birmingham, UK,
| | - PB Pynsent
- Royal Orthopaedic Hospital, Birmingham, UK
| | - A Abudu
- Royal Orthopaedic Hospital, Birmingham, UK
| | | |
Collapse
|
6
|
Clinical Course Score (CCS): a new clinical score to evaluate efficacy of neurotrauma treatment in traumatic brain injury and subarachnoid hemorrhage. J Neurosurg Anesthesiol 2016; 27:26-30. [PMID: 24879534 DOI: 10.1097/ana.0000000000000083] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
BACKGROUND Neurotrauma continues to represent a challenging public health issue requiring continual improvement in therapeutic approaches. As no such current system exists, we present in this study the Clinical Course Score (CCS) as a new clinical score to evaluate the efficacy of neurotrauma treatment. METHODS The CCS was calculated in neurotrauma patients to be the difference between the grade of the Glasgow Outcome Scale 6 months after discharge from our department and the grade of a 1 to 5 point reduced Glasgow Coma Scale on admission. We assessed the CCS in a total of 248 patients (196 traumatic brain injury [TBI] patients and 52 subarachnoid hemorrhage [SAH] patients) who were treated in our Department of Neurosurgery between January 2011 and December 2012. RESULTS We found negative CCS grades both in mild TBI and in mild SAH patients. In patients with severe TBI or SAH, we found positive CCS grades. In SAH patients, we found higher CCS scores in younger patients compared with elderly subjects in both mild and severe cases. CONCLUSIONS The CCS can be useful in evaluating different therapeutic approaches during neurotrauma therapy. This new score might improve assessment of beneficial effects of therapeutic procedures.
Collapse
|
7
|
Affiliation(s)
| | - Sherman C Stein
- Department of NeurosurgeryUniversity of Pennsylvania, Philadelphia, PA, USA
| |
Collapse
|
8
|
Wilson JTL. Lessons from traumatic head injury for assessing functional status after brain tumour. J Neurooncol 2012; 108:239-46. [DOI: 10.1007/s11060-012-0812-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2011] [Accepted: 01/27/2012] [Indexed: 11/25/2022]
|
9
|
Measuring functional and quality of life outcomes following major head injury: common scales and checklists. Injury 2011; 42:281-7. [PMID: 21145059 DOI: 10.1016/j.injury.2010.11.047] [Citation(s) in RCA: 120] [Impact Index Per Article: 9.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/05/2010] [Accepted: 11/12/2010] [Indexed: 02/02/2023]
Abstract
Traumatic brain injury (TBI) is a major public health issue, which results in significant mortality and long term disability. The profound impact of TBI is not only felt by the individuals who suffer the injury but also their care-givers and society as a whole. Clinicians and researchers require reliable and valid measures of long term outcome not only to truly quantify the burden of TBI and the scale of functional impairment in survivors, but also to allow early appropriate allocation of rehabilitation supports. In addition, clinical trials which aim to improve outcomes in this devastating condition require high quality measures to accurately assess the impact of the interventions being studied. In this article, we review the properties of an ideal measure of outcome in the TBI population. Then, we describe the key components and performance of the measurement tools most commonly used to quantify outcome in clinical studies in TBI. These measurement tools include: the Glasgow Outcome Scale (GOS) and extended Glasgow Outcome Scale (GOSe); Disability Rating Scale (DRS); Functional Independence Measure (FIM); Functional Assessment Measure (FAM); Functional Status Examination (FSE) and the TBI-specific and generic quality of life measures used in TBI patients (SF-36 and SF-12, WHOQOL-BREF, SIP, EQ-5D, EBIQ, and QOLIBRI).
Collapse
|
10
|
Baker AJ, Rhind SG, Morrison LJ, Black S, Crnko NT, Shek PN, Rizoli SB. Resuscitation with hypertonic saline-dextran reduces serum biomarker levels and correlates with outcome in severe traumatic brain injury patients. J Neurotrauma 2010; 26:1227-40. [PMID: 19637968 DOI: 10.1089/neu.2008.0868] [Citation(s) in RCA: 58] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
In the treatment of severe traumatic brain injury (TBI), the choice of fluid and osmotherapy is important. There are practical and theoretical advantages to the use of hypertonic saline. S100B, neuron-specific enolase (NSE), and myelin-basic protein (MBP) are commonly assessed biomarkers of brain injury with potential utility as diagnostic and prognostic indicators of outcome after TBI, but they have not previously been studied in the context of fluid resuscitation. This randomized controlled trial compared serum concentrations of S100B, NSE, and MBP in adult severe TBI patients resuscitated with 250 mL of 7.5% hypertonic saline plus 6% dextran70 (HSD; n = 31) versus 0.9% normal saline (NS; n = 33), and examined their relationship with neurological outcome at discharge. Blood samples drawn on admission (<or=3 h post-injury), and at 12, 24, and 48 h post-resuscitation were assayed by ELISA for the selected biomarkers. Serial comparisons of biomarker concentrations were made by ANOVA, and relationships between biomarkers and outcome were assessed by multiple regression. On admission, mean (+/-SEM) S100B and NSE concentrations were increased 60-fold (0.73 +/- 0.08 microg/L) and sevenfold (37.0 +/- 4.8 microg/L), respectively, in patients resuscitated with NS, compared to controls (0.01 +/- 0.01 and 6.2 +/- 0.6, respectively). Compared with NS resuscitation, S100B and NSE were twofold and threefold lower in HSD-treated patients and normalized within 12 h. MBP levels were not significantly different from controls in either treatment arm until 48 h post-resuscitation, when a delayed increase (0.58 +/- 0.29 microg/L) was observed in NS-treated patients. Biomarkers were elevated in the patient group showing an unfavorable outcome. HSD-resuscitated patients with favorable outcomes exhibited the lowest serum S100B and NSE concentrations, while maximal levels were found in NS-treated patients with unfavorable outcomes. The lowest biomarker levels were seen in survivors resuscitated with HSD, while maximal levels were in NS-resuscitated patients with fatal outcome. Pre-hospital resuscitation with HSD is associated with a reduction in serum S100B, NSE, and MBP concentrations, which are correlated with better outcome after severe TBI.
Collapse
Affiliation(s)
- Andrew J Baker
- Brain Injury Laboratory, Cara Phelan Centre for Trauma Research, St. Michael's Hospital, University of Toronto, Toronto, Ontario, Canada.
| | | | | | | | | | | | | |
Collapse
|
11
|
Wagner J, Dusick JR, McArthur DL, Cohan P, Wang C, Swerdloff R, Boscardin WJ, Kelly DF. Acute gonadotroph and somatotroph hormonal suppression after traumatic brain injury. J Neurotrauma 2010; 27:1007-19. [PMID: 20214417 DOI: 10.1089/neu.2009.1092] [Citation(s) in RCA: 52] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
Hormonal dysfunction is a known consequence of moderate and severe traumatic brain injury (TBI). In this study we determined the incidence, time course, and clinical correlates of acute post-TBI gonadotroph and somatotroph dysfunction. Patients had daily measurement of serum luteinizing hormone (LH), follicle-stimulating hormone (FSH), testosterone, estradiol, growth hormone, and insulin-like growth factor-1 (IGF-1) for up to 10 days post-injury. Values below the fifth percentile of a healthy cohort were considered abnormal, as were non-measurable growth hormone (GH) values. Outcome measures were frequency and time course of hormonal suppression, injury characteristics, and Glasgow Outcome Scale (GOS) score. The cohort consisted of 101 patients (82% males; mean age 35 years; Glasgow Coma Scale [GCS] score <or=8 in 87%). In men, 100% had at least one low testosterone value, and 93% of all values were low; in premenopausal women, 43% had at least one low estradiol value, and 39% of all values were low. Non-measurable GH levels occurred in 38% of patients, while low IGF-1 levels were observed in 77% of patients, but tended to normalize within 10 days. Multivariate analysis revealed associations of younger age with low FSH and low IGF-1, acute anemia with low IGF-1, and older age and higher body mass index (BMI) with low GH. Hormonal suppression was not predictive of GOS score. These results indicate that within 10 days of complicated mild, moderate, and severe TBI, testosterone suppression occurs in all men and estrogen suppression occurs in over 40% of women. Transient somatotroph suppression occurs in over 75% of patients. Although this acute neuroendocrine dysfunction may not be TBI-specific, low gonadal steroids, IGF-1, and GH may be important given their putative neuroprotective functions.
Collapse
Affiliation(s)
- Justin Wagner
- University of Southern California Keck School of Medicine, Los Angeles, California, USA
| | | | | | | | | | | | | | | |
Collapse
|
12
|
Abstract
Preclinical as well as clinical studies in traumatic brain injury (TBI) have established the likely association of secondary injury and outcome in adults in children following severe injury. Similarly, there is growing evidence in experimental laboratory studies that moderate hypothermia has a beneficial effect on outcome, though the exact mechanisms remain to be absolutely defined. The Pediatric TBI Guidelines provided the knowledge and background for standard management of children following severe TBI and highlighted that there are very few clinical studies to date. In particular with respect to temperature regulation and the use of hypothermia, initial findings of case series of small numbers were promising. Further preliminary randomized clinical trials, both single institution and multicenter, have provided the initial data on safety and efficacy, though larger, Phase III studies are necessary to ensure both the safety and efficacy of hypothermia in pediatric TBI prior to implementation as part of the standard of care. It is expected that hypothermia initiated early after severe TBI will have a protective effect on the pediatric brain and can be done safely, but this still remains to be definitively tested.
Collapse
Affiliation(s)
- P David Adelson
- Children's Neuroscience Institute, Phoenix Children's Hospital, Phoenix, Arizona 85016, USA.
| |
Collapse
|
13
|
Lu J, Murray GD, Steyerberg EW, Butcher I, McHugh GS, Lingsma H, Mushkudiani N, Choi S, Maas AIR, Marmarou A. Effects of Glasgow Outcome Scale misclassification on traumatic brain injury clinical trials. J Neurotrauma 2008; 25:641-51. [PMID: 18578634 DOI: 10.1089/neu.2007.0510] [Citation(s) in RCA: 42] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
The Glasgow Outcome Scale (GOS) is the primary endpoint for efficacy analysis of clinical trials in traumatic brain injury (TBI). Accurate and consistent assessment of outcome after TBI is essential to the evaluation of treatment results, particularly in the context of multicenter studies and trials. The inconsistent measurement or interobserver variation on GOS outcome, or for that matter, on any outcome scales, may adversely affect the sensitivity to detect treatment effects in clinical trial. The objective of this study is to examine effects of nondifferential misclassification of the widely used five-category GOS outcome scale and in particular to assess the impact of this misclassification on detecting a treatment effect and statistical power. We followed two approaches. First, outcome differences were analyzed before and after correction for misclassification using a dataset of 860 patients with severe brain injury randomly sampled from two TBI trials with known differences in outcome. Second, the effects of misclassification on outcome distribution and statistical power were analyzed in simulation studies on a hypothetical 800-patient dataset. Three potential patterns of nondifferential misclassification (random, upward and downward) on the dichotomous GOS outcome were analyzed, and the power of finding treatments differences was investigated in detail. All three patterns of misclassification reduce the power of detecting the true treatment effect and therefore lead to a reduced estimation of the true efficacy. The magnitude of such influence not only depends on the size of the misclassification, but also on the magnitude of the treatment effect. In conclusion, nondifferential misclassification directly reduces the power of finding the true treatment effect. An awareness of this procedural error and methods to reduce misclassification should be incorporated in TBI clinical trials.
Collapse
Affiliation(s)
- Juan Lu
- Department of Neurosurgery, Virginia Commonwealth University, Richmond, VA, USA
| | | | | | | | | | | | | | | | | | | |
Collapse
|
14
|
Abstract
Traumatic brain injury (TBI) is considered the most important cause of disability among young people and the most common neurological cause of morbidity. Consequently, there is increasing interest in scales to monitor recovery in TBI. Among these scales, two have been widely adopted: the Glasgow Outcome Scale (GOS) and the Disability Rating Scale (DRS). The purpose of this paper is to compare the results found in DRS and in the original and extended GOS. Sixty-three closed-head injury victims, aged between 12 and 65, on an outpatient follow-up program at a trauma center in the city of São Paulo, with 6 months to 3 years post-TBI, had their characteristics and outcomes assessed. When comparing the results obtained by the scales, it was concluded that although the three of them were strongly correlated, extended GOS showed to be more sensitive in detecting changes in victims with better post-traumatic conditions.
Collapse
|
15
|
Adelson PD, Ragheb J, Kanev P, Brockmeyer D, Beers SR, Brown SD, Cassidy LD, Chang Y, Levin H. Phase II clinical trial of moderate hypothermia after severe traumatic brain injury in children. Neurosurgery 2006; 56:740-54; discussion 740-54. [PMID: 15792513 DOI: 10.1227/01.neu.0000156471.50726.26] [Citation(s) in RCA: 202] [Impact Index Per Article: 11.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2004] [Accepted: 12/02/2004] [Indexed: 11/19/2022] Open
Abstract
OBJECTIVE To determine whether moderate hypothermia (HYPO) (32-33 degrees C) begun in the early period after severe traumatic brain injury (TBI) and maintained for 48 hours is safe compared with normothermia (NORM) (36.5-37.5 degrees C). METHODS After severe (Glasgow Coma Scale score < or =8) nonpenetrating TBI, 48 children less than 13 years of age admitted within 6 hours of injury were randomized after stratification by age to moderate HYPO (32-33 degrees C) treatment in conjunction with standardized head injury management versus NORM in a multicenter trial. An additional 27 patients were entered into a parallel single-institution trial of excluded patients because of late transfer or consent (delayed in transfer >6 h but within 24 h of admission), unknown time of injury (e.g., child abuse), and adolescence (e.g., aged 13-18 yr). Assessments of safety included mortality, infection, coagulopathy, arrhythmias, and hemorrhage as well as ability to maintain target temperature, mean intracranial pressure (ICP), and percent time of ICP less than 20 mm Hg during the cooling and subsequent rewarming phases. Additionally, assessments of neurocognitive outcomes were obtained at 3 and 6 months of follow-up. RESULTS Moderate HYPO after severe TBI in children was found to be safe relative to standard management and NORM in children of all ages and in children with delay of initiation of treatment up to 24 hours. Although there was decreased mortality in HYPO in both studies, there was an increased potential for arrhythmias with HYPO, although they were manageable with fluid administration or rewarming. Additionally, there was a reduction in mean ICP during the first 72 hours after injury in both studies, although rebound ICP elevations in HYPO compared with those in NORM were noted for up to 10 to 12 hours after rewarming. Although functional outcome at 3 or 6 months did not differ between treatment groups, functional outcome tended to improve from the 3- to 6-month cognitive assessment in HYPO compared with NORM, although the sample size was too small for any definitive conclusions. CONCLUSION HYPO is likely a safe therapeutic intervention for children after severe TBI up to 24 hours after injury. Further studies are necessary and warranted to determine its effect on functional outcome and intracranial hypertension.
Collapse
Affiliation(s)
- P David Adelson
- Department of Neurosurgery, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA.
| | | | | | | | | | | | | | | | | |
Collapse
|
16
|
Cohan P, Wang C, McArthur DL, Cook SW, Dusick JR, Armin B, Swerdloff R, Vespa P, Muizelaar JP, Cryer HG, Christenson PD, Kelly DF. Acute secondary adrenal insufficiency after traumatic brain injury: a prospective study. Crit Care Med 2005; 33:2358-66. [PMID: 16215393 DOI: 10.1097/01.ccm.0000181735.51183.a7] [Citation(s) in RCA: 207] [Impact Index Per Article: 10.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
OBJECTIVE To determine the prevalence, time course, clinical characteristics, and effect of adrenal insufficiency (AI) after traumatic brain injury (TBI). DESIGN Prospective intensive care unit-based cohort study. SETTING Three level 1 trauma centers. PATIENTS A total of 80 patients with moderate or severe TBI (Glasgow Coma Scale score, 3-13) and 41 trauma patients without TBI (Injury Severity Score, >15) enrolled between June 2002 and November 2003. MEASUREMENTS Serum cortisol and adrenocorticotropic hormone levels were drawn twice daily for up to 9 days postinjury; AI was defined as two consecutive cortisols of < or =15 microg/dL (25th percentile for extracranial trauma patients) or one cortisol of < 5 microg/dL. Principal outcome measures included: injury characteristics, hemodynamic data, usage of vasopressors, metabolic suppressive agents (high-dose pentobarbital and propofol), etomidate, and AI status. MAIN RESULTS AI occurred in 42 TBI patients (53%). Adrenocorticotropic hormone levels were lower at the time of AI (median, 18.9 vs. 36.1 pg/mL; p = .0001). Compared with patients without AI, those with AI were younger (p = .01), had higher injury severity (p = .02), had a higher frequency of early ischemic insults (hypotension, hypoxia, severe anemia) (p = .02), and were more likely to have received etomidate (p = .049). Over the acute postinjury period, patients with AI had lower trough mean arterial pressure (p = .001) and greater vasopressor use (p = .047). Mean arterial pressure was lower in the 8 hrs preceding a low (< or =15 microg/dL) cortisol level (p = .003). There was an inverse relationship between cortisol levels and vasopressor use (p = .0005) and between cortisol levels within 24 hrs of injury and etomidate use (p = .002). Use of high-dose propofol and pentobarbital was strongly associated with lower cortisol levels (p < .0001). CONCLUSIONS Approximately 50% of patients with moderate or severe TBI have at least transient AI. Younger age, greater injury severity, early ischemic insults, and the use of etomidate and metabolic suppressive agents are associated with AI. Because lower cortisol levels were associated with lower blood pressure and higher vasopressor use, consideration should be given to monitoring cortisol levels in intubated TBI patients, particularly those receiving high-dose pentobarbital or propofol. A randomized trial of stress-dose hydrocortisone in TBI patients with AI is underway.
Collapse
Affiliation(s)
- Pejman Cohan
- Division of Neurosurgery, UCLA School of Medicine, University of California at Los Angeles, Los Angeles, CA, USA
| | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
17
|
Boto G, Gómez P, Lobato R, De la Cruz J. Revisión de los ensayos clínicos sobre prevención del daño neurológico en el traumatismo craneoencefálico grave y análisis de su fracaso terapéutico. Neurocirugia (Astur) 2005. [DOI: 10.1016/s1130-1473(05)70433-4] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
|
18
|
Barker FG, Amin-Hanjani S, Butler WE, Hoh BL, Rabinov JD, Pryor JC, Ogilvy CS, Carter BS. Age-dependent differences in short-term outcome after surgical or endovascular treatment of unruptured intracranial aneurysms in the United States, 1996-2000. Neurosurgery 2004; 54:18-28; discussion 28-30. [PMID: 14683537 DOI: 10.1227/01.neu.0000097195.48840.c4] [Citation(s) in RCA: 132] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2003] [Accepted: 08/12/2003] [Indexed: 11/19/2022] Open
Abstract
INTRODUCTION Unruptured intracranial aneurysm patients are frequently eligible for both open surgery ("clipping") and endovascular repair ("coiling"). We compared short-term end points (mortality, discharge disposition, complications, length of stay, and charges) for clipping and coiling in a nationally representative discharge database. METHODS We conducted a retrospective cohort study using Nationwide Inpatient Sample data from 1996 to 2000. Multivariate logistic regression analyses adjusted for age, sex, race, payer status, geographic region, presenting signs and symptoms, admission type and source, procedure timing, hospital caseload, and possible clustering of outcomes within hospitals. The results were confirmed by performing propensity score analysis. RESULTS A total of 3498 patients had clipping, and 421 underwent coiling. Clipped patients were slightly younger (P < 0.001). Medical comorbidity was similar between the groups. More clipped patients had urgent or emergency admissions (P = 0.02). More coiling procedures were performed on hospital Day 1 (P = 0.007). When only death and discharge to long-term care were counted as adverse outcomes, there was no significant difference between clipping and coiling. On the basis of a four-level discharge status outcome scale (dead, long-term care, short-term rehabilitation, or discharge to home), coiled patients had a significantly better discharge disposition (odds ratio, 2.1; P < 0.001). With regard to patient age, most of the difference in discharge disposition was in patients older than 65 years of age. The degree of difference between treatments increased from 1996 to 2000. Neurological complications were coded twice as frequently in clipped patients as in coiled patients (P = 0.002). Length of stay was longer (5 d versus 2 d, P < 0.001) and charges were higher ($21,800 versus $13,200, P = 0.007) for clipped patients than for coiled patients. CONCLUSION There was no significant difference in mortality rates or discharge to long-term facilities after clipping or coiling of unruptured aneurysms. When discharge to short-term rehabilitation was counted as an adverse event, coiled patients had significantly better outcomes than clipped patients at the time of hospital discharge, but most of the coiling advantage was concentrated in patients older than 65 years of age. Even in older patients, long-term end points-including long-term functional status in patients discharged to rehabilitation and efficacy in preventing hemorrhage-will be critical in determining the best treatment option for patients with unruptured aneurysms.
Collapse
Affiliation(s)
- Fred G Barker
- Neurosurgical Service, Massachusetts General Hospital, Boston, Massachusetts 02114, USA.
| | | | | | | | | | | | | | | |
Collapse
|
19
|
Abstract
BACKGROUND Glutamate is the principal excitatory neurotransmitter in the brain. Injury to the brain can cause an ionic imbalance in cerebral tissue, creating an excitotoxic cascade involving glutamate and other excitatory amino acids, that leads to neuronal death in the tissue surrounding the original injury site. Research has centred around inhibiting this increase in excitatory amino acid during injury either pre- or post-synaptically. Animal studies appeared promising, but as yet, those results have not been repeated in human clinical trials. OBJECTIVES To assess systematically the efficacy of excitatory amino acid inhibitors on improving patient outcome following traumatic brain injury. SEARCH STRATEGY Online searches of the databases; CENTRAL, MEDLINE, EMBASE, IDdb3, and Science Citation Index. Online searches of clinical trial registers. General online searches of the Internet. Authors of published works and associated pharmaceutical companies were contacted. SELECTION CRITERIA Trials were included if they were randomised, double-blind, controlled trials where excitatory amino acid inhibitors were administered to patients with traumatic brain injury, within 24 hours of sustaining that injury, and compared to a control group. DATA COLLECTION AND ANALYSIS Twelve trials, involving eight compounds, were identified that appeared to fit the inclusion criteria. Further investigation excluded three of these trials. Two of the remaining trials are ongoing. Of the seven included studies, one trial did not report GOS data and we were unable to acquire them. Three trials have not been published and the data were not made available to us. One trial is currently being prepared for publication, leaving two trials where data were available. Data were extracted by two independent reviewers. MAIN RESULTS Data were available for two of the seven relevant trials identified, with 760 recruited participants. Mortality is similar between patients who receive excitatory amino acid inhibitors and those that receive placebo: odds ratio (OR) 1.11; 95% confidence interval (CI) 0.78, 1.60. Patients who have a favourable outcome six months after injury are also similar between treatment and placebo groups: OR 0.86; 95% CI 0.64, 1.16. REVIEWER'S CONCLUSIONS The case for efficacy of excitatory amino acid inhibitor therapy remains unproven. To date, no product has proven to be efficacious (as determined by the criteria applied) for improving the outcomes of brain-injured patients. Early termination, unpublished, and underpowered studies limit a clear appreciation of the merits of this form of intervention. Additional studies, some of which remain in progress, may more clearly define the efficacy and effectiveness issues.
Collapse
Affiliation(s)
- Charlene Willis
- The University of QueenslandQueensland Institute of Medical Research (QIMR)Level 3, Mayne Medical SchoolHerston RoadBrisbaneQueenslandAustralia4006
| | - Sean Lybrand
- Merck, Sharp & Dohme (Australia) Pty LtdHealth OutcomesPO Box 79GranvilleNew South WalesAustralia2142
| | - Nicholas Bellamy
- Mayne Medical School, The University of QueenslandCentre of National Research on Disability and Rehabilitation MedicineLevel 3Herston RoadBrisbaneQueenslandAustralia4006
| | | |
Collapse
|
20
|
Glenn TC, Kelly DF, Boscardin WJ, McArthur DL, Vespa P, Oertel M, Hovda DA, Bergsneider M, Hillered L, Martin NA. Energy dysfunction as a predictor of outcome after moderate or severe head injury: indices of oxygen, glucose, and lactate metabolism. J Cereb Blood Flow Metab 2003; 23:1239-50. [PMID: 14526234 DOI: 10.1097/01.wcb.0000089833.23606.7f] [Citation(s) in RCA: 224] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
UNLABELLED The purpose of this study was to determine if the relationship between abnormalities in glucose, lactate, and oxygen metabolism were predictive of neurologic outcome after moderate or severe head injury, relative to other known prognostic factors. Serial assessments of the cerebral metabolic rates for glucose, lactate, and oxygen were performed using a modified Kety-Schmidt method. In total, 31 normal control subjects were studied once, and 49 TBI patients (mean age 36+/-16 years, median GCS 7) were studied five times median per patient from postinjury days 0 to 9. Univariate and multivariate analyses were performed. Univariate analysis showed that the 6-month postinjury Glasgow Outcome Scale (GOS) was most strongly associated with the mean cerebral metabolic rate of oxygen (CMRO2) (P = 0.0001), mean arterial lactate level (P = 0.0001), mean arterial glucose (P = 0.0008), mean cerebral blood flow (CBF), (P = 0.002), postresuscitation GCS (P = 0.003), and pupillary status (P = 0.004). Brain lactate uptake was observed in 44% of all metabolic studies, and 76% of patients had at least one episode of brain lactate uptake. By dichotomized GOS, patients achieving a favorable outcome (GOS 4-5) were distinguished from those with an unfavorable outcome (GOS1-3) by having a higher CMRO2 (P = 0.003), a higher rate of abnormal brain lactate uptake relative to arterial lactate levels (P = 0.04), and lesser degrees of blood-brain barrier damage based on CT findings (P = 0.03). CONCLUSIONS During the first 6 days after moderate or severe TBI, CMRO2 and arterial lactate levels are the strongest predictors of neurologic outcome. However, the frequent occurrence of abnormal brain lactate uptake despite only moderate elevations in arterial lactate levels in the favorable outcome patients suggests the brain's ability to use lactate as a fuel may be another key outcome predictor. Future studies are needed to determine to what degree nonglycolytic energy production from alternative fuels such as lactate occurs after TBI and whether alternative fuel administration is a viable therapy for TBI patients.
Collapse
|
21
|
Fuchs S, Lewis RJ. Tools for the measurement of outcome after minor head injury in children: summary from the Ambulatory Pediatric Association/EMSC Outcomes Research Conference. Acad Emerg Med 2003; 10:368-75. [PMID: 12670852 DOI: 10.1111/j.1553-2712.2003.tb01351.x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
This article summarizes discussions held during a conference on outcomes research in emergency medical services for children. It provides detailed information on existing outcome measures for pediatric minor head injury. Benefits and/or limitations in their applicability for use in pediatric emergency medicine and pediatric minor head injury research are highlighted.
Collapse
Affiliation(s)
- Susan Fuchs
- Department of Pediatrics, The Feinberg School of Medicine, Northwestern University, Chicago, IL, USA.
| | | |
Collapse
|
22
|
Narayan RK, Michel ME, Ansell B, Baethmann A, Biegon A, Bracken MB, Bullock MR, Choi SC, Clifton GL, Contant CF, Coplin WM, Dietrich WD, Ghajar J, Grady SM, Grossman RG, Hall ED, Heetderks W, Hovda DA, Jallo J, Katz RL, Knoller N, Kochanek PM, Maas AI, Majde J, Marion DW, Marmarou A, Marshall LF, McIntosh TK, Miller E, Mohberg N, Muizelaar JP, Pitts LH, Quinn P, Riesenfeld G, Robertson CS, Strauss KI, Teasdale G, Temkin N, Tuma R, Wade C, Walker MD, Weinrich M, Whyte J, Wilberger J, Young AB, Yurkewicz L. Clinical trials in head injury. J Neurotrauma 2002; 19:503-57. [PMID: 12042091 PMCID: PMC1462953 DOI: 10.1089/089771502753754037] [Citation(s) in RCA: 650] [Impact Index Per Article: 29.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Traumatic brain injury (TBI) remains a major public health problem globally. In the United States the incidence of closed head injuries admitted to hospitals is conservatively estimated to be 200 per 100,000 population, and the incidence of penetrating head injury is estimated to be 12 per 100,000, the highest of any developed country in the world. This yields an approximate number of 500,000 new cases each year, a sizeable proportion of which demonstrate significant long-term disabilities. Unfortunately, there is a paucity of proven therapies for this disease. For a variety of reasons, clinical trials for this condition have been difficult to design and perform. Despite promising pre-clinical data, most of the trials that have been performed in recent years have failed to demonstrate any significant improvement in outcomes. The reasons for these failures have not always been apparent and any insights gained were not always shared. It was therefore feared that we were running the risk of repeating our mistakes. Recognizing the importance of TBI, the National Institute of Neurological Disorders and Stroke (NINDS) sponsored a workshop that brought together experts from clinical, research, and pharmaceutical backgrounds. This workshop proved to be very informative and yielded many insights into previous and future TBI trials. This paper is an attempt to summarize the key points made at the workshop. It is hoped that these lessons will enhance the planning and design of future efforts in this important field of research.
Collapse
Affiliation(s)
- Raj K Narayan
- Department of Neurosurgery, Temple University Hospital, Philadelphia, Pennsylvania 19140, USA.
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
23
|
Choi SC, Clifton GL, Marmarou A, Miller ER. Misclassification and treatment effect on primary outcome measures in clinical trials of severe neurotrauma. J Neurotrauma 2002; 19:17-22. [PMID: 11852975 DOI: 10.1089/089771502753460204] [Citation(s) in RCA: 42] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022] Open
Abstract
The power of clinical trials depends mainly on the choice of the primary outcome measure, the statistical test, and the sample size. The most widely used outcome measure has been the five-category Glasgow Outcome Scale (GOS). Contrary to intuition, we show that more categories do not necessarily increase the power of a trial and actually can decrease power. This is so for two reasons. The more categories of outcome measure used, the more the likelihood for misclassifications. The effect of 0%, 10%, and 20% misclassification rate upon power is illustrated. Misclassification rates in two completed trials are examined based on comparative overlap in GOS and Disability Rating Scale (DRS) categories. The outcome results of the "National Acute Brain Injury Study: Hypothermia" indicate that the ideal number of categories also depends upon the effect of study treatment. In the recently completed hypothermia trial, the use of a dichotomized GOS (good recovery/moderate disability versus severe disability/vegetative/dead) is shown to be more sensitive than use of three or more categories of the GOS. The results point to the importance of training study investigators who will collect the outcome data. The results also indicate that the number of categories should be carefully determined using the pilot data or the data from phase II trials.
Collapse
Affiliation(s)
- Sung C Choi
- Department of Biostatistics, Medical College of Virginia, Virginia Commonwealth University, Richmond 23298-0032, USA.
| | | | | | | |
Collapse
|
24
|
Abstract
Multicenter clinical trials are the most powerful agent to evaluate new therapies in medicine, but have failed to impact traumatic brain injury, in which at least 20 such trials have been performed, without a positive result. Such trials need to be carefully planned, with a run-in period to ensure center compliance. Stratification, careful monitoring, adequate sample size, interim analysis and adequate numbers of patients per center are all vital requirements for a useful outcome in such trials.
Collapse
Affiliation(s)
- S C Choi
- Medical College of Virginia, Virginia Commonwealth University, Richmond, VA 23298, USA
| | | |
Collapse
|
25
|
Abstract
Injury to the brain is the leading factor in mortality and morbidity from traumatic injury. The devastating personal, social, and financial consequences of traumatic brain injury (TBI) are compounded by the fact that most people with TBI are young and previously healthy. From the emergency physician's standpoint, patients with severe TBI are those with a presenting Glasgow Coma Scale score of less than 9. Over the past 30 years, mortality from severe traumatic brain injury for those patients who survive to the hospital has been reduced by half from nearly 50% to approximately 25%. Because most of the pathologic processes that determine outcome are fully active during the first hours after TBI, the decisions of emergency care providers may be crucial. This review addresses new concepts and information in the pathophysiology of TBI and secondary brain injury and demonstrates how emergency management may be linked to neurologic outcome.
Collapse
Affiliation(s)
- B J Zink
- Department of Emergency Medicine, University of Michigan, Ann Arbor, MI 48109-0303, USA.
| |
Collapse
|
26
|
Abstract
There is a growing volume of research on trauma brain injury (TBI) as evidenced by a recent Medline search that reported over 6000 articles published on TBI in the past 5 years.
Collapse
Affiliation(s)
- D Lovasik
- University of Pittsburgh Health System, Pennsylvania, USA
| | | | | |
Collapse
|