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El Baassiri MG, Raouf Z, Badin S, Escobosa A, Sodhi CP, Nasr IW. Dysregulated brain-gut axis in the setting of traumatic brain injury: review of mechanisms and anti-inflammatory pharmacotherapies. J Neuroinflammation 2024; 21:124. [PMID: 38730498 PMCID: PMC11083845 DOI: 10.1186/s12974-024-03118-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/29/2024] [Accepted: 04/30/2024] [Indexed: 05/13/2024] Open
Abstract
Traumatic brain injury (TBI) is a chronic and debilitating disease, associated with a high risk of psychiatric and neurodegenerative diseases. Despite significant advancements in improving outcomes, the lack of effective treatments underscore the urgent need for innovative therapeutic strategies. The brain-gut axis has emerged as a crucial bidirectional pathway connecting the brain and the gastrointestinal (GI) system through an intricate network of neuronal, hormonal, and immunological pathways. Four main pathways are primarily implicated in this crosstalk, including the systemic immune system, autonomic and enteric nervous systems, neuroendocrine system, and microbiome. TBI induces profound changes in the gut, initiating an unrestrained vicious cycle that exacerbates brain injury through the brain-gut axis. Alterations in the gut include mucosal damage associated with the malabsorption of nutrients/electrolytes, disintegration of the intestinal barrier, increased infiltration of systemic immune cells, dysmotility, dysbiosis, enteroendocrine cell (EEC) dysfunction and disruption in the enteric nervous system (ENS) and autonomic nervous system (ANS). Collectively, these changes further contribute to brain neuroinflammation and neurodegeneration via the gut-brain axis. In this review article, we elucidate the roles of various anti-inflammatory pharmacotherapies capable of attenuating the dysregulated inflammatory response along the brain-gut axis in TBI. These agents include hormones such as serotonin, ghrelin, and progesterone, ANS regulators such as beta-blockers, lipid-lowering drugs like statins, and intestinal flora modulators such as probiotics and antibiotics. They attenuate neuroinflammation by targeting distinct inflammatory pathways in both the brain and the gut post-TBI. These therapeutic agents exhibit promising potential in mitigating inflammation along the brain-gut axis and enhancing neurocognitive outcomes for TBI patients.
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Affiliation(s)
- Mahmoud G El Baassiri
- Pediatric Surgery, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, 21287, USA
| | - Zachariah Raouf
- Pediatric Surgery, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, 21287, USA
| | - Sarah Badin
- Pediatric Surgery, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, 21287, USA
| | - Alejandro Escobosa
- Pediatric Surgery, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, 21287, USA
| | - Chhinder P Sodhi
- Pediatric Surgery, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, 21287, USA
| | - Isam W Nasr
- Pediatric Surgery, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, 21287, USA.
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Syzdykbayev M, Kazymov M, Aubakirov M, Kurmangazina A, Kairkhanov E, Kazangapov R, Bryzhakhina Z, Imangazinova S, Sheinin A. A Modern Approach to the Treatment of Traumatic Brain Injury. MEDICINES (BASEL, SWITZERLAND) 2024; 11:10. [PMID: 38786549 PMCID: PMC11123131 DOI: 10.3390/medicines11050010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/05/2024] [Revised: 04/18/2024] [Accepted: 04/27/2024] [Indexed: 05/25/2024]
Abstract
Background: Traumatic brain injury manifests itself in various forms, ranging from mild impairment of consciousness to severe coma and death. Traumatic brain injury remains one of the leading causes of morbidity and mortality. Currently, there is no therapy to reverse the effects associated with traumatic brain injury. New neuroprotective treatments for severe traumatic brain injury have not achieved significant clinical success. Methods: A literature review was performed to summarize the recent interdisciplinary findings on management of traumatic brain injury from both clinical and experimental perspective. Results: In the present review, we discuss the concepts of traditional and new approaches to treatment of traumatic brain injury. The recent development of different drug delivery approaches to the central nervous system is also discussed. Conclusions: The management of traumatic brain injury could be aimed either at the pathological mechanisms initiating the secondary brain injury or alleviating the symptoms accompanying the injury. In many cases, however, the treatment should be complex and include a variety of medical interventions and combination therapy.
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Affiliation(s)
- Marat Syzdykbayev
- Department of Hospital Surgery, Anesthesiology and Reanimatology, Semey Medical University, Semey 071400, Kazakhstan
| | - Maksut Kazymov
- Department of General Practitioners, Semey Medical University, Semey 071400, Kazakhstan
| | - Marat Aubakirov
- Department of Pediatric Surgery, Semey Medical University, Semey 071400, Kazakhstan
| | - Aigul Kurmangazina
- Committee for Medical and Pharmaceutical Control of the Ministry of Health of the Republic of Kazakhstan for East Kazakhstan Region, Ust-Kamenogorsk 070004, Kazakhstan
| | - Ernar Kairkhanov
- Pavlodar Branch of Semey Medical University, Pavlodar S03Y3M1, Kazakhstan
| | - Rustem Kazangapov
- Pavlodar Branch of Semey Medical University, Pavlodar S03Y3M1, Kazakhstan
| | - Zhanna Bryzhakhina
- Department Psychiatry and Narcology, Semey Medical University, Semey 071400, Kazakhstan
| | - Saule Imangazinova
- Department of Therapy, Astana Medical University, Astana 010000, Kazakhstan
| | - Anton Sheinin
- Sagol School of Neuroscience, Tel-Aviv University, Tel-Aviv 69978, Israel
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Moran JL, Linden A. Problematic meta-analyses: Bayesian and frequentist perspectives on combining randomized controlled trials and non-randomized studies. BMC Med Res Methodol 2024; 24:99. [PMID: 38678213 PMCID: PMC11056075 DOI: 10.1186/s12874-024-02215-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2022] [Accepted: 04/10/2024] [Indexed: 04/29/2024] Open
Abstract
PURPOSE In the literature, the propriety of the meta-analytic treatment-effect produced by combining randomized controlled trials (RCT) and non-randomized studies (NRS) is questioned, given the inherent confounding in NRS that may bias the meta-analysis. The current study compared an implicitly principled pooled Bayesian meta-analytic treatment-effect with that of frequentist pooling of RCT and NRS to determine how well each approach handled the NRS bias. MATERIALS & METHODS Binary outcome Critical-Care meta-analyses, reflecting the importance of such outcomes in Critical-Care practice, combining RCT and NRS were identified electronically. Bayesian pooled treatment-effect and 95% credible-intervals (BCrI), posterior model probabilities indicating model plausibility and Bayes-factors (BF) were estimated using an informative heavy-tailed heterogeneity prior (half-Cauchy). Preference for pooling of RCT and NRS was indicated for Bayes-factors > 3 or < 0.333 for the converse. All pooled frequentist treatment-effects and 95% confidence intervals (FCI) were re-estimated using the popular DerSimonian-Laird (DSL) random effects model. RESULTS Fifty meta-analyses were identified (2009-2021), reporting pooled estimates in 44; 29 were pharmaceutical-therapeutic and 21 were non-pharmaceutical therapeutic. Re-computed pooled DSL FCI excluded the null (OR or RR = 1) in 86% (43/50). In 18 meta-analyses there was an agreement between FCI and BCrI in excluding the null. In 23 meta-analyses where FCI excluded the null, BCrI embraced the null. BF supported a pooled model in 27 meta-analyses and separate models in 4. The highest density of the posterior model probabilities for 0.333 < Bayes factor < 1 was 0.8. CONCLUSIONS In the current meta-analytic cohort, an integrated and multifaceted Bayesian approach gave support to including NRS in a pooled-estimate model. Conversely, caution should attend the reporting of naïve frequentist pooled, RCT and NRS, meta-analytic treatment effects.
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Affiliation(s)
- John L Moran
- The Queen Elizabeth Hospital, Woodville, SA, 5011, Australia.
| | - Ariel Linden
- Department of Medicine, School of Medicine, University of California, San Francisco, USA
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Kelly-Hedrick M, Liu SY, Komisarow J, Hatfield J, Ohnuma T, Treggiari MM, Colton K, Arulraja E, Vavilala MS, Laskowitz DT, Mathew JP, Hernandez A, James ML, Raghunathan K, Krishnamoorthy V. Early Beta-Blocker Utilization in Critically Ill Patients With Moderate-Severe Traumatic Brain Injury: A Retrospective Cohort Study. J Intensive Care Med 2024:8850666241236724. [PMID: 38449336 DOI: 10.1177/08850666241236724] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/08/2024]
Abstract
BACKGROUND There is limited evidence that beta-blockers may provide benefit for patients with moderate-severe traumatic brain injury (TBI) during the acute injury period. Larger studies on utilization patterns and impact on outcomes in clinical practice are lacking. OBJECTIVE The present study uses a large, national hospital claims-based dataset to examine early beta-blocker utilization patterns and its association with clinical outcomes among critically ill patients with moderate-severe TBI. METHODS We conducted a retrospective cohort study of the administrative claims Premier Healthcare Database of adults (≥17 years) with moderate-severe TBI admitted to the intensive care unit (ICU) from 2016 to 2020. The exposure was receipt of a beta-blocker during day 1 or 2 of ICU stay (BB+). The primary outcome was hospital mortality, and secondary outcomes were: hospital length of stay (LOS), ICU LOS, discharge to home, and vasopressor utilization. In a sensitivity analysis, we explored the association of beta-blocker class (cardioselective and noncardioselective) with hospital mortality. We used propensity weighting methods to address possible confounding by treatment indication. RESULTS A total of 109 665 participants met inclusion criteria and 39% (n = 42 489) were exposed to beta-blockers during the first 2 days of hospitalization. Of those, 42% received cardioselective only, 43% received noncardioselective only, and 14% received both. After adjustment, there was no association with hospital mortality in the BB+ group compared to the BB- group (adjusted odds ratio [OR] = 0.99, 95% confidence interval [CI] = 0.94, 1.04). The BB+ group had longer hospital stays, lower chance of discharged home, and lower risk of vasopressor utilization, although these difference were clinically small. Beta-blocker class was not associated with hospital mortality. CONCLUSION In this retrospective cohort study, we found variation in use of beta-blockers and early exposure was not associated with hospital mortality. Further research is necessary to understand the optimal type, dose, and timing of beta-blockers for this population.
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Affiliation(s)
- Margot Kelly-Hedrick
- Critical Care and Perioperative Population Health Research (CAPER) Program, Department of Anesthesiology, Duke University, Durham, NC, USA
- Duke University School of Medicine, Durham, NC, USA
| | - Sunny Yang Liu
- Critical Care and Perioperative Population Health Research (CAPER) Program, Department of Anesthesiology, Duke University, Durham, NC, USA
- Duke University School of Medicine, Durham, NC, USA
| | - Jordan Komisarow
- Critical Care and Perioperative Population Health Research (CAPER) Program, Department of Anesthesiology, Duke University, Durham, NC, USA
- Department of Neurosurgery, Duke University, Durham, NC, USA
| | - Jordan Hatfield
- Critical Care and Perioperative Population Health Research (CAPER) Program, Department of Anesthesiology, Duke University, Durham, NC, USA
- Department of Neurosurgery, Duke University, Durham, NC, USA
| | - Tetsu Ohnuma
- Critical Care and Perioperative Population Health Research (CAPER) Program, Department of Anesthesiology, Duke University, Durham, NC, USA
- Department of Anesthesiology, Duke University, Durham, NC, USA
| | - Miriam M Treggiari
- Critical Care and Perioperative Population Health Research (CAPER) Program, Department of Anesthesiology, Duke University, Durham, NC, USA
- Department of Anesthesiology, Duke University, Durham, NC, USA
- Department of Population Health Sciences, Duke University, Durham, NC, USA
| | | | - Evangeline Arulraja
- Critical Care and Perioperative Population Health Research (CAPER) Program, Department of Anesthesiology, Duke University, Durham, NC, USA
| | - Monica S Vavilala
- Department of Anesthesiology and Pain Medicine, University of Washington, Seattle, WA, USA
| | | | - Joseph P Mathew
- Department of Anesthesiology, Duke University, Durham, NC, USA
| | | | - Michael L James
- Department of Anesthesiology, Duke University, Durham, NC, USA
| | - Karthik Raghunathan
- Critical Care and Perioperative Population Health Research (CAPER) Program, Department of Anesthesiology, Duke University, Durham, NC, USA
- Department of Anesthesiology, Duke University, Durham, NC, USA
- Department of Population Health Sciences, Duke University, Durham, NC, USA
| | - Vijay Krishnamoorthy
- Critical Care and Perioperative Population Health Research (CAPER) Program, Department of Anesthesiology, Duke University, Durham, NC, USA
- Department of Anesthesiology, Duke University, Durham, NC, USA
- Department of Population Health Sciences, Duke University, Durham, NC, USA
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Hussain R, Nedergaard M. Managing noradrenaline after traumatic brain injury. Clin Transl Med 2024; 14:e1562. [PMID: 38279839 PMCID: PMC10819077 DOI: 10.1002/ctm2.1562] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2024] [Accepted: 01/12/2024] [Indexed: 01/29/2024] Open
Affiliation(s)
- Rashad Hussain
- Center for Translational NeuromedicineUniversity of RochesterRochesterNew YorkUSA
| | - Maiken Nedergaard
- Center for Translational NeuromedicineUniversity of RochesterRochesterNew YorkUSA
- Center for Translational NeuroscienceUniversity of CopenhagenCopenhagenDenmark
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Alshaya AI, Aldhaeefi M, Alodhaiyan N, Alqahtani M, Althewaibi S, Alshahrani W, Al Sulaiman K, Al Harbi SA, Vishwakarma R, Aldabbagh T. Clonidine safety and effectiveness in the management of suspected paroxysmal sympathetic hyperactivity post-traumatic brain injury: A retrospective cohort study. Sci Prog 2023; 106:368504231201298. [PMID: 37933150 PMCID: PMC10631352 DOI: 10.1177/00368504231201298] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2023]
Abstract
INTRODUCTION Traumatic brain injury (TBI) is a leading cause of mortality and morbidity worldwide. In addition, TBI may cause paroxysmal sympathetic hyperactivity (PSH), which is associated with poor clinical outcomes. This study aimed to evaluate the safety and effectiveness of clonidine in patients with TBI and suspected PSH. METHODS A retrospective cohort study for critically ill patients with TBI with suspected PSH admitted to intensive care units (ICUs) from 1 May 2016 to 31 January 2020 at a tertiary academic medical center. Eligible patients were categorized based on clonidine use during their ICU stay (Clonidine group vs. Control group). The primary outcome was the improvement in functional outcomes during ICU stay, defined by a delta Glasgow Coma Score (GCS). Secondary outcomes included ICU and hospital length of stay, heart rate variation, and 90-day mortality. RESULTS A total of 2915 patients were screened, of which 169 were included. Based on multiple regression analysis, patients who received clonidine showed better improvement in functional outcomes by a higher mean delta GCS than patients who did not (Beta Coeff. 0.41; CI: 0.07 - 0.74; P = 0.02). In addition, the patient's GCS upon ICU discharge and IV opioids requirement on day three were higher in the clonidine group than control (beta coefficient (95% CI): 0.18 (0.03, 0.32); p = 0.02 and beta coefficient (95% CI): 1.38 (0.24, 2.52); p = 0.02, respectively). No statistical differences were observed in any of the other secondary outcomes after adjusting for confounders. CONCLUSION This study found that patients who received clonidine had better functional outcomes during their ICU stay, as shown by their delta GCS than those who did not. Other outcomes were similar between the groups. More data are needed to explore the role of clonidine in patients with TBI with suspected PSH.
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Affiliation(s)
- Abdulrahman I Alshaya
- Department of Pharmacy Practice, College of Pharmacy, King Saud bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
- King Abdullah International Medical Research Center, Riyadh, Saudi Arabia
- Department of Pharmaceutical Care Services, King Abdulaziz Medical City, Riyadh, Saudi Arabia
| | - Mohammed Aldhaeefi
- Department of Pharmacy Practice, College of Pharmacy, King Saud bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
- King Abdullah International Medical Research Center, Riyadh, Saudi Arabia
- Department of Pharmaceutical Care Services, King Abdulaziz Medical City, Riyadh, Saudi Arabia
- Department of Clinical and Administrative Pharmacy Sciences, College of Pharmacy, Howard University, Washington, USA
| | - Nada Alodhaiyan
- College of Pharmacy, King Saud bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
| | - Maha Alqahtani
- College of Pharmacy, King Saud bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
| | - Sarah Althewaibi
- College of Pharmacy, King Saud bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
| | - Wala Alshahrani
- College of Pharmacy, King Saud bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
| | - Khalid Al Sulaiman
- Department of Pharmacy Practice, College of Pharmacy, King Saud bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
- King Abdullah International Medical Research Center, Riyadh, Saudi Arabia
- Department of Pharmaceutical Care Services, King Abdulaziz Medical City, Riyadh, Saudi Arabia
| | - Shmeylan A. Al Harbi
- Department of Pharmacy Practice, College of Pharmacy, King Saud bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
- King Abdullah International Medical Research Center, Riyadh, Saudi Arabia
- Department of Pharmaceutical Care Services, King Abdulaziz Medical City, Riyadh, Saudi Arabia
| | - Ramesh Vishwakarma
- Statistics Department, European Organization for Research and Treatment of Cancer (EORTC) Headquarters, Brussels, Belgium
| | - Tariq Aldabbagh
- Department of Critical Care, King Abdulaziz Medical City, Riyadh, Saudi Arabia
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Smith JA, Nguyen T, Davis BC, Lahiri DK, Hato T, Obukhov AG, White FA. Propranolol treatment during repetitive mild traumatic brain injuries induces transcriptomic changes in the bone marrow of mice. Front Neurosci 2023; 17:1219941. [PMID: 37817806 PMCID: PMC10561692 DOI: 10.3389/fnins.2023.1219941] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2023] [Accepted: 07/25/2023] [Indexed: 10/12/2023] Open
Abstract
Introduction There are 1.5 million new mild traumatic brain injuries (mTBI) annually in the US, with many of the injured experiencing long-term consequences lasting months after the injury. Although the post injury mechanisms are not well understood, current knowledge indicates peripheral immune system activation as a causal link between mTBI and long-term side effects. Through a variety of mechanisms, peripheral innate immune cells are recruited to the CNS after TBI to repair and heal the injured tissue; however, the recruitment and activation of these cells leads to further inflammation. Emerging evidence suggests sympathetic nervous system (SNS) activity plays a substantial role in the recruitment of immune cells post injury. Methods We sought to identify the peripheral innate immune response after repeated TBIs in addition to repurposing the nonselective beta blocker propranolol as a novel mTBI therapy to limit SNS activity and mTBI pathophysiology in the mouse. Mice underwent repetitive mTBI or sham injury followed by i.p. saline or propranolol. Isolated mRNA derived from femur bone marrow of mice was assayed for changes in gene expression at one day, one week, and four weeks using Nanostring nCounter® stem cell characterization panel. Results Differential gene expression analysis for bone marrow uncovered significant changes in many genes following drug alone, mTBI alone and drug combined with mTBI. Discussion Our data displays changes in mRNA at various timepoints, most pronounced in the mTBI propranolol group, suggesting a single dose propranolol injection as a viable future mTBI therapy in the acute setting.
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Affiliation(s)
- Jared A. Smith
- Department of Anesthesia, Indiana University School of Medicine, Indianapolis, IN, United States
| | - Tyler Nguyen
- Department of Anesthesia, Indiana University School of Medicine, Indianapolis, IN, United States
| | - Brittany C. Davis
- Department of Anesthesia, Indiana University School of Medicine, Indianapolis, IN, United States
| | - Debomoy K. Lahiri
- Department of Psychiatry, Indiana University School of Medicine, Indianapolis, IN, United States
| | - Takashi Hato
- Department of Medicine, Indiana University, Indianapolis, IN, United States
| | - Alexander G. Obukhov
- Department of Anatomy, Cell Biology & Physiology, Indiana University School of Medicine, Indianapolis, IN, United States
| | - Fletcher A. White
- Department of Anesthesia, Indiana University School of Medicine, Indianapolis, IN, United States
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Kelly-Hedrick M, Liu SY, Temkin N, Barber J, Komisarow J, Manley G, Ohnuma T, Colton K, Treggiari MM, Monson EE, Vavilala MS, Grandhi R, Laskowitz DT, Mathew JP, Hernandez A, James ML, Raghunathan K, Goldstein B, Markowitz AJ, Krishnamoorthy V. Association of Early Beta-Blocker Exposure and Functional Outcomes in Critically Ill Patients With Moderate to Severe Traumatic Brain Injury: A Transforming Clinical Research and Knowledge in Traumatic Brain Injury Study. Crit Care Explor 2023; 5:e0958. [PMID: 37693305 PMCID: PMC10484371 DOI: 10.1097/cce.0000000000000958] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/12/2023] Open
Abstract
OBJECTIVES We aimed to 1) describe patterns of beta-blocker utilization among critically ill patients following moderate-severe traumatic brain injury (TBI) and 2) examine the association of early beta-blocker exposure with functional and clinical outcomes following injury. DESIGN Retrospective cohort study. SETTING ICUs at 18 level I, U.S. trauma centers in the Transforming Clinical Research and Knowledge in TBI (TRACK-TBI) study. PATIENTS Greater than or equal to 17 years enrolled in the TRACK-TBI study with moderate-severe TBI (Glasgow Coma Scale of <13) were admitted to the ICU after a blunt TBI. INTERVENTIONS None. MEASUREMENTS Primary exposure was a beta blocker during the first 7 days in the ICU, with a primary outcome of 6-month Glasgow Outcome Scale-Extended (GOSE). Secondary outcomes included: length of hospital stay, in-hospital mortality, 6-month and 12-month mortality, 12-month GOSE score, and 6-month and 12-month measures of disability, well-being, quality of life, and life satisfaction. MAIN RESULTS Of the 450 eligible participants, 57 (13%) received early beta blockers (BB+ group). The BB+ group was on average older, more likely to be on a preinjury beta blocker, and more likely to have a history of hypertension. In the BB+ group, 34 participants (60%) received metoprolol only, 19 participants (33%) received propranolol only, 3 participants (5%) received both, and 1 participant (2%) received atenolol only. In multivariable regression, there was no difference in the odds of a higher GOSE score at 6 months between the BB+ group and BB- group (odds ratio = 0.86; 95% CI, 0.48-1.53). There was no association between BB exposure and secondary outcomes. CONCLUSIONS About one-sixth of subjects in our study received early beta blockers, and within this group, dose, and timing of beta-blocker administration varied substantially. No significant differences in GOSE score at 6 months were demonstrated, although our ability to draw conclusions is limited by overall low total doses administered compared with prior studies.
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Affiliation(s)
- Margot Kelly-Hedrick
- Critical Care and Perioperative Population Health Research (CAPER) Unit, Department of Anesthesiology, Duke University, Durham, NC
- Duke University School of Medicine, Duke University, Durham, NC
| | - Sunny Yang Liu
- Critical Care and Perioperative Population Health Research (CAPER) Unit, Department of Anesthesiology, Duke University, Durham, NC
- Duke University School of Medicine, Duke University, Durham, NC
| | - Nancy Temkin
- Departments of Biostatistics, University of Washington, Seattle, WA
- Departments of Neurosurgery, University of Washington, Seattle, WA
| | - Jason Barber
- Departments of Neurosurgery, University of Washington, Seattle, WA
| | | | - Geoffrey Manley
- Departments of Brain and Spinal Injury Center, University of California, San Francisco, San Francisco, CA
| | - Tetsu Ohnuma
- Critical Care and Perioperative Population Health Research (CAPER) Unit, Department of Anesthesiology, Duke University, Durham, NC
- Departments of Anesthesiology, Duke University, Durham, NC
| | | | - Miriam M Treggiari
- Critical Care and Perioperative Population Health Research (CAPER) Unit, Department of Anesthesiology, Duke University, Durham, NC
- Departments of Brain and Spinal Injury Center, University of California, San Francisco, San Francisco, CA
- Departments of Population Health Sciences, Duke University, Durham, NC
| | - Eric E Monson
- Libraries Center for Data and Visualization Sciences, Duke University, Durham, NC
| | - Monica S Vavilala
- Departments of Anesthesiology and Pain Medicine, University of Washington, Seattle, WA
| | - Ramesh Grandhi
- Department of Neurosurgery, University of Utah, Salt Lake City, UT
| | - Daniel T Laskowitz
- Departments of Neurosurgery, Duke University, Durham, NC
- Departments of Anesthesiology, Duke University, Durham, NC
- Departments of Neurology, Duke University, Durham, NC
| | | | | | - Michael L James
- Critical Care and Perioperative Population Health Research (CAPER) Unit, Department of Anesthesiology, Duke University, Durham, NC
- Departments of Anesthesiology, Duke University, Durham, NC
- Departments of Neurology, Duke University, Durham, NC
| | - Karthik Raghunathan
- Critical Care and Perioperative Population Health Research (CAPER) Unit, Department of Anesthesiology, Duke University, Durham, NC
- Departments of Anesthesiology, Duke University, Durham, NC
- Departments of Population Health Sciences, Duke University, Durham, NC
| | - Ben Goldstein
- Departments of Biostatistics and Bioinformatics, Duke University, Durham, NC
| | - Amy J Markowitz
- Departments of Brain and Spinal Injury Center, University of California, San Francisco, San Francisco, CA
| | - Vijay Krishnamoorthy
- Critical Care and Perioperative Population Health Research (CAPER) Unit, Department of Anesthesiology, Duke University, Durham, NC
- Departments of Anesthesiology, Duke University, Durham, NC
- Departments of Population Health Sciences, Duke University, Durham, NC
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Tignanelli CJ, Arbabi S, Iskander G, Kralovich K, Scott J, Sangji NF, Hemmila MR. Association of Discontinuing Preinjury Beta-Adrenergic Blockade Medications With Mortality in Severe Blunt Traumatic Brian Injury. ANNALS OF SURGERY OPEN 2023; 4:e324. [PMID: 37746607 PMCID: PMC10513140 DOI: 10.1097/as9.0000000000000324] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2023] [Accepted: 07/14/2023] [Indexed: 09/26/2023] Open
Abstract
Background Beta-adrenergic receptor blocker (BB) administration has been shown to improve survival after traumatic brain injury (TBI). However, studies to date that observe a benefit did not distinguish between continuation of preinjury BB versus de novo initiation of BB. Objectives To determine the effect of continuation of preinjury BB and de novo initiation of BB on risk-adjusted mortality and complications for patients with TBI. Methods Trauma quality collaborative data (2016-2021) were analyzed. Patients were excluded with hospitalization <48 hours, direct admission, or penetrating injury. Severe TBI was identified as a head abbreviated injury scale (AIS) value of 3 to 5. Patients were placed into 4 groups based on the preinjury BB use and administration of BB during hospitalization. Propensity score matching was used to create 1:1 matched cohorts of patients for comparisons. Odd ratios of mortality accounting for hospital clustering were calculated. A sensitivity analysis was performed excluding patients with AIS >2 injuries in all other body regions to create a cohort of isolated TBI patients. Results A total of 15,153 patients treated at 35 trauma centers were available for analysis. Patients were divided into 4 cohort groupings related to preinjury BB use and postinjury receipt of BB. The odds of mortality was significantly reduced for patients with a TBI on a preinjury BB who had the medication continued in the acute setting (as compared with patients on preinjury BB who did not) (odds ratio [OR], 0.73; 95% confidence interval [CI], 0.54-0.98; P = 0.04). Patients with a TBI who were not on preinjury BB did not benefit from de novo initiation of BB with regard to mortality (OR, 0.83; 95% CI, 0.64-1.08; P = 0.2). In the sensitivity analysis, excluding polytrauma patients, patients on preinjury BB who had BB continued had a reduction in mortality when compared with patients in which BB was stopped following a TBI (OR, 0.65; 95% CI, 0.47-0.91; P = 0.01). Conclusions Continuing BB is associated with reduced odds of mortality in patients with a TBI on preinjury BB. We were unable to demonstrate benefit from instituting beta blockade in patients who are not on a BB preinjury.
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Affiliation(s)
| | - Saman Arbabi
- Department of Surgery, University of Washington, Seattle, WA
| | - Gaby Iskander
- Division of Acute Care Surgery, Spectrum Health, Grand Rapids, MI
| | | | - John Scott
- Department of Surgery, University of Michigan, Ann Arbor, MI
| | | | - Mark R. Hemmila
- Department of Surgery, University of Michigan, Ann Arbor, MI
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10
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Wang X, Li X, Ma L, Chen H, You C. Pharmacological components with neuroprotective effects in the management of traumatic brain injury: evidence from network meta-analysis. Neurol Sci 2023; 44:1665-1678. [PMID: 36642741 DOI: 10.1007/s10072-023-06600-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2022] [Accepted: 12/31/2022] [Indexed: 01/17/2023]
Abstract
BACKGROUND Neuroprotective drugs have been used to prevent secondary brain injury in patients with traumatic brain injury; however, the optimal medication remains questionable. We performed a Bayesian network meta-analysis to evaluate the safety and efficacy of different medications with known neuroprotective properties in this group of patients. METHODS Several databases were searched to identify any eligible trials comparing pharmacological components with confirmed neuroprotective mechanisms. Bayesian network meta-analysis was performed to combine direct and indirect evidence. The surface under the cumulative ranking curve was obtained to determine the ranking probability of the treatment agents for each outcome. The primary outcome was all-cause mortality. RESULTS A total of 23 trials comprising 4,325 participants were identified. The pooled relative risk (RR) showed administration of erythropoietin (RR: 0.68; 95% CrI: 0.50-0.93) and propranolol (RR: 0.43; 95% CrI: 0.20-0.85) decreased all-cause mortality compared with placebo. We also found erythropoietin (RR: 1.55; 95% CrI: 1.03-2.35), propranolol (RR: 1.52; 95% CrI: 1.05-2.20), and progesterone (RR: 1.47; 95% CrI: 1.03-2.10) showed better efficacy in functional recovery. CONCLUSION Overall, erythropoietin and propranolol were associated with reduced mortality in adults with traumatic brain injury. These treatment agents were also associated with improved functional outcomes.
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Affiliation(s)
- Xing Wang
- Department of Neurosurgery, West China Hospital, Sichuan University, Chengdu, Sichuan, People's Republic of China
| | - Xiaolong Li
- Department of Neurosurgery, West China Hospital, Sichuan University, Chengdu, Sichuan, People's Republic of China
| | - Lu Ma
- Department of Neurosurgery, West China Hospital, Sichuan University, Chengdu, Sichuan, People's Republic of China
| | - Hui Chen
- Department of Neurosurgery, Sichuan Friendship Hospital, Chengdu, Sichuan, People's Republic of China.
| | - Chao You
- Department of Neurosurgery, West China Hospital, Sichuan University, Chengdu, Sichuan, People's Republic of China.
- West China Brain Research Centre, Sichuan University, Chengdu, Sichuan, People's Republic of China.
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11
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Huerta de la Cruz S, Santiago-Castañeda CL, Rodríguez-Palma EJ, Medina-Terol GJ, López-Preza FI, Rocha L, Sánchez-López A, Freeman K, Centurión D. Targeting hydrogen sulfide and nitric oxide to repair cardiovascular injury after trauma. Nitric Oxide 2022; 129:82-101. [PMID: 36280191 PMCID: PMC10644383 DOI: 10.1016/j.niox.2022.10.003] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2022] [Revised: 10/06/2022] [Accepted: 10/18/2022] [Indexed: 11/06/2022]
Abstract
The systemic cardiovascular effects of major trauma, especially neurotrauma, contribute to death and permanent disability in trauma patients and treatments are needed to improve outcomes. In some trauma patients, dysfunction of the autonomic nervous system produces a state of adrenergic overstimulation, causing either a sustained elevation in catecholamines (sympathetic storm) or oscillating bursts of paroxysmal sympathetic hyperactivity. Trauma can also activate innate immune responses that release cytokines and damage-associated molecular patterns into the circulation. This combination of altered autonomic nervous system function and widespread systemic inflammation produces secondary cardiovascular injury, including hypertension, damage to cardiac tissue, vascular endothelial dysfunction, coagulopathy and multiorgan failure. The gasotransmitters nitric oxide (NO) and hydrogen sulfide (H2S) are small gaseous molecules with potent effects on vascular tone regulation. Exogenous NO (inhaled) has potential therapeutic benefit in cardio-cerebrovascular diseases, but limited data suggests potential efficacy in traumatic brain injury (TBI). H2S is a modulator of NO signaling and autonomic nervous system function that has also been used as a drug for cardio-cerebrovascular diseases. The inhaled gases NO and H2S are potential treatments to restore cardio-cerebrovascular function in the post-trauma period.
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Affiliation(s)
- Saúl Huerta de la Cruz
- Departamento de Farmacobiología, Cinvestav-Coapa, Mexico City, Mexico; Department of Pharmacology, University of Vermont, Burlington, VT, USA.
| | | | - Erick J Rodríguez-Palma
- Neurobiology of Pain Laboratory, Departamento de Farmacobiología, Cinvestav, Sede Sur, Mexico City, Mexico.
| | | | | | - Luisa Rocha
- Departamento de Farmacobiología, Cinvestav-Coapa, Mexico City, Mexico.
| | | | - Kalev Freeman
- Department of Emergency Medicine, University of Vermont, Burlington, VT, USA.
| | - David Centurión
- Departamento de Farmacobiología, Cinvestav-Coapa, Mexico City, Mexico.
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12
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El-Swaify ST, Kamel M, Ali SH, Bahaa B, Refaat MA, Amir A, Abdelrazek A, Beshay PW, Basha AKMM. Initial neurocritical care of severe traumatic brain injury: New paradigms and old challenges. Surg Neurol Int 2022; 13:431. [DOI: 10.25259/sni_609_2022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2022] [Accepted: 08/29/2022] [Indexed: 11/04/2022] Open
Abstract
Background:
Early neurocritical care aims to ameliorate secondary traumatic brain injury (TBI) and improve neural salvage. Increased engagement of neurosurgeons in neurocritical care is warranted as daily briefings between the intensivist and the neurosurgeon are considered a quality indicator for TBI care. Hence, neurosurgeons should be aware of the latest evidence in the neurocritical care of severe TBI (sTBI).
Methods:
We conducted a narrative literature review of bibliographic databases (PubMed and Scopus) to examine recent research of sTBI.
Results:
This review has several take-away messages. The concept of critical neuroworsening and its possible causes is discussed. Static thresholds of intracranial pressure (ICP) and cerebral perfusion pressure may not be optimal for all patients. The use of dynamic cerebrovascular reactivity indices such as the pressure reactivity index can facilitate individualized treatment decisions. The use of ICP monitoring to tailor treatment of intracranial hypertension (IHT) is not routinely feasible. Different guidelines have been formulated for different scenarios. Accordingly, we propose an integrated algorithm for ICP management in sTBI patients in different resource settings. Although hyperosmolar therapy and decompressive craniectomy are standard treatments for IHT, there is a lack high-quality evidence on how to use them. A discussion of the advantages and disadvantages of invasive ICP monitoring is included in the study. Addition of beta-blocker, anti-seizure, and anticoagulant medications to standardized management protocols (SMPs) should be considered with careful patient selection.
Conclusion:
Despite consolidated research efforts in the refinement of SMPs, there are still many unanswered questions and novel research opportunities for sTBI care.
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Affiliation(s)
- Seif Tarek El-Swaify
- Department of Neurosurgery, Faculty of Medicine, Ain Shams University, Cairo, Egypt
| | - Menna Kamel
- School of Medicine, Faculty of Medicine, Ain Shams University, Cairo, Egypt
| | - Sara Hassan Ali
- School of Medicine, Faculty of Medicine, Ain Shams University, Cairo, Egypt
| | - Bassem Bahaa
- Faculty of Medicine, Ain Shams University, Cairo, Egypt
| | | | - Abdelrahman Amir
- School of Medicine, Faculty of Medicine, Ain Shams University, Cairo, Egypt
| | | | - Pavly Wagih Beshay
- School of Medicine, Faculty of Medicine, Ain Shams University, Cairo, Egypt
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13
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Zagales I, Selvakumar S, Ngatuvai M, Fanfan D, Kornblith L, Santos RG, Ibrahim J, Elkbuli A. Beta-Blocker Therapy in Patients With Severe Traumatic Brain Injury: A Systematic Review and Meta-Analysis. Am Surg 2022:31348221101583. [PMID: 35575287 DOI: 10.1177/00031348221101583] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
INTRODUCTION Traumatic brain injury (TBI), a leading cause of morbidity and mortality among trauma patients worldwide, poses the risk of secondary neurological insult due to significant catecholamine surge. We aim to investigate the effectiveness and outcomes of beta-blocker administration in patients with severe TBI. METHODS A search through PubMed, EMBASE, JAMA network, and Google Scholar databases was conducted for relevant peer-reviewed original studies published before February 15, 2022. A standard random-effects model was used, as justified by a high Cohen's Q test. RESULTS Twelve studies met inclusion criteria and were included in the meta-analysis. Severe TBI patients who were administered beta-blockers had a significantly reduced incidence of in-hospital mortality compared to the non-beta-blocker group (14.5% vs 19.2%). However, the beta-blocker group was reported to have a significantly greater number of ventilator days (5.58 vs 2.60 days). Similarly, intensive care unit (9.00 vs 6.84 days) and hospital (17.30 vs 11.02 days) lengths of stay (LOS) were increased in the beta-blocker group compared to those who were not administered beta-blocker therapy, but only the difference in hospital-LOS was significant. CONCLUSIONS Beta-blockers have significantly decreased in-hospital mortality in patients with severe TBI despite being associated with an increase in ventilator days and hospital-LOS. The administration of beta-blocker therapy in the management of severe TBI may be warranted and should be discussed in future guidelines.
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Affiliation(s)
- Israel Zagales
- Universidad Iberoamericana (UNIBE) Escuela de Medicina, Santo Domingo, Dominican Republic
| | - Sruthi Selvakumar
- Dr. Kiran.C. Patel College of Allopathic Medicine, 2814NSU NOVA Southeastern University, Fort Lauderdale, FL, USA
| | - Micah Ngatuvai
- Dr. Kiran.C. Patel College of Allopathic Medicine, 2814NSU NOVA Southeastern University, Fort Lauderdale, FL, USA
| | - Dino Fanfan
- Herbert Wertheim College of Medicine,5450Florida International University, Miami, FL, USA
| | - Lucy Kornblith
- Division of Trauma and Surgical Critical Care, Department of Surgery, 36558Zuckerberg San Francisco General Hospital and Trauma Center, San Francisco, CA.,Department of Surgery, University of San Francisco, San Francisco, CA, USA
| | - Radleigh G Santos
- Department of Mathematics, 2814NSU NOVA Southeastern University, Fort Lauderdale, FL, USA
| | - Joseph Ibrahim
- Division of Trauma and Surgical Critical Care, Department of Surgery, 25105Orlando Regional Medical Center, Orlando, FL, USA.,Department of Surgical Education, 25105Orlando Regional Medical Center, Orlando, FL, USA
| | - Adel Elkbuli
- Division of Trauma and Surgical Critical Care, Department of Surgery, 25105Orlando Regional Medical Center, Orlando, FL, USA.,Department of Surgical Education, 25105Orlando Regional Medical Center, Orlando, FL, USA
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14
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Lopez AJ, ElSaadani M, Jacovides CL, George A, Culkin MC, Ahmed S, Kumar MA, Kaplan LJ, Smith DH, Pascual JL. Beta blockade in TBI: Dose-dependent reductions in BBB leukocyte mobilization and permeability in vivo. J Trauma Acute Care Surg 2022; 92:781-791. [PMID: 35045056 PMCID: PMC9038675 DOI: 10.1097/ta.0000000000003537] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Traumatic brain injury (TBI) is accompanied by a hyperadrenergic catecholamine state that can cause penumbral neuroinflammation. Prospective human studies demonstrate improved TBI survival with beta blockade (bb), although mechanisms remain unclear. We hypothesized that deranged post-TBI penumbral blood brain barrier (BBB) leukocyte mobilization and permeability are improved by bb. METHODS CD1 male mice (n = 64) were randomly assigned to severe TBI-controlled cortical impact: 6 m/s velocity, 1 mm depth, 3 mm diameter-or sham craniotomy, and IP injection of either saline or propranolol (1, 2, or 4 mg/kg) every 12 hours for 2 days. At 48 hours, in vivo pial intravital microscopy visualized live endothelial-leukocyte (LEU) interactions and BBB microvascular leakage. Twice daily clinical recovery was assessed by regaining of lost body weight and the Garcia Neurological Test (motor, sensory, reflex, balance assessments). Brain edema was determined by hemispheric wet-to-dry ratios. RESULTS Propranolol after TBI reduced both in vivo LEU rolling and BBB permeability in a dose-dependent fashion compared with no treatment (p < 0.001). Propranolol reduced cerebral edema (p < 0.001) and hastened recovery of lost body weight at 48 hours (p < 0.01). Compared with no treatment (14.9 ± 0.2), 24-hour Garcia Neurologic Test scores were improved with 2 (15.8 ± 0.2, p = 0.02) and 4 (16.1 ± 0.1, p = 0.001) but not with 1 mg/kg propranolol. CONCLUSION Propranolol administration reduces post-TBI LEU mobilization and microvascular permeability in the murine penumbral neurovasculature and leads to reduced cerebral edema. This is associated with hastened recovery of post-TBI weight loss and neurologic function with bb treatment. Dose-dependent effects frame a mechanistic relationship between bb and improved human outcomes after TBI.
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Affiliation(s)
- Alfonso J. Lopez
- Division of Traumatology, Surgical Critical Care and Emergency Surgery, Department of Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
- Center for Brain Injury and Repair, Department of Neurosurgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Mohamed ElSaadani
- Division of Traumatology, Surgical Critical Care and Emergency Surgery, Department of Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
- Center for Brain Injury and Repair, Department of Neurosurgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Christina L. Jacovides
- Division of Traumatology, Surgical Critical Care and Emergency Surgery, Department of Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
- Center for Brain Injury and Repair, Department of Neurosurgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Anastasia George
- Center for Brain Injury and Repair, Department of Neurosurgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Matthew C. Culkin
- Division of Traumatology, Surgical Critical Care and Emergency Surgery, Department of Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
- Center for Brain Injury and Repair, Department of Neurosurgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Syed Ahmed
- Division of Traumatology, Surgical Critical Care and Emergency Surgery, Department of Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
- Center for Brain Injury and Repair, Department of Neurosurgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Monisha A. Kumar
- Center for Brain Injury and Repair, Department of Neurosurgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Lewis J. Kaplan
- Division of Traumatology, Surgical Critical Care and Emergency Surgery, Department of Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
- Center for Brain Injury and Repair, Department of Neurosurgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Douglas H. Smith
- Center for Brain Injury and Repair, Department of Neurosurgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Jose L. Pascual
- Division of Traumatology, Surgical Critical Care and Emergency Surgery, Department of Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
- Center for Brain Injury and Repair, Department of Neurosurgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
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15
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Baron DH, Skrobot OA, Palmer JC, Sharma K, Kehoe P. The Renin Angiotensin System as a potential treatment target for Traumatic Brain Injury. J Neurotrauma 2022; 39:473-486. [PMID: 35029131 DOI: 10.1089/neu.2021.0401] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/09/2022] Open
Abstract
Traumatic brain injury (TBI) is a major health concern and leading cause of death and disability in young adults in the UK and worldwide, however, there is a paucity of disease modifying therapies for the treatment of TBI. This review investigates the potential of the renin-angiotensin system (RAS) as a treatment pathway for traumatic brain injury (TBI) in adults. Relevant electronic databases were searched on 18 December 2019, updated 16 May 2021. All English language articles with adult human or animal populations investigating RAS drugs as an intervention for TBI or reporting genetic evidence relevant to the RAS and TBI were screened. Eighteen preclinical RCTs (n=2269) and 2 clinical cohort studies (n=771) were included. Meta-analyses of 6 preclinical randomised-controlled trials (n=99) indicated candesartan improved neurological function short-term (<7 days: standardised mean difference (SMD) 0.61, 95% confidence interval (CI) 0.19 - 1.03, I2=0%) and long-term (≥7 days: SMD 1.06, 95% CI 0.38; 1.73, I2=0%) post-TBI. Findings were similar for most secondary outcomes. There was a suggestion of benefit from other RAS-targeting drugs, although evidence was limited due to few small studies. There was insufficient evidence to enable strong assessment of these drugs on mortality post-TBI. We conclude that angiotensin-receptor blockers, especially candesartan, show positive outcomes post-TBI in preclinical studies with moderate quality of evidence (GRADE). More research into the effect of regulatory-RAS targeting drugs is needed. Clinical trials of candesartan following TBI are recommended, due to strong and consistent evidence of neuroprotection shown by these preclinical studies.
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Affiliation(s)
- Daniel Hendrik Baron
- University of Bristol, 1980, Dementia Research Group, Clinical Neurosciences, School of Clinical Sciences, Bristol, United Kingdom of Great Britain and Northern Ireland;
| | - Olivia A Skrobot
- University of Bristol, 1980, Translational Health Sciences, Dementia Research Group, Clinical Neurosciences, School of Clinical Sciences, Bristol, Bristol, United Kingdom of Great Britain and Northern Ireland;
| | - Jennifer C Palmer
- University of Bristol, 1980, Population Health Sciences, Bristol Medical School, Bristol, Bristol, United Kingdom of Great Britain and Northern Ireland.,University of Bristol, 1980, MRC Integrative Epidemiology Unit, Bristol, Bristol, United Kingdom of Great Britain and Northern Ireland;
| | - Kanchan Sharma
- University of Bristol, 1980, Translational Health Sciences, Bristol, Bristol, United Kingdom of Great Britain and Northern Ireland.,North Bristol NHS Trust, 1982, Neurology, Westbury on Trym, Bristol, United Kingdom of Great Britain and Northern Ireland;
| | - Patrick Kehoe
- University of Bristol, 1980, Translational Health Sciences, Dementia Research Group,, Clinical Neurosciences, School of Clinical Sciences, Bristol, - None -, United Kingdom of Great Britain and Northern Ireland, BS10 5NB.,University of Bristol;
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16
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El-Menyar A, Asim M, Bahey AAA, Chughtai T, Alyafai A, Abdelrahman H, Rizoli S, Peralta R, Al-Thani H. Beta blocker use in traumatic brain injury based on the high-sensitive troponin status (BBTBBT): methodology and protocol implementation of a double-blind randomized controlled clinical trial. Trials 2021; 22:890. [PMID: 34876207 PMCID: PMC8650244 DOI: 10.1186/s13063-021-05872-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2020] [Accepted: 11/24/2021] [Indexed: 11/21/2022] Open
Abstract
Background Beta-adrenergic receptor blockers (BB) play an important role in the protection of organs that are susceptible for secondary injury due to stress-induced adrenergic surge. However, the use of BB in traumatic brain injury (TBI) patients is not yet the standard of care which necessitates clear scientific evidence to be used. The BBTBBT study aims to determine whether early administration of propranolol based on the high-sensitive troponin T(HsTnT) status will improve the outcome of TBI patients. We hypothesized that early propranolol use is effective in reducing 10- and 30-day mortality in TBI patients. Secondary outcomes will include correlation between serum biomarkers (troponin, epinephrine, cytokines, enolase, S100 calcium binding protein B) and the severity of injury and the impact of BB use on the duration of hospital stay and functional status at a 3-month period. Methods The BBTBBT study is a prospective, randomized, double-blinded, placebo-controlled three-arm trial of BB use in mild-to-severe TBI patients based on the HsTnT status. All enrolled patients will be tested for HsTnT at the first 4 and 6 h post-injury. Patients with positive HsTnT will receive BB if there is no contraindication (group 1). Patients with negative HsTnT will be randomized to receive either propranolol (group 2) or placebo (group 3). The time widow for receiving the study treatment is the first 24 h post-injury. Discussion Early BB use may reduce the catecholamine storm and subsequently the cascade of immune and inflammatory changes associated with TBI. HsTnT could be a useful fast diagnostic and prognostic tool in TBI patients. This study will be of great clinical interest to improve survival and functional outcomes of TBI patients. Trial registration ClinicalTrials.gov NCT04508244. Registered on 7 August 2020. Recruitment started on 29 December 2020 and is ongoing. Supplementary Information The online version contains supplementary material available at 10.1186/s13063-021-05872-8.
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Affiliation(s)
- Ayman El-Menyar
- Clinical Research, Trauma & Vascular Surgery Section, Hamad General Hospital (HGH), PO Box 3050, Doha, Qatar. .,Clinical Medicine, Weill Cornell Medical College, Doha, Qatar.
| | - Mohammad Asim
- Clinical Research, Trauma & Vascular Surgery Section, Hamad General Hospital (HGH), PO Box 3050, Doha, Qatar
| | | | - Talat Chughtai
- Department of Surgery, Trauma Surgery Section, HGH, Doha, Qatar.,Department of Surgery, Qatar University, Doha, Qatar
| | | | | | - Sandro Rizoli
- Department of Surgery, Trauma Surgery Section, HGH, Doha, Qatar
| | - Ruben Peralta
- Department of Surgery, Trauma Surgery Section, HGH, Doha, Qatar
| | - Hassan Al-Thani
- Department of Surgery, Trauma Surgery Section, HGH, Doha, Qatar
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