The Impact of Substance Abuse on Mortality in Patients With Severe Traumatic Brain Injury

How does drug abuse affect outcomes after trauma? A trauma quality improvement program study

BACKGROUND

The protective effects of drug abuse on ICU admissions and ventilator weaning after trauma are debated. This study examines the impact of drug abuse on mortality, ICU admissions, and complications.

METHODS

Trauma patients ≥16 years from the TQIP database (2020-2022) with admission toxicology testing (TOX) were analyzed. The primary outcome was mortality; secondary outcomes included in-hospital complications.

RESULTS

Among 861,450 patients, decreased mortality odds were noted with cannabinoid (OR ​= ​0.842), amphetamine (OR ​= ​0.800), cocaine (OR ​= ​0.851), opioid (OR ​= ​0.625), and benzodiazepine (OR ​= ​0.843) (P ​< ​0.001). Reduced ICU admission odds were linked to opioid (OR ​= ​0.882), barbiturate (OR ​= ​0.824), oxycodone (OR ​= ​0.829), ecstasy (OR ​= ​0.811), and methadone (OR ​= ​0.809). Lower intubation odds were seen with opioid (OR ​= ​0.663), barbiturate (OR ​= ​0.733), oxycodone (OR ​= ​0.754), and ecstasy (OR ​= ​0.627). Methamphetamine (OR ​= ​0.682) was associated with reduced ARDS odds.

CONCLUSIONS

Recreational drugs may independently reduce ICU admissions, intubation, and mortality, warranting further investigation.

LEVEL OF EVIDENCE

Level III retrospective study.

Methamphetamine and traumatic brain injury outcomes: an analysis of 29,416 patients from the national trauma data bank

BACKGROUND

Methamphetamine (Meth) use is rising in the US. Most research focuses on severe TBI, neglecting milder cases. We evaluated Meth's impact on patient outcomes and hospital resource use across all TBI severities.

METHODS

This study included National Trauma Data Bank (NTDB) patients from 2017-2019, aged 18-54, with near-isolated TBI, a drug screen, and negative blood alcohol. Meth+ patients were compared to Meth- patients on demographics, injury severity, and outcomes using χ² and Wilcoxon rank-sum tests.

RESULTS

Of 29,416 patients with TBI patients, 337 (1%) were Meth+. Meth+ patients had significantly higher ICU admissions (61% vs. 50%, p < 0.001), mechanical ventilation (32% vs. 22%, p < 0.001), and tracheostomy (7% vs. 4%, p < 0.008). Meth+ had longer hospital stays (median 4 vs. 3 days, p < 0.001) and higher cerebral monitor use (8% vs. 5%, p < 0.05). Mortality rates were similar (5% vs. 5%, p = 0.46). Meth+ patients had more preexisting mental health/personality (20% vs. 12%, p < 0.001) and substance use disorders (44% vs. 6%, p < 0.001).

CONCLUSIONS

Meth use in patients with near-isolated TBI patients is linked to greater injury severity, increased resource use, and longer hospital stays but does not significantly impact mortality. Targeted interventions are needed to manage clinical challenges and optimize resource utilization.

Title: Marijuana Use Associated with Decreased Mortality in Trauma Patients

BACKGROUND

The incidence of trauma patients with a positive marijuana screen (pMS) is increasing but the effects of marijuana on outcomes have varied in previous studies. A recent statewide analysis demonstrated decreased mortality for intensive care unit (ICU) trauma patients with pMS. Thus, we hypothesized a pMS to be associated with a decreased risk of mortality for all trauma patients.

METHODS

The 2017 Trauma Quality Improvement Program (TQIP) database was queried for adult (≥18 years-old) pMS patients, who were compared to patients negative for all drugs and alcohol (nDS). Patients not drug tested or testing positive for drug(s)/alcohol other than marijuana were excluded. Multivariable logistic regression was used to evaluate risk of mortality after controlling for known predictors of mortality including age, sex, injury severity, vital signs, and comorbidities. Additional subgroup analyses were performed for ICU patients and younger adults (<40 years-old).

RESULTS

From 141 737 tested patients, 23 310 (16.4%) had an isolated pMS. Patients with pMS were younger (P < .001) but had a similar median injury severity score (ISS) (9, P = .42) compared to nDS patients. On multivariable analysis the associated risk of mortality was lower for pMS (OR .79, .71-.87, P < .001) compared to nDS patients. Subgroups analyses also demonstrated decreased associated risk of mortality for ICU and younger patients (both P < .05).

DISCUSSION

Patients with a pMS had decreased associated risk of mortality compared to nDS patients, including subgroups of ICU and younger patients. These findings require corroboration with future prospective clinical study and basic science evaluation to ascertain the exact pathophysiologic basis and thereby target potential interventions.

Pre-injury chronic alcohol abuse predicts intracranial hemorrhagic progression, unfavorable clinical outcome, and mortality in severe traumatic brain injury

OBJECTIVE

We aimed to determine the incidence of pre-injury alcohol abuse in TBI at our neurointensive care unit (NICU), the relation to intracranial hemorrhage evolution, and clinical outcome.

METHODS

Patients with TBI treated at our NICU at Uppsala university hospital, Sweden, 2008-2018, were included. Clinical, radiological, and outcome variables were evaluated.

RESULTS

Of 844 patients with TBI, 147 (17%) had a history of pre-injury alcohol abuse and these patients were slightly older, but had a similar Charlson co-morbidity index as the other patients. They were more often injured by falls and more frequently developed acute subdural hematomas and cerebral contusions. Their platelets were lower and their IVY bleeding time slightly longer. Patients with pre-injury alcohol abuse more often exhibited an intracranial hemorrhage progression on the second computed tomography. Pre-injury alcohol abuse was an independent predictor of increased mortality (odds ratio = 2.96, p-value = 0.001) and decreased favorable outcome (odds ratio = 0.46, p-value = 0.001) in multiple regression analyses.

CONCLUSIONS

Pre-injury alcohol abuse was common in severe TBI, associated with coagulopathy, worse intracranial hemorrhage/injury evolution, and independently predicted poor clinical outcome. These patients deserve more attention in care and research to address specific challenges including disturbed hemostasis.

Relationship of Time of Injury Marijuana Exposure and Traumatic Brain Injury: A Systematic Review

BACKGROUND

Traumatic brain injury (TBI) is a significant nursing concern, as it is a leading cause of mortality, morbidity, and disability in the United States. Notably, up to 51% of all TBI patients have substance use exposure at the time of injury. Marijuana remains the most widely used illicit drug in the United States. However, little is known about marijuana exposure and TBI incidence and severity, particularly at the time of injury.

METHODS

A systematic literature review was conducted following PRISMA guidelines in PubMed to determine the relationship between marijuana exposure and TBI severity.Heterogeneity of study designs, concepts, samples, and variables in included studies precluded a meta-analysis. Hence, a descriptive analysis of findings was conducted.

RESULTS

The search yielded 939 studies, of which eight met inclusion criteria. Only one study found a connection between positive marijuana toxicology screen and mortality outcomes in TBI patients. There was significant variation in how marijuana exposure was defined, conceptualized, and operationalized in the other studies.

CONCLUSIONS

This review identified the need for larger, better-designed studies to address the significant knowledge gap about the relationship between marijuana use and its influence on TBI. Data and knowledge derived from such studies can help inform policy and aid in the development of nursing interventions that target prevention and increase awareness of TBI risk when under the influence of marijuana.

Impact of opioid use disorder on resource utilization and readmissions after operative trauma

BACKGROUND

Although patients with opioid use disorder have been shown to be more susceptible to traumatic injury, the impact of opioid use disorder after trauma-related admission remains poorly characterized. The present nationally representative study evaluated the association of opioid use disorder on clinical outcomes after traumatic injury warranting operative intervention.

METHODS

The 2010 to 2018 Nationwide Readmissions Database was used to identify adult trauma victims who underwent major operative procedures. Injury severity was quantified using International Classification of Diseases Trauma Mortality Prediction Model. Entropy balancing was used to adjust for intergroup differences. Multivariable regression models were developed to assess the association of opioid use disorder on in-hospital mortality, perioperative complications, resource utilization, and readmissions.

RESULTS

Of an estimated 5,089,003 hospitalizations, 54,097 (1.06%) had a diagnosis of opioid use disorder with increasing prevalence during the study period. Compared with others, opioid use disorder had a lower proportion of extremity injuries and falls but greater predicted mortality measured by Trauma Mortality Prediction Model. After adjustment, opioid use disorder was associated with decreased odds of in-hospital mortality (adjusted odds ratio: 0.61; 95% confidence interval, 0.53-0.70) but had greater likelihood of pneumonia, infectious complications, and acute kidney injury. Additionally, opioid use disorder was associated with longer hospitalization duration as well as greater index costs and risk of readmission within 30 days (adjusted odds ratio: 1.36; 95% confidence interval, 1.25-1.49).

CONCLUSION

Opioid use disorder in operative trauma has significantly increased in prevalence and is associated with decreased in-hospital index mortality but greater resource utilization and readmission.

Use of Medical Cannabis to Treat Traumatic Brain Injury

There is not a single pharmacological agent with demonstrated therapeutic efficacy for traumatic brain injury (TBI). With recent legalization efforts and the growing popularity of medical cannabis, patients with TBI will inevitably consider medical cannabis as a treatment option. Pre-clinical TBI research suggests that cannabinoids have neuroprotective and psychotherapeutic properties. In contrast, recreational cannabis use has consistently shown to have detrimental effects. Our review identified a paucity of high-quality studies examining the beneficial and adverse effects of medical cannabis on TBI, with only a single phase III randomized control trial. However, observational studies demonstrate that TBI patients are using medical and recreational cannabis to treat their symptoms, highlighting inconsistencies between public policy, perception of potential efficacy, and the dearth of empirical evidence. We conclude that randomized controlled trials and prospective studies with appropriate control groups are necessary to fully understand the efficacy and potential adverse effects of medical cannabis for TBI.

Chronic alcoholism and all-cause mortality among disabled individuals: Findings from the Korea National Health Insurance Service-National Sample Cohort

BACKGROUND

Alcohol use among adults with mild to severe disability is an under-researched topic in the literature. Few studies have attempted to assess the impact of alcohol misuse, abuse, and chronic alcoholism among this target group. Thus, we investigated the association between chronic alcoholism and mortality among disabled individuals in South Korea.

METHODS

We used data from the National Health Insurance Service National Sample Cohort (NHIS-NSC) for the years 2003-2013, which included data on 61,013 disabled individuals. Among these patients, a multivariate Cox proportional hazards model was used to estimate the hazard ratio of mortality associated with chronic alcoholism.

RESULTS

A total of 800 individuals died during the study period. Individuals who had medical claims for chronic alcoholism following their disability diagnosis had greater risk of mortality than individuals without chronic alcoholism (hazard ratio [HR]: 1.57, 95% confidence interval [CI]: 1.06-2.31, p = 0.0244). Individuals with a physical disability (HR: 2.30, 95% CI: 1.06-4.95, p = 0.0342), brain lesion (HR: 1.96, 95% CI: 1.03-3.74, p = 0.0405), and/or kidney failure (HR: 4.98, 95% CI: 1.07-23.25, p = 0.0411) had greatest mortality risk when diagnosed with chronic alcoholism, compared to individuals who were not diagnosed with chronic alcoholism.

CONCLUSIONS

Chronic alcoholism following disability diagnosis was associated with greater mortality risk in a nationally representative population of disabled individuals, especially among individuals with a physical disability, brain lesion, and/or kidney failure. Such findings reveal that certain social and political measures must be implemented to help disabled individuals suffering from alcoholism, especially according to disability diagnosis.

The combined effects of alcohol and marijuana use prior to traumatic brain injury on mortality

Background

Alcohol (ETOH) intoxication is a common comorbidity in traumatic brain injury (TBI), and marijuana (THC) has been implicated as a major risk factor for trauma. The objective this study was to investigate the combined effects of ETOH and THC on mortality after TBI.

Materials and methods

A retrospective review of patient data was performed to assess adult (>18 years) patients with brain injuries between January 2012 and December 2018. Included patients sustained TBI (Abbreviated Injury Scale (AIS 1-6)) and were divided into two groups: No Substances and THC + ETOH.

Results

1085 (median age 52 years [range: 18–97 years]; 33.5% female (364/1085)) patients met the inclusion criteria. Significant differences for mortality at discharge were found between groups (p = 0.0025) with higher mortality in the No Substances group. On multiple logistic regression, a positive test for both ETOH + THC was found not to independently predict mortality at discharge, while age, Glasgow Coma Scale, intensive care unit stay, Injury Severity Score, length of hospital stay, and days on ventilator were independent predictors.

Conclusions

After controlling for confounding variables, positive ETOH + THC screens were not found to be independent predictors of mortality at discharge. Therefore, our results indicated no survival benefit for TBI patients with concomitant ETOH and THC use prior to injury.

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No survival benefit of alcohol and marijuana for all traumatic brain injury levels

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Glasgow Coma Scale predicts mortality for all traumatic brain injury levels

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Length of stay predicts mortality for all traumatic brain injury levels

Targeting the endocannabinoid system: a predictive, preventive, and personalized medicine-directed approach to the management of brain pathologies

Cannabis-inspired medical products are garnering increasing attention from the scientific community, general public, and health policy makers. A plethora of scientific literature demonstrates intricate engagement of the endocannabinoid system with human immunology, psychology, developmental processes, neuronal plasticity, signal transduction, and metabolic regulation. Despite the therapeutic potential, the adverse psychoactive effects and historical stigma, cannabinoids have limited widespread clinical application. Therefore, it is plausible to weigh carefully the beneficial effects of cannabinoids against the potential adverse impacts for every individual. This is where the concept of "personalized medicine" as a promising approach for disease prediction and prevention may take into the account. The goal of this review is to provide an outline of the endocannabinoid system, including endocannabinoid metabolizing pathways, and will progress to a more in-depth discussion of the therapeutic interventions by endocannabinoids in various neurological disorders.

Traumatic brain injury and alcohol intoxication: effects on injury patterns and short-term outcome

Purpose

A significant number of patients with traumatic brain injuries (TBI) are diagnosed with elevated blood alcohol concentration (BAC). Recent literature suggests a neuroprotective effect of alcohol on TBI, possibly associated with less morbidity and mortality. Our goal is to analyze the association of different levels of BAC with TBI characteristics and outcome.

Methods

Adult patients with moderate to severe TBI (AIS ≥ 2) and measured BAC admitted to the Trauma Centre West (TCW), during the period 2010–2015, were retrospectively analyzed. Data included injury severity (AIS), length of hospitalization, admittance to the Intensive Care Unit (ICU) and in-hospital mortality. The association of BAC with ICU admittance and in-hospital mortality was analyzed using multivariable logistic regression analysis with correction for potentially confounding variables.

Results

BACs were available in 2,686 patients of whom 42% had high, 26% moderate, 6% low and 26% had normal levels. Patients with high BAC’s were predominantly male, were younger, had lower ISS scores, lower AIS-head scores and less concomitant injuries compared to patients in the other BAC subgroups. High BACs were associated with a lower risk for in-hospital mortality (AOR 0.36, 95% CI 0.14–0.97). Also, patients with moderate and high BACs were less often admitted to the ICU (respectively, AOR 0.36, 95% CI 0.25–0.52 and AOR 0.40, 95% CI 0.29–0.57).

Conclusion

The current study suggests that in patients with moderate to severe TBI, increasing BACs are associated with less severe TBI, less ICU admissions and a higher survival. Further research into the pathophysiological mechanism is necessary to help explain these findings.

Associations of Alcohol and Drug Misuse with Hospital Outcomes in Traumatic Injury Patients

Background: Traumatic injury is one of the most common causes of mortality worldwide. Previous research suggests that alcohol and drug misuse can increase the risk of experiencing these injuries. Method: Data on all hospital admissions due to traumatic injury in the Detroit metropolitan area between 2006 and 2014 were obtained from the Michigan State Inpatient Database. Patients with no recorded substance misuse comorbidity were compared with those who had (a) alcohol misuse comorbidity only, (b) drug misuse comorbidity only, and (c) both alcohol and drug misuse comorbidities. Outcomes examined included in-hospital mortality, length of stay, and total cost of care. Results: Generalized linear modeling was used to examine the relationship between substance misuse comorbidities and each of the three outcomes. Lower mortality was related to drug and drug/alcohol misuse. Longer length of stay was related to alcohol, drug, and alcohol/drug misuse. Total costs were higher for patients with comorbid alcohol misuse, but lower for those with comorbid drug misuse. These patterns of results were not changed after controlling for differences in background demographics and injury characteristics. Discussion: Alcohol and drug misuse were highly prevalent in trauma patients, in comparison to estimate for the US population as a whole. The relationship between substance misuse comorbidity and outcomes among trauma patient is not straightforward. Substance misuse of all types was related to longer hospitalization, but its association with cost and mortality was mixed. Assessment of substance misuse background at intake may help optimize care for trauma patients.

Cannabis, alcohol and cigarette use during the acute post-concussion period

Objective: To document the prevalence of acute post-concussion cannabis, alcohol and cigarette use and their association with clinical recovery and symptom burden.Methods: A prospective cohort study was conducted. Concussions were physician-diagnosed and presented to the emergency department and concussion clinic within 7 days post-injury. Participants were assessed weekly and followed for a minimum 4 weeks. A survival analysis (using physician-determined recovery to both cognitive and physical activities) in addition to a weekly symptom score analysis was conducted.Results: A total of 307 acute concussions with a mean age of 33.7 years (SD, 13.0) were included. Acute post-concussion cannabis, alcohol and cigarette use were identified in 43 (14.0%), 125 (40.7%) and 61 (19.9%) individuals. Acute cannabis, alcohol and cigarette use were not associated with recovery to cognitive (p > .05) or physical activity (p > .05). Acute cigarette use was associated with a higher unadjusted symptom severity score at week1 (p = .003). Acute cannabis use was associated with lower symptom severity scores at week-3 (p = .061) and week-4 (p = .029).Conclusion: In conclusion, cannabis, alcohol and cigarette use were prevalent in the acute period post-concussion; however, were not observed to impact recovery within the first 4 weeks post-injury. Amongst unrecovered individuals, acute cannabis use was associated with lower symptom burden, while cigarette use was associated with greater initial symptom burden.

Effects of ethyl alcohol on injuries severity according to injury severity scales in pedestrian fatal injury in traffic crashes

INTRODUCTION

The dominant cause of injuries in traffic crashes. A significant portion of them affects victims under the influence of ethyl alcohol. The goal of the studies was to assess the correlation between the state of sobriety and the severity of injuries expressed by injury severity scales in fatal pedestrian victims of traffic crashes. Research Material and Method: The data were obtained from the Warsaw Medical University's Department of Forensic Medicine. The analysis covered the data for 2009-2013 and included 200 fatal pedestrian victims hit by passenger cars. The assessment of the effect of risk factors on injury severity expressed in terms of injury severity scales such as Life Threat Indicator (LTI), International Classification based Injury Severity Score (ICISS), Injury Severity Score (ISS) and New Injury Severity Score (NISS), was made using adequately selected methods of statistical analysis.

RESULTS

As alcohol concentration increases in women, the values of LTI, ICISS-10 and ICISS-15 decrease, which denotes more severe injuries. In the ISS and NISS, the effect of alcohol concentration on the severity of injuries turned out to be negligible. However, these injuries are significantly heavier in women than in men. According to all the scales used, the older the victims, the milder injuries cause their death.

CONCLUSIONS

The studies show that ethyl alcohol concentration may harm injury severity, especially in the case of women. The assessment of the severity of injuries in traffic crash victims is significantly influenced by their age and gender. The more risk factors the scale takes into consideration, the more precise is the assessment.

Executive (dys)function after traumatic brain injury: special considerations for behavioral pharmacology

Executive function is an umbrella term that includes cognitive processes such as decision-making, impulse control, attention, behavioral flexibility, and working memory. Each of these processes depends largely upon monoaminergic (dopaminergic, serotonergic, and noradrenergic) neurotransmission in the frontal cortex, striatum, and hippocampus, among other brain areas. Traumatic brain injury (TBI) induces disruptions in monoaminergic signaling along several steps in the neurotransmission process - synthesis, distribution, and breakdown - and in turn, produces long-lasting deficits in several executive function domains. Understanding how TBI alters monoamingeric neurotransmission and executive function will advance basic knowledge of the underlying principles that govern executive function and potentially further treatment of cognitive deficits following such injury. In this review, we examine the influence of TBI on the following measures of executive function - impulsivity, behavioral flexibility, and working memory. We also describe monoaminergic-systems changes following TBI. Given that TBI patients experience alterations in monoaminergic signaling following injury, they may represent a unique population with regard to pharmacotherapy. We conclude this review by discussing some considerations for pharmacotherapy in the field of TBI.

Alcohol in Traumatic Brain Injury: Toxic or Therapeutic?

BACKGROUND

Alcohol (EtOH) poses a challenge in traumatic brain injuries (TBIs) given its metabolic and neurologic impact. Studies have had opposing results regarding mortality and complication rates in the intoxicated TBI patient. We hypothesized that trauma mechanism, brain injury severity, and blood alcohol concentration (BAC) would influence the impact of EtOH on mortality in TBI.

METHODS

We performed a single-institution retrospective review of consecutive adult trauma patients tested for EtOH and a diagnosis of TBI. The primary outcome was mortality, and secondary outcomes included infectious complications. The primary analysis included univariate and multivariate regression comparing mortality between intoxicated and sober patients, at different values of BAC, different brain injury severities, and among mechanisms of trauma.

RESULTS

Admission EtOH was assessed in 583 patients with TBI, with 256 testing positive for EtOH and 327 testing negative. Overall, EtOH was associated with lower mortality on univariate analysis (4.7% versus 8.9%, P = 0.05) but not on multivariate analysis (P = 0.21). There was no effect of EtOH on mortality when patients were stratified by brain injury severity or among penetrating trauma victims. However, EtOH was associated with lower overall infectious complications on univariate and multivariate regression. Finally, EtOH was predictive of mortality with an area under the receiver operator characteristic curve of 0.83.

CONCLUSIONS

We found that EtOH is not associated with mortality in the patient with TBI, suggesting no causative effect. However, EtOH showed some predictability of mortality based on a receiver operator characteristic analysis. Interestingly, EtOH was associated with lower infectious complications, suggesting an immunomodulatory effect of EtOH in TBI.

Enduring Neuroprotective Effect of Subacute Neural Stem Cell Transplantation After Penetrating TBI

Traumatic brain injury (TBI) is the largest cause of death and disability of persons under 45 years old, worldwide. Independent of the distribution, outcomes such as disability are associated with huge societal costs. The heterogeneity of TBI and its complicated biological response have helped clarify the limitations of current pharmacological approaches to TBI management. Five decades of effort have made some strides in reducing TBI mortality but little progress has been made to mitigate TBI-induced disability. Lessons learned from the failure of numerous randomized clinical trials and the inability to scale up results from single center clinical trials with neuroprotective agents led to the formation of organizations such as the Neurological Emergencies Treatment Trials (NETT) Network, and international collaborative comparative effectiveness research (CER) to re-orient TBI clinical research. With initiatives such as TRACK-TBI, generating rich and comprehensive human datasets with demographic, clinical, genomic, proteomic, imaging, and detailed outcome data across multiple time points has become the focus of the field in the United States (US). In addition, government institutions such as the US Department of Defense are investing in groups such as Operation Brain Trauma Therapy (OBTT), a multicenter, pre-clinical drug-screening consortium to address the barriers in translation. The consensus from such efforts including "The Lancet Neurology Commission" and current literature is that unmitigated cell death processes, incomplete debris clearance, aberrant neurotoxic immune, and glia cell response induce progressive tissue loss and spatiotemporal magnification of primary TBI. Our analysis suggests that the focus of neuroprotection research needs to shift from protecting dying and injured neurons at acute time points to modulating the aberrant glial response in sub-acute and chronic time points. One unexpected agent with neuroprotective properties that shows promise is transplantation of neural stem cells. In this review we present (i) a short survey of TBI epidemiology and summary of current care, (ii) findings of past neuroprotective clinical trials and possible reasons for failure based upon insights from human and preclinical TBI pathophysiology studies, including our group's inflammation-centered approach, (iii) the unmet need of TBI and unproven treatments and lastly, (iv) present evidence to support the rationale for sub-acute neural stem cell therapy to mediate enduring neuroprotection.

Functional Outcomes and Health-Related Quality of Life After Severe Traumatic Brain Injury: A Review

Throughout recovery, patients with severe traumatic brain injury (TBI) show physical and functional improvement, but continue to have cognitive and psychosocial problems. The aim of this article was to review the literature regarding the functional and health-related quality of life (HRQOL) outcomes in severe TBI. There were 15 articles reviewed, 13 of them were quantitative studies and two were narrative review. Most of the articles showed an improvement occurs rapidly at 6 months post-injury. There were several factors that influence the outcome after TBI, most of it was the Glasgow Coma Scale (GCS) on admission, age, educational level, duration of posttraumatic amnesia (PTA), and length of stay (LOS) in the Intensive Care Unit (ICU). Thus, health care workers should help the survivors of severe TBI in the recovery process to ensure the latter can attain maximum function and quality of life.

The impact of methamphetamines in patients with traumatic brain injury, a retrospective review

OBJECTIVE

Both neurotoxic and neuroprotective effects of methamphetamines (METH) are being studied. There are few studies evaluating the effects of METH on patients with traumatic brain injury (TBI). The objective of this study is to compare clinical outcomes after TBI in METH users versus non-METH users.

PATIENT AND METHODS

A retrospective review of 304 patients with severe traumatic head injury were performed. Patients were evaluated and stratified based on toxicology screening for methamphetamines (METH) or none. Of the patients reviewed with a full toxicology, 24 of those patients were positive for METH, and 60 patients were negative. Patients were evaluated based on demographics, type of injury, Glasgow Coma Scale (GCS), and Glasgow Outcome Scale (GOS).

RESULTS

METH patients were younger upon presentation (43.5 versus 55.8, p = 0.003), with a larger improvement in GCS and GOS upon discharge (P = 0.012, 0.0001 respectively). There was no significant difference in length of hospital stay, initial presenting GCS and GOS, or discharge GCS and GOS.

CONCLUSIONS

Our findings demonstrate an improved change in GCS and GOS for those positive with METH than those without. Surprisingly, substance positive patients did not have a worse outcome score. Further investigation is necessary to evaluate the potential neuro-protective effects of METH in TBI.

The Impact of Methamphetamine Use on Trauma Patients at a Level I Trauma Center: A 10-Year Retrospective Review

The effects of methamphetamines (MAs) on trauma patient outcomes have been evaluated, but with discordant results. The purpose of this study was to identify hospital outcomes associated with MA use after traumatic injury. Retrospective review of adult trauma patients admitted to an American College of Surgeons verified–Level I trauma center who received a urine drug screen (UDS) between January 1, 2004 and December 31, 2013. Logistic regression analysis was used to identify factors associated with mortality. Patients with a negative UDS were used as controls. Among the 2321 patients included, 75.1 per cent were male, 81.9 per cent were white, and the average age was 39. Patients were grouped by UDS results (negative, MA only, other drug plus MA, or other drug without MA). A positive drug screen result of other drug without MA demonstrated a significantly lower risk for mortality, but longer intensive care unit and hospital length of stay, as well as increased ventilator days than negative results. Results of MA only did not alter the risk of mortality. These findings suggest that patients who test positive for MAs are not at an increased risk of in-hospital mortality when compared with patients having a negative drug screen.

Association of Alcohol With Mortality After Traumatic Brain Injury

Although alcohol exposure results in reduced mortality after traumatic brain injury (TBI) in animal models, clinical trials based on proposed mechanisms have been disappointing and have reported conflicting results. Methodological issues common to many of these clinical studies may have contributed to the spurious results. Our objective was to evaluate the association between blood alcohol concentration (BAC) and in-hospital mortality after TBI, and overcome methodological problems of prior studies. We conducted a retrospective cohort study on individuals treated for isolated TBI (n = 1,084) at the R Adams Cowley Shock Trauma Center (Baltimore, Maryland) from 1997 to 2012. We excluded individuals with injury to other body regions and examined multiple cutpoints of BAC. Our primary outcome was in-hospital mortality. In adjusted logistic regression models, the upper level of each blood alcohol categorization from 0.10 g/dL (odds ratio = 0.63, 95% confidence interval: 0.40, 0.97) through 0.30 g/dL (odds ratio = 0.25, 95% confidence interval: 0.08, 0.84) was associated with reduced risk of mortality after TBI compared with individuals with undetectable BAC. In sensitivity analyses among individuals without penetrating brain injuries (95% firearm-related) (n = 899), the protective association was eliminated. This study provides evidence that the observed protective association between BAC and in-hospital mortality after TBI resulted from bias introduced by inclusion of penetrating injuries.

Cannabis Use Has Negligible Effects Following Severe Traumatic Injury

Nearly half of all states have legalized medical marijuana or recreational-use marijuana. As more states move toward legalization, the effects on injured patients must be evaluated. This study sought to determine effects of cannabis positivity at the time of severe injury on hospital outcomes compared with individuals negative for illicit substances and those who were users of other illicit substances. A Level I trauma center performed a retrospective chart review covering subjects over a 2-year period with toxicology performed and an Injury Severity Score (ISS) of more than 16. These individuals were divided into the negative and positive toxicology groups, further divided into the marijuana-only, other drugs-only, and mixed-use groups. Differences in presenting characteristics, hospital length of stay, intensive care unit (ICU) stays, ventilator days, and death were compared. A total of 8,441 subjects presented during the study period; 2,134 (25%) of these had toxicology performed; 843 (40%) had an ISS of more than 16, with 347 having negative tests (NEG); 70 (8.3%) substance users tested positive only for marijuana (MO), 323 (38.3%) for other drugs-only, excluding marijuana (OD), and 103 (12.2%) subjects showed positivity for mixed-use (MU). The ISS was similar for all groups. No differences were identified in Glasgow Coma Scale (GCS), ventilator days, blood administration, or ICU/hospital length of stay when comparing the MO group with the NEG group. Significant differences occurred between the OD group and the NEG/MO/MU groups for GCS, ICU length of stay, and hospital charges. Cannabis users suffering from severe injury demonstrated no detrimental outcomes in this study compared with nondrug users.

Acute Alcohol Exposure and Risk of Mortality of Patients with Traumatic Brain Injury: A Systematic Review and Meta-Analysis

After traumatic brain injury (TBI), patients usually live with significant disability and socioeconomic burdens. Acute exposure to alcohol is considered a major risk factor for TBI. Numerous studies have examined whether alcohol exposure is related to the risk of mortality in patients with TBI, yet the results remain inconsistent. We performed a meta-analysis to assess whether acute alcohol exposure affects the mortality rate of TBI patients. We searched PubMed, EMBASE, and the Cochrane Library up to November 2015 for relevant studies. We screened studies based on their inclusion criteria and selected the studies that reported mortality rate, which included 18 observational studies. We used R to analyze the included data. An initial result showed that the presence of a positive blood alcohol concentration (BAC) had no significant relation with mortality rate (OR = 0.92, 95% CI = 0.83 to 1.01), but there was notable heterogeneity along with variable results according to sensitivity analysis. For the BAC-positive population, low BAC (1 to 100 mg/dl) carried a higher risk of mortality than moderate BAC (100 to 230 mg/dl) (OR = 1.40, 95% CI = 1.09 to 1.81), moderate and high BAC as a single category (>100 mg/dl) (OR = 1.57, 95% CI = 1.28 to 1.94), or high BAC (>230 mg/dl) (OR = 1.76, 95% CI = 1.34 to 2.30). However, moderate BAC did not increase the mortality risk when compared with high BAC (OR = 1.20, 95% CI = 0.89 to 1.63). Whether positive BAC at the time of admission after TBI reduces mortality rate compared with the rate under negative BAC remains unknown. In addition, low BAC (1 to 100 mg/dl) poses a risk of mortality compared with higher BAC. Further studies assessing the effect of alcohol between the BAC-positive group and the BAC-negative group are still needed.

The Differential Impact of Alcohol and Interpersonal Violence on the Severity of Violent Traumatic Brain Injuries among American Indians

Research shows connections between substance use and traumatic brain injury (TBI), high rates of substance use and interpersonal violence (IPV) in American Indians with TBI, and connections between IPV and TBI. This study assessed the effects of substance use at the time of a violent TBI and possible mediators such as American Indian race on injury severity (injury severity score [ISS]). A secondary data analysis of 3,351 individuals who experienced a TBI due to violence was conducted. American Indians with TBI were more likely to experience IPV (χ² = 4.19; p = .04) and had significantly higher blood alcohol content level (BAC) scores (t = - 16.78; p = .000) than other racial groups. A regression model explained 27% of the variance in ISS. Significant interaction terms uncovered positive relationships between: (a) American Indian race and ISS when the injury aetiology was not IPV and BAC scores were lower than the legal limit, and (b) IPV and ISS when patients were not American Indian. Alcohol was negatively associated with ISS among American Indians, suggesting that BAC may impact individuals with TBI differentially as a function of race.

Alcohol Intake and Reduced Mortality in Patients with Traumatic Brain Injury

BACKGROUND

The purpose of our study was to determine whether alcohol intake influences short-term mortality in patients with traumatic brain injury (TBI), using a comprehensive trauma database.

METHODS

We collected data from 7 emergency departments (EDs) between June 1, 2008 and May 31, 2010, using the same data form. Cases were included if they met the following criteria: (i) older than 15 and (ii) injuries including TBI. Demographics and outcomes were compared between patients with and without alcohol intake. We present the risk of mortality using hazard ratios and 95% confidence intervals.

RESULTS

A total of 76,596 trauma patients visited the EDs during the study period; 12,980 patients were older than 15 and had TBI. There were 4,009 (30.9%) patients in the alcohol-intake group, of whom 3,306 (82.5%) patients were male, 1,450 (36.2%) patients were moved by ambulance, and 1,218 (30.4%) patients' injuries were intentional. The most frequent injury mechanism was falling down with alcohol intake and blunt injury without alcohol intake. Mortality rate was 1.0% with alcohol intake and 2.0% without alcohol intake. After adjusting for all factors related to mortality, the hazard ratio of mortality was 0.72 in the alcohol-intake group.

CONCLUSIONS

Mortality rate due to TBI in the alcohol-intake group appears to be lower compared to that in the no-alcohol-intake group after adjusting for main confounding variables.

The Moderation of Blood Alcohol Levels on Higher Odds of Survival among American Indians with Violent, Blunt-Force Traumatic Brain Injuries

This study assessed the moderation of blood alcohol level (BAL) and American Indian race on survival of patients with violent traumatic brain injury (TBI). An initial logistic regression model indicated that those who were American Indian and insured had higher odds of survival and those with higher injury severity scores and low-medium BAL were less likely to survive. A second logistic regression model including a relationship between American Indians and BAL found that American Indians had a higher odds of survival which tripled when they have no BAL. Low-medium and high BAL were associated with less likelihood of survival among White patients.

The neuroprotective potential of low-dose methamphetamine in preclinical models of stroke and traumatic brain injury

Methamphetamine is a psychostimulant that was initially synthesized in 1920. Since then it has been used to treat attention deficit hyperactive disorder (ADHD), obesity and narcolepsy. However, methamphetamine has also become a major drug of abuse worldwide. Under conditions of abuse, which involve the administration of high repetitive doses, methamphetamine can produce considerable neurotoxic effects. However, recent evidence from our laboratory indicates that low doses of methamphetamine can produce robust neuroprotection when administered within 12h after severe traumatic brain injury (TBI) in rodents. Thus, it appears that methamphetamine under certain circumstances and correct dosing can produce a neuroprotective effect. This review addresses the neuroprotective potential of methamphetamine and focuses on the potential beneficial application for TBI.

Ethanol and isolated traumatic brain injury

The aim of this systematic review was to determine whether ethanol is neuroprotective or associated with adverse effects in the context of traumatic brain injury (TBI). Approximately 30-60% of TBI patients are intoxicated with ethanol at the time of injury. We performed a systematic review of the literature using a combination of keywords for ethanol and TBI. Manuscripts were included if the population studied was human subjects with isolated moderate to severe TBI, acute ethanol intoxication was studied as an exposure variable and mortality reported as an outcome. The included studies were assessed for heterogeneity. A meta-analysis was performed and the pooled odds ratio (OR) for the association between ethanol and in-hospital mortality reported. There were seven studies eligible for analysis. A statistically significant association favouring reduced mortality with ethanol intoxication was found (OR 0.78; 95% confidence interval 0.73-0.83). Heterogeneity among selected studies was not statistically significant (p=0.25). Following isolated moderate-severe TBI, ethanol intoxication was associated with reduced in-hospital mortality. The retrospective nature of the studies, varying definitions of brain injury, degree of intoxication and presence of potential confounders limits our confidence in this conclusion. Further research is recommended to explore the potential use of ethanol as a therapeutic strategy following TBI.

The prevalence of positive drug and alcohol screens in elderly trauma patients

BACKGROUND

Alcohol and drug abuse are recognized to be significantly prevalent in trauma patients, and are frequent harbingers of injury. The incidence of substance abuse in elderly trauma patients has, however, been limitedly examined. The authors sought to identify the spectrum of positive alcohol and drug toxicology screens in patients ≥65 years admitted to a Level I trauma center.

METHODS

Patients ≥65 years old admitted to an American College of Surgeons (ACS) Level I trauma center over a 60--month period were identified from the trauma registry. Demographic data, blood alcohol content (BAC), and urine drug screen (UDS) results at admission were obtained and analyzed. The positive results were compared with individuals below 65 years in different substance categories using Fisher's exact test.

RESULTS

In the 5-year period studied, of the 4139 patients ≥65 years, 1302 (31.5%) underwent toxicological substance screening. A positive BAC was present in 11.1% of these patients and a positive UDS in 48.3%. The mean BAC level in those tested was 163 mg/dL and 69% of patients had a level >80 mg/dL.

CONCLUSIONS

These data show that alcohol and drug abuse are an issue in patients ≥65 years in our institution, though not as pervasive a problem as in younger populations. Admission toxicology screens, however, are important as an aid to identify geriatric individuals who may require intervention.

Acute alcohol intoxication and long-term outcome in patients with traumatic brain injury

The effect of blood alcohol concentration (BAC) on outcome after traumatic brain injury (TBI) is controversial. We sought to assess the independent effect of positive BAC on long-term outcome in patients with TBI treated in the intensive care unit (ICU). We performed a retrospective analysis of 405 patients with TBI, admitted to the ICU of a large urban Level 1 trauma center between January 2009 and December 2012. Outcome was six-month mortality and unfavorable neurological outcome (defined as a Glasgow Outcome Scale score of 1 [death], 2, [vegetative state], or 3 [severe disability]). Patients were categorized by admission BAC into: no BAC (0.0‰; n=99), low BAC (<2.3‰; n=140) and high BAC (≥2.3‰; n=166). Logistic regression analysis, adjusting for baseline risk and severity of illness, was used to assess the independent effect of BAC on outcome (using the no BAC group as the reference). Overall six-month mortality was 25% and unfavorable outcome was 46%. Multivariate analysis showed low BAC to independently reduce risk of six-month mortality compared with no BAC (low BAC adjusted odds ratio [AOR] 0.41, 95% confidence interval [CI] 0.19-0.88, p=0.021) and high BAC (AOR 0.58, 95% CI 0.29-1.15, p=0.120). Furthermore, a trend towards reduced risk of six-month unfavorable neurological outcome for patients with positive BAC, compared to patients with negative BAC, was noted, although this did not reach statistical significance (low BAC AOR 0.65, 95% CI 0.34-1.22, p=0.178, and high BAC AOR 0.59, 95% CI 0.32-1.09, p=0.089). In conclusion, low admission BAC (<2.3‰) was found to independently reduce risk of six-month mortality for patients with TBI, and a trend towards improved long-term neurological outcome was found for BAC-positive patients. The role of alcohol as a neuroprotective agent warrants further studies.

Effect of Marijuana Use on Outcomes in Traumatic Brain Injury

Traumatic brain injury (TBI) is associated with significant morbidity and mortality. Several studies have demonstrated neuroprotective effects of cannabinoids. The objective of this study was to establish a relationship between the presence of a positive toxicology screen for tetrahydrocannabinol (THC) and mortality after TBI. A 3-year retrospective review of registry data at a Level I center of patients sustaining TBI having a toxicology screen was performed. Pediatric patients (younger than 15 years) and patients with a suspected nonsurvivable injury were excluded. The THC(+) group was compared with the THC(-) group with respect to injury mechanism, severity, disposition, and mortality. Logistic regression was used to determine independent associations with mortality. There were 446 cases meeting all inclusion criteria. The incidence of a positive THC screen was 18.4 per cent (82). Overall mortality was 9.9 per cent (44); however, mortality in the THC(+) group (2.4% [two]) was significantly decreased compared with the THC(-) group (11.5% [42]; P = 0.012). After adjusting for differences between the study cohorts on logistic regression, a THC(+) screen was independently associated with survival after TBI (odds ratio, 0.224; 95% confidence interval, 0.051 to 0.991; P = 0.049). A positive THC screen is associated with decreased mortality in adult patients sustaining TBI.

Complications associated with blood alcohol concentration following injury

Alcohol increases the risk of injuring oneself and others. However, following an injury there appears to be a benefit to alcohol in mediating the body's response to a traumatic injury and reducing mortality. The physiological mechanism underlying this reported association is poorly understood. One approach to explaining the pathways by which alcohol affects acute mortality following a traumatic injury is to identify differential prevalence of medical complications associated with increased mortality. The goal of this study was to evaluate the association between blood alcohol concentration and complications subsequent to a traumatic injury that are associated with increased in-hospital mortality. This study involved a retrospective analysis of traumatic injuries occurring between 2000 and 2009 as reported by all level I and II trauma units in the state of Illinois. The study includes all patients with blood alcohol toxicological examination levels ranging from zero to 500 mg/dL and meeting additional inclusion criteria (n = 84,974). A reduction in complications of cardiac and renal function by 23.5% and 30.0%, respectively, was attributable to blood alcohol concentration. In addition, blood alcohol concentration was associated with fewer cases of pneumothorax and convulsions. However, blood alcohol concentration continued to be positively associated with aspiration pneumonitis and acute pancreatitis in the final models. The net impact of alcohol following an injury is protective, largely attributable to a reduction in complications relating to cardiac and renal function. This study helps to explain the observed protective effect from blood alcohol concentrations in reducing in-hospital mortality after an injury, as reported in many studies.

Acute alcohol intoxication, diffuse axonal injury and intraventricular bleeding in patients with isolated blunt traumatic brain injury

OBJECTIVE

The influence of blood alcohol level (BAL) on outcome remains unclear. This study investigated the relationships between BAL, type and number of diffuse axonal injury (DAI), intraventricular bleeding (IVB) and 6-month outcome.

METHODS

This study reviewed 419 patients with isolated blunt traumatic brain injury. First, it compared clinical and radiological characteristics between patients with good recovery and disability. Second, it compared BAL among DAI lesions. Third, it evaluated the correlation between the BAL and severity of IVB, number of DAI and corpus callosum injury lesions.

RESULTS

Regardless of BAL, older age, male gender, severe Glasgow Coma Scale score (<9), abnormal pupil, IVB and lesion on genu of corpus callosum were significantly related to disability. There were no significant differences between the BAL and lesions of DAI. Simple regression analysis revealed that there were no significant correlation between BAL and severity of IVB, number of DAI and corpus callosum injury lesions.

CONCLUSIONS

Acute alcohol intoxication was not associated with type and number of DAI lesion, IVB and disability. This study suggested that a specific type of traumatic lesion, specifically lesion on genu of corpus callosum and IVB, might be more vital for outcome.

Preinjury alcohol exposure attenuates the neuroinflammatory response to traumatic brain injury

BACKGROUND

Traumatic brain injury (TBI) initiates a neuroinflammatory response that increases the risk of TBI-related mortality. Acute alcohol intoxication at the time of TBI is associated with improved survival. Ethanol is recognized as a systemic immunomodulator that may also impart neuroprotection. The effects of alcohol on TBI-induced neuroinflammation, however, are unknown. We hypothesized that ethanol treatment prior to TBI may provide neuroprotection by diminishing the neuroinflammatory response to injury.

MATERIALS AND METHODS

Mice underwent gavage with ethanol (EtOH) or water (H2O) prior to TBI. Animals were subjected to blunt TBI or sham injury (Sham). Posttraumatic rapid righting reflex (RRR) and apnea times were assessed. Cerebral and serum samples were analyzed by ELISA for inflammatory cytokine levels. Serum neuron-specific enolase (NSE), a biomarker of injury severity, was also measured.

RESULTS

Neurologic recovery from TBI was more rapid in H2O-treated mice compared with EtOH-treated mice. However, EtOH/TBI mice had a 4-fold increase in RRR time compared with EtOH/Sham, whereas H2O/TBI mice had a 15-fold increase in RRR time compared with H2O/Sham. Ethanol intoxication at the time of TBI significantly increased posttraumatic apnea time. Preinjury EtOH treatment was associated with reduced levels of proinflammatory cytokines IL-6, KC, MCP-1, and MIP-1α post TBI. NSE was significantly increased post injury in the H2O/TBI group compared with H2O/Sham but was not significantly reduced by EtOH pretreatment.

CONCLUSIONS

Alcohol treatment prior to TBI reduces the local neuroinflammatory response to injury. The decreased neurologic and inflammatory impact of TBI in acutely intoxicated patients may be responsible for improved clinical outcomes.

Dose-response relationship between in-hospital mortality and alcohol following acute injury

Although the relationship between alcohol and injury incidence is well researched, there continues to be dispute about the relationship between alcohol and mortality following an injury. Findings from past studies have varied primarily because of methodological issues and have failed to characterize the dose-response relationship. The main objective of this study was to evaluate the dose response relationship of in-hospital mortality and blood alcohol concentration (BAC). This study was a retrospective analysis of traumatic injuries occurring between 1995 and 2009 as reported by all level 1 and 2 trauma units in the State of Illinois. The study includes all patients with blood alcohol toxicological examination levels ranging from zero to 500 mg/dl (N = 190,612). The Illinois trauma registry includes all patients sustaining traumatic injuries and admitted to a trauma center for ≥12 h. A total of 6733 patients meeting the inclusion criteria died following admission. Patients that were dead on arrival and those that died during the initial assessment within the emergency room were excluded. In the adjusted multivariable model, a decrease in in-hospital mortality was strongly associated with an increase in blood alcohol concentration (adjusted OR = 0.83 per 100 mg/dl units change in BAC; CI 95%: 0.80, 0.85; p < 0.001). The direction of the dose response relationship was consistent across the stratified models, with the exception of patients suffering burns. The largest reduction of in-hospital case fatality rates by blood alcohol concentration was observed among patients suffering penetrating or severe injuries (Injury Severity Score ≥ 16). In the clinical setting, it is important to understand not only how to recognize intoxicated patients, but also how alcohol may affect the course of treatment. The consistency of the findings across the multivariable models indicates that blood alcohol concentration is strongly associated with lower in-hospital mortality among those that survive long enough to receive treatment in specialized trauma units.

Treatment with low-dose methamphetamine improves behavioral and cognitive function after severe traumatic brain injury

BACKGROUND

Methamphetamine increases the release and blocks the reuptake of dopamine. The moderate activation of dopamine receptors may elicit neuroprotective effects. We have recently demonstrated that low doses of methamphetamine reduce neuronal loss after ischemic injury. On the basis of this finding, we hypothesized that methamphetamine could also prevent neuronal loss and improve functional behavior after severe traumatic brain injury (TBI).

METHODS

The rat lateral fluid percussion injury model was used to generate severe TBI. Three hours after injury, animals were treated with saline or methamphetamine. Neurological severity scores and foot fault assessments were used to determine whether treatment enhanced recovery after injury. The potential for methamphetamine treatment to improve cognitive function was assessed using the Morris water maze. Forty-eight hours after injury, paraffin-embedded brain sections were TUNEL stained to measure apoptotic cell death. Sections were also stained with antibody to doublecortin to quantify immature neurons within the dentate gyrus.

RESULTS

Treatment with low-dose methamphetamine significantly reduced both behavioral and cognitive dysfunction after severe TBI. Methamphetamine-treated animals scored significantly lower on neurological severity scores and had significantly less foot faults after TBI compared with saline-treated control rats. Furthermore, methamphetamine treatment restored learning and memory function to near normal ability after TBI. At 48 hours after injury, apoptotic cell death within the hippocampus was significantly reduced, and the presence of immature neurons was significantly increased in methamphetamine-treated rats compared with saline-treated controls.

CONCLUSION

Treatment with low-dose methamphetamine after severe TBI elicits a robust neuroprotective response resulting in significant improvements in behavioral and cognitive functions.

Alcohol use at time of injury and survival following traumatic brain injury: results from the National Trauma Data Bank

OBJECTIVE

Premised on biological evidence from animal research, recent clinical studies have, for the most part, concluded that elevated blood alcohol concentration levels are independently associated with higher survival or decreased mortality in patients with moderate to severe traumatic brain injury (TBI). This study aims to provide some counterevidence to this claim and to further future investigations.

METHOD

Incident data were drawn from the largest U.S. trauma registry, the National Trauma Data Bank, for emergency department admission years 2002-2006. TBI was identified according to the National Trauma Data Bank's definition using International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM), codes. To eliminate confounding, the exact matching method was used to match alcohol-positive with alcohol-negative incidents on sex, age, race/ethnicity, and facility. Logistic regression compared in-hospital mortality between 44,043 alcohol-positive and 59,817 matched alcohol-negative TBI incidents, with and without causes and intents of TBI and Injury Severity Score as covariates. A sensitivity analysis was performed within a subsample of isolated moderate to severe TBI incidents.

RESULTS

Alcohol use at the time of injury was found to be significantly associated with an increased risk for TBI. Including varied causes and intents of TBI and Injury Severity Score as potential confounders in the regression model explained away the statistical significance of the seemingly protective effect of alcohol against TBI mortality for all TBIs and for isolated moderate to severe TBIs.

CONCLUSIONS

The null finding shows that the purported reduction in TBI mortality attributed to positive blood alcohol likely is attributable to residual confounding. Accordingly, the risk of TBI associated with alcohol use should not be overlooked.

Correlating the Blood Alcohol Concentration with Outcome after Traumatic Brain Injury: Too Much Is Not a Bad Thing

Although recent evidence suggests a beneficial effect of alcohol for patients with traumatic brain injury (TBI), the level of alcohol that confers the protective effect is unknown. Our objective was to investigate the relationship between admission blood alcohol concentration (BAC) and outcomes in patients with isolated moderate to severe TBI. From 2005 to 2009, the Los Angeles County Trauma Database was queried for all patients ≥14 years of age with isolated moderate to severe TBI and admission serum alcohol levels. Patients were then stratified into four levels based on admission BAC: None (0 mg/dL), low (0-100 mg/dL), moderate (100-230 mg/dL), and high (≥230 mg/dL). Demographics, patient characteristics, and outcomes were compared across levels. In evaluating 3794 patients, the mortality rate decreased with increasing BAC levels (linear trend P < 0.0001). In determining the relationship between BAC and mortality, multivariable logistic regression analysis demonstrated a high BAC level was significantly protective (adjusted odds ratio 0.55; 95% confidence interval: 0.38-0.8; P = 0.002). In the largest study to date, a high (≥230 mg/dL) admission BAC was independently associated with improved survival in patients with isolated moderate to severe TBI. Additional research is warranted to investigate the potential therapeutic implications.

[Classification of mental disorders in the Intensive Care Unit]

PURPOSE

To determine the incidence and characteristics of mental disorders (MD) in the Intensive Care Unit (ICU), and to define a classification system adapted to the ICU environment.

DESIGN

A retrospective, descriptive analysis.

SETTING

Intensive Care Unit, Arnau de Vilanova Hospital in Lérida (Spain).

PATIENTS

All patients with MD admitted during 5-year period (January, 1 2004 to December 31, 2008).

MAIN VARIABLES

General variables included clinical-demographic data, diagnostic variables, procedures, severity score, length of stay and mortality. Specific variables included psychiatric history, screening for substance abuse, psychiatric assessment, monitoring and transfer to a psychiatric center. Classification of the MD was as follows: 1) acute substance intoxication (SI); 2) suicide attempts (SA); and 3) MD associated with the main diagnosis (AMD).

RESULTS

A total of 146 patients had MD (7.8%); they were predominantly male (74%) and were younger than the general ICU population (43.9 vs. 55.3 years, p<0.001). The ICU stays of the patients with MDs were shorter (4 days vs. 7 days, p<0.001), and there was less hospital mortality (17.1 vs. 25%, p<0.05). They also showed a higher incidence of pneumonia (19.9 vs. 13.8%, p<0.05), but no differences in the level of severity were observed. The SI group (24.7%) contained the highest number of young people; the SA group (36.3%) showed a predominance of women; and the AMD (39%) group had the longest stays and the highest mortality. Psychiatric consultation was carried out mainly in the SA group (62.3%).

CONCLUSIONS

MD is a relatively common problem in the ICU. Collaboration with the Psychiatry Department seldom occurs, but must be encouraged to develop fully integrated management of critical patients with MD.

Alcohol is associated with a lower pneumonia rate after traumatic brain injury

BACKGROUND

Recent evidence supports the beneficial effect of alcohol on patients with traumatic brain injury (TBI). Pneumonia is a known complication following TBI; thus, the purpose of this study was to evaluate the effects of alcohol on pneumonia rates following moderate to severe TBI.

METHODS

From 2005 to 2009, the Los Angeles County Trauma Database was queried for all patients ≥ 14 y of age with isolated moderate to severe TBI and admission serum alcohol levels. The incidence of pneumonia was compared between TBI patients with and without a positive blood alcohol concentration (BAC) level. The study population was then stratified into four BAC levels: None (0 mg/dL), low (0-100 mg/dL), moderate (100-230 mg/dL), and high (≥ 230 mg/dL). Pneumonia rates were compared across these levels.

RESULTS

A total of 3547 patients with isolated, moderate to severe TBI were evaluated. Nearly 66% tested positive for alcohol. The pneumonia rate was significantly lower in the TBI patients who tested positive for alcohol (2.5%) compared with those who tested negative (4.0%, P = 0.017). The pneumonia rate also decreased across increasing BAC levels (linear trend P = 0.03). After logistic regression analysis, a positive ethanol (ETOH) level was associated with a reduced incidence of pneumonia (AOR = 0.62; 95%CI: 0.41-0.93; P = 0.020).

CONCLUSION

A positive serum alcohol level was associated with a significantly lower pneumonia rate in isolated, moderate to severe TBI patients. This may explain the observed mortality reduction in TBI patients who test positive for alcohol. Additional research is warranted to investigate the potential therapeutic implications of this association.

Low dose methamphetamine mediates neuroprotection through a PI3K-AKT pathway

High doses of methamphetamine induce the excessive release of dopamine resulting in neurotoxicity. However, moderate activation of dopamine receptors can promote neuroprotection. Therefore, we used in vitro and in vivo models of stroke to test the hypothesis that low doses of methamphetamine could induce neuroprotection. We demonstrate that methamphetamine does induce a robust, dose-dependent, neuroprotective response in rat organotypic hippocampal slice cultures exposed to oxygen-glucose deprivation (OGD). A similar dose dependant neuroprotective effect was observed in rats that received an embolic middle cerebral artery occlusion (MCAO). Significant improvements in behavioral outcomes were observed in rats when methamphetamine administration delayed for up to 12 h after MCAO. Methamphetamine-mediated neuroprotection was significantly reduced in slice cultures by the addition of D1 and D2 dopamine receptor antagonist. Treatment of slice cultures with methamphetamine resulted in the dopamine-mediated activation of AKT in a PI3K dependant manner. A similar increase in phosphorylated AKT was observed in the striatum, cortex and hippocampus of methamphetamine treated rats following MCAO. Methamphetamine-mediated neuroprotection was lost in rats when PI3K activity was blocked by wortmannin. Finally, methamphetamine treatment decreased both cleaved caspase 3 levels in slice cultures following OGD and TUNEL staining within the striatum and cortex in rats following transient MCAO. These data indicate that methamphetamine can mediate neuroprotection through activation of a dopamine/PI3K/AKT-signaling pathway.

The intriguing effects of ecstasy (MDMA) on cognitive function in mice subjected to a minimal traumatic brain injury (mTBI)

RATIONALE

The use of ecstasy (MDMA) among young adults has dramatically increased over the years. Since MDMA may impair the users' driving ability, the risk of being involved in a motor vehicle accident (MVA) is notably increased. Minimal traumatic brain injury (mTBI) a common consequence of MVAs-produces short- and long-term physical, cognitive, and emotional impairments.

OBJECTIVES

To investigate the effects of an acute dose of MDMA in mice subjected to closed head mTBI.

METHODS

Mice received 10 mg/kg MDMA 1 h prior to the induction of mTBI. Behavioral tests were conducted 7 and 30 days post-injury. In addition to the behavioral tests, phosphorylation of IGF-1R, ERK, and levels of tyrosine hydroxylase (TH) were measured.

RESULTS

mTBI mice showed major cognitive impairments in all cognitive tests conducted. No additional impairments were seen if mTBI was preceded by one dose of MDMA. On the contrary, a beneficial effect was seen in these mice. The western blot analysis of TH revealed a significant decrease in the mTBI mice. These decreases were reversed in mice that were subjected to MDMA prior to the trauma.

CONCLUSIONS

The presence of MDMA at the time of mTBI minimizes the alteration of visual and spatial memory of the injured mice. The IGF-1R pathway was activated due to mTBI and MDMA but was not the main contributor to the cognitive improvements. MDMA administration inverted the TH decreases seen after injury. We believe this may be the major cause of the cognitive improvements seen in these mice.

A systematic review of factors contributing to outcomes in patients with traumatic brain injury

AIM AND OBJECTIVE

To review, systematically, factors contributing to outcomes in patients with traumatic brain injury.

BACKGROUND

Traumatic brain injury is a leading cause of death and disability. Several studies have determined the significant predictors of outcomes after traumatic brain injury. The comprehensive identification of these reliable factors for traumatic brain injury is critical to both clinical practice and research.

DESIGN

Systematic literature review.

METHODS

Eligible studies that combined at least two variables to predict outcomes in patient with traumatic brain injury were identified via electronic database searches, footnote chasing and contact with clinical experts. Quality of selected studies was assessed in terms of internal and external validity using 15 questions. Two reviewers independently examined titles, abstracts and whether each met the predefined inclusion criteria.

RESULTS

A total of 46 studies which met review criteria were finally selected. Most studies satisfied internal validity in terms of validity of research variables and multivariate analysis, but few were validated externally. The following factors were significantly associated with unfavourable outcomes: sociodemographic factors such as older age, male gender, lower level of education; clinical factors such as lower Glasgow Coma Scale score, injury caused by motor vehicle crash, hypotension, hypoxia, increased intracranial pressure, no pupil reaction, hypo- or hyperglycaemia, anaemia, coagulopathy, hypo- or hyperthermia, abnormal level of electrolytes, duration of coma; higher level of computed tomography classification by Marshall category; type of intracerebral lesions.

CONCLUSION

Further studies on integrating the sociodemographic factors, the course of the clinical condition and a unified CT scoring system, are recommended for the evaluation and improvement of the prognosis of traumatic brain injury.

RELEVANCE TO CLINICAL PRACTICE

A systematic review of factors contributing to outcome for patients with traumatic brain injury will be invaluable in triage criteria, injury prognostication, care and discharge planning, resource use and patient and family counselling.

Night admission to the emergency department: a factor delaying time to surgery in patients with head injury

AIM

To investigate factors influencing time from patient's arrival at the emergency department to surgery in patients with head injury.

BACKGROUND

A better understanding of factors influencing variation in time from patient's arrival at the emergency department to surgery for patients with head trauma could reduce mortality and morbidity associated with injury.

DESIGN

A cross-sectional study of secondary data.

METHODS

The sample represented 493 patients with head injury requiring surgery from the 17 level I and II trauma centres. Data were extracted from the National Trauma Data Bank version 4.0. Two-level hierarchical models were used to analyse data at the patient level while incorporating a unique random effect for each trauma centre. Factors entered in the models included patient characteristics and trauma centre characteristics.

RESULTS

Patients with a Glasgow coma scale score of 3-8 in the first ED assessment had earlier time to surgery compared with those with a Glasgow coma scale of 13-15 (β = -0·31, 95% CI = -0·43-0·18). Patients who arrived at the hospital during the nighttime (6pm-8am) had a significantly delayed time to surgery than those who arrived during the daytime (8am-6pm) (β = -0·15, 95% CI = -0·26 to -0·04).

CONCLUSIONS

The more severely the injured patients were the faster surgery was performed. The time, when patients arrived to the emergency department was found to be a significant factor influencing time to surgery. Patients who arrived at emergency department at night had longer time to surgery than those who arrived during daytime, despite they were more severely head injured than those who arrived during the day.

RELEVANCE TO CLINICAL PRACTICE

When surgical intervention in head-injured patients is anticipated, especially during the night shift, time from patient's arrival at emergency department to surgery should be consistently assessed to identify opportunities for improvement in the structure and process of trauma care.