1
|
Bouvier D, Cantais A, Laspougeas A, Lorton F, Plenier Y, Cottier M, Fournier P, Tran A, Moreau E, Durif J, Sarret C, Mourgues C, Sturtz F, Oudart JB, Raffort J, Gonzalo P, Cristol JP, Masson D, Pereira B, Sapin V. Serum S100B Level in the Management of Pediatric Minor Head Trauma: A Randomized Clinical Trial. JAMA Netw Open 2024; 7:e242366. [PMID: 38502126 PMCID: PMC10951739 DOI: 10.1001/jamanetworkopen.2024.2366] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/19/2023] [Accepted: 01/23/2024] [Indexed: 03/20/2024] Open
Abstract
Importance Minor head trauma (HT) is one of the most common causes of hospitalization in children. A diagnostic test could prevent unnecessary hospitalizations and cranial computed tomographic (CCT) scans. Objective To evaluate the effectiveness of serum S100B values in reducing exposure to CCT scans and in-hospital observation in children with minor HT. Design, Setting, and Participants This multicenter, unblinded, prospective, interventional randomized clinical trial used a stepped-wedge cluster design to compare S100B biomonitoring and control groups at 11 centers in France. Participants included children and adolescents 16 years or younger (hereinafter referred to as children) admitted to the emergency department with minor HT. The enrollment period was November 1, 2016, to October 31, 2021, with a follow-up period of 1 month for each patient. Data were analyzed from March 7 to May 29, 2023, based on the modified intention-to-treat and per protocol populations. Interventions Children in the control group had CCT scans or were hospitalized according to current recommendations. In the S100B biomonitoring group, blood sampling took place within 3 hours after minor HT, and management depended on serum S100B protein levels. If the S100B level was within the reference range according to age, the children were discharged from the emergency department. Otherwise, children were treated as in the control group. Main Outcomes and Measures Proportion of CCT scans performed (absence or presence of CCT scan for each patient) in the 48 hours following minor HT. Results A total of 2078 children were included: 926 in the control group and 1152 in the S100B biomonitoring group (1235 [59.4%] boys; median age, 3.2 [IQR, 1.0-8.5] years). Cranial CT scans were performed in 299 children (32.3%) in the control group and 112 (9.7%) in the S100B biomonitoring group. This difference of 23% (95% CI, 19%-26%) was not statistically significant (P = .44) due to an intraclass correlation coefficient of 0.32. A statistically significant 50% reduction in hospitalizations (95% CI, 47%-53%) was observed in the S100B biomonitoring group (479 [41.6%] vs 849 [91.7%]; P < .001). Conclusions and Relevance In this randomized clinical trial of effectiveness of the serum S100B level in the management of pediatric minor HT, S100B biomonitoring yielded a reduction in the number of CCT scans and in-hospital observation when measured in accordance with the conditions defined by a clinical decision algorithm. Trial Registration ClinicalTrials.gov Identifier: NCT02819778.
Collapse
Affiliation(s)
- Damien Bouvier
- Department of Biochemistry and Molecular Genetics, Centre Hospitalier Universitaire (CHU) Clermont-Ferrand, Université Clermont Auvergne, Centre National de la Recherche Scientifique (CNRS), Institut National de la Santé et de la Recherche Médicale (INSERM), Génétique, Reproduction et Développement, Clermont-Ferrand, France
| | - Aymeric Cantais
- Department of Pediatrics, CHU Saint-Etienne, Saint-Etienne, France
| | | | - Fleur Lorton
- Pediatric Emergency Department, Nantes Université, CHU Nantes, INSERM, Centre d’Investigation Clinique 1413, Nantes, France
| | | | - Maria Cottier
- Department of Pediatrics, CHU Montpellier, Montpellier, France
| | | | - Antoine Tran
- Department of Pediatrics, CHU Nice, Nice, France
| | - Emilie Moreau
- Department of Pediatrics, Assistance Publique–Hôpitaux de Marseille, Marseille, France
| | - Julie Durif
- Department of Biochemistry and Molecular Genetics, CHU Clermont-Ferrand, Clermont-Ferrand, France
| | - Catherine Sarret
- Department of Pediatrics, CHU Clermont-Ferrand, Université Clermont Auvergne, CNRS, SIGMA, Thérapies Guidées par l’Image, Clermont-Ferrand, France
| | - Charline Mourgues
- Biostatistics Unit (Délégation à la Recherche Clinique et à l’Innovation), CHU Clermont-Ferrand, Clermont-Ferrand, France
| | - Franck Sturtz
- Department of Biochemistry, CHU Limoges, Limoges, France
| | - Jean-Baptiste Oudart
- Faculté de Médecine, Université de Reims Champagne-Ardenne, Matrice Extracellulaire et Dynamique Cellulaire Unit, UMR CNRS 7369, Reims, France
| | | | - Philippe Gonzalo
- Department of Biochemistry and Pharmacology, CHU Saint-Etienne, Saint-Etienne, France
| | | | - Damien Masson
- Department of Biochemistry, CHU Nantes, Nantes, France
| | - Bruno Pereira
- Biostatistics Unit (Délégation à la Recherche Clinique et à l’Innovation), CHU Clermont-Ferrand, Clermont-Ferrand, France
| | - Vincent Sapin
- Department of Biochemistry and Molecular Genetics, Centre Hospitalier Universitaire (CHU) Clermont-Ferrand, Université Clermont Auvergne, Centre National de la Recherche Scientifique (CNRS), Institut National de la Santé et de la Recherche Médicale (INSERM), Génétique, Reproduction et Développement, Clermont-Ferrand, France
| |
Collapse
|
2
|
Theakstone A, Brennan PM, Ashton K, Czeiter E, Jenkinson M, Syed K, Reed M, Baker M. Vibrational spectroscopy for the triage of traumatic brain injury CT priority and hospital admissions. J Neurotrauma 2022; 39:773-783. [PMID: 35236121 PMCID: PMC9225408 DOI: 10.1089/neu.2021.0410] [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] [Indexed: 11/12/2022] Open
Abstract
Computed Tomogram (CT) brain imaging is routinely used to support clinical decision-making in patients with traumatic brain injury (TBI). However, only 7% of scans demonstrate evidence of TBI. The other 93% of scans contribute a significant cost to the healthcare system and a radiation risk to patients. There may be better strategies to identify which patients, particularly those with mild TBI, are at risk of deterioration and require hospital admission. We introduce a blood serum liquid biopsy that utilises attenuated total reflectance (ATR)-Fourier transform infrared (FTIR) spectroscopy with machine learning algorithms as a decision-making tool to identify which mild TBI patients will most benefit from CT brain imaging. Serum samples were obtained from (n=298) patients who had acquired a TBI and were enrolled in CENTER-TBI, and from asymptomatic control patients (n=87). Injury patients (all severities) were stratified against non-injury controls. The mild TBI cohort was further examined by stratifying those who had at least one CT abnormality against those who had no CT abnormalities. The test performed exceptionally well in classifications of mild injury patients versus non-injury controls (sensitivity = 96.4% and specificity = 98.0%) and also provided a sensitivity of 80.2% when stratifying mild patients with at least one CT abnormality against those without. The results provided illustrate the test ability to identify 4 out of every 5 CT abnormalities and shows great promise to be introduced as a triage tool for CT priority in mild TBI patients.
Collapse
Affiliation(s)
- Ashton Theakstone
- University of Strathclyde, 3527, 99 George Street, Glasgow, United Kingdom of Great Britain and Northern Ireland, G1 1RD;
| | - Paul M Brennan
- The University of Edinburgh Centre for Clinical Brain Sciences, 439257, Translational Neurosurgery, Edinburgh, Edinburgh, United Kingdom of Great Britain and Northern Ireland;
| | - Katherine Ashton
- Lancashire Teaching Hospitals NHS Foundation Trust, 6724, Neuropathology, Preston, Lancashire, United Kingdom of Great Britain and Northern Ireland;
| | - Endre Czeiter
- University of Pecs Medical School, 37657, Department of Neurosurgery, Pecs, Hungary.,University of Pecs, 37656, Neurotrauma Research Group, Szentágothai Research Centre, Pecs, Hungary.,University of Pecs, 37656, MTA-PTE Clinical Neuroscience MR Research Group, Pecs, Hungary;
| | - Michael Jenkinson
- The Walton Centre NHS Foundation Trust, 195157, Liverpool, Liverpool, United Kingdom of Great Britain and Northern Ireland.,University of Liverpool, 4591, Department of Pharmacology & Therapeutics, Liverpool, Merseyside, United Kingdom of Great Britain and Northern Ireland;
| | - Khaja Syed
- The Walton Centre NHS Foundation Trust, 195157, Liverpool, Liverpool, United Kingdom of Great Britain and Northern Ireland;
| | - Matthew Reed
- Royal Infirmary of Edinburgh, 59843, Department of Emergency Medicine, Edinburgh, Edinburgh, United Kingdom of Great Britain and Northern Ireland;
| | - Matthew Baker
- Dxcover Limited, Glasgow, United Kingdom of Great Britain and Northern Ireland;
| |
Collapse
|
3
|
Rhame K, Le D, Ventura A, Horner A, Andaluz N, Miller C, Stolz U, Ngwenya LB, Adeoye O, Kreitzer N. Management of the mild traumatic brain injured patient using a multidisciplinary observation unit protocol. Am J Emerg Med 2020; 46:176-182. [PMID: 33071105 DOI: 10.1016/j.ajem.2020.06.088] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2020] [Revised: 05/30/2020] [Accepted: 06/27/2020] [Indexed: 10/23/2022] Open
Abstract
OBJECTIVES We developed an ED based multidisciplinary observation unit (OU) protocol for patients with mild traumatic brain injury (mTBI). We describe the cohort of patients who were placed in the ED OU and we evaluated if changes to our inclusion and exclusion criteria should be made. METHODS We conducted a retrospective cohort study to evaluate subjects who were admitted to the mTBI observation protocol. We included adults within 24 h of sustaining an mTBI with a Glasgow Coma Scale (GCS) of 14 or 15 who had pre-specified head CT findings, and did not meet exclusion criteria. Predictors of need for hospital admission after completing the OU protocol were determined using multivariable logistic regression analysis. RESULTS The mean age was 49 (SD 23), 58 (33%) were female, and 136 (78%) were Caucasian. No subjects discharged home required a surgical intervention or ICU admission, and there were no deaths in discharged or admitted subjects. 28 subjects (16%) were admitted to the hospital following their OU stay. Subjects admitted were older (mean age: 56 vs. 48, p = 0.1) and had a higher proportion of traumatic bleeds on head CT (85% vs. 76%, p = 0.3). In multivariable logistic regression, GCS of 15 (aOR 4.24), African-American race (aOR 5.84), and no comorbid cardiac disease predicted discharge home after the observation protocol (aOR 0.28). CONCLUSIONS A period of observation for a pre-defined cohort of patients with mTBI provided a triage plan that could allow appropriate patient management without requiring admission in the majority of subjects.
Collapse
Affiliation(s)
- Katherine Rhame
- University of Cincinnati College of Medicine, United States of America
| | - Diana Le
- University of Cincinnati College of Medicine, United States of America
| | - Amanda Ventura
- University of Cincinnati Department of Emergency Medicine, United States of America
| | - Amy Horner
- University of Cincinnati Department of Neurosurgery, United States of America
| | - Norberto Andaluz
- University of Louisville Department of Neurosurgery, United States of America
| | - Christopher Miller
- University Hospitals, Case Western Reserve University School of Medicine, United States of America
| | - Uwe Stolz
- University of Cincinnati Department of Emergency Medicine, United States of America
| | - Laura B Ngwenya
- University of Cincinnati Department of Neurosurgery, United States of America; University of Cincinnati, Department of Neurology and Rehabilitation Medicine, United States of America; University of Cincinnati Collaborative for Research on Acute Neurological Injury, United States of America
| | - Opeolu Adeoye
- University of Cincinnati Department of Emergency Medicine, United States of America; University of Cincinnati Division of Neurocritical Care, United States of America
| | - Natalie Kreitzer
- University of Cincinnati Department of Emergency Medicine, United States of America; University of Cincinnati Division of Neurocritical Care, United States of America.
| |
Collapse
|
4
|
Bouvier D, Balayssac D, Durif J, Mourgues C, Sarret C, Pereira B, Sapin V. Assessment of the advantage of the serum S100B protein biomonitoring in the management of paediatric mild traumatic brain injury-PROS100B: protocol of a multicentre unblinded stepped wedge cluster randomised trial. BMJ Open 2019; 9:e027365. [PMID: 31129587 PMCID: PMC6537998 DOI: 10.1136/bmjopen-2018-027365] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
INTRODUCTION S100B serum analysis in clinical routine could reduce the number of cranial CT (CCT) scans performed on children with mild traumatic brain injury (mTBI). Sampling should take place within 3 hours of trauma and cut-off levels should be based on paediatric reference ranges. The aim of this study is to evaluate the utility of measuring serum S100B in the management of paediatric mTBI by demonstrating a decrease in the number of CCT scans prescribed in an S100B biomonitoring group compared with a 'conventional management' control group, with the assumption of a 30% relative decrease of the number of CCT scans between the two groups. METHODS AND ANALYSIS The protocol is a randomised, multicentre, unblinded, prospective, interventional study (nine centres) using a stepped wedge cluster design, comparing two groups (S100B biomonitoring and control). Children in the control group will have CCT scans or be hospitalised according to the current recommendations of the French Society of Paediatrics (SFP). In the S100B biomonitoring group, blood sampling to determine serum S100B protein levels will take place within 3 hours after mTBI and subsequent management will depend on the assay. If S100B is in the normal range according to age, the children will be discharged from the emergency department after 6 hours' observation. If the result is abnormal, CCT scans or hospitalisation will be prescribed in accordance with current SFP recommendations. The primary outcome measure will be the proportion of CCT scans performed (absence/presence of CCT scan for each patient) in the 48 hours following mTBI. ETHICS AND DISSEMINATION The protocol presented (Version 5, 03 November 2017) has been approved by the ethics committee Comité de Protection des Personnes sud-est 6 (first approval 08 June 2016, IRB: 00008526). Participation in the study is voluntary and anonymous. The study findings will be disseminated in international peer-reviewed journals and presented at relevant conferences. TRIAL REGISTRATION NUMBER NCT02819778.
Collapse
Affiliation(s)
- Damien Bouvier
- Biochemistry and Molecular Genetic Department, CHU Clermont-Ferrand, Université Clermont Auvergne, CNRS, INSERM, GReD, Clermont-Ferrand, France
| | - David Balayssac
- DRCI, CHU Clermont-Ferrand, Université Clermont-Auvergne, INSERM U1107, NEURO-DOL, Clermont-Ferrand, France
| | - Julie Durif
- Biochemistry and Molecular Genetic Department, CHU Clermont-Ferrand, Clermont-Ferrand, France
| | | | - Catherine Sarret
- Pediatric Department, CHU Clermont-Ferrand, Clermont-Ferrand, France
| | - Bruno Pereira
- DRCI, CHU Clermont-Ferrand, Clermont-Ferrand, France
| | - Vincent Sapin
- Biochemistry and Molecular Genetic Department, CHU Clermont-Ferrand, Université Clermont Auvergne, CNRS, INSERM, GReD, Clermont-Ferrand, France
| |
Collapse
|
5
|
Impact of guidelines for the management of minor head injury on the utilization and diagnostic yield of CT over two decades, using natural language processing in a large dataset. Eur Radiol 2019; 29:2632-2640. [PMID: 30643942 PMCID: PMC6443919 DOI: 10.1007/s00330-018-5954-5] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2018] [Revised: 11/02/2018] [Accepted: 12/04/2018] [Indexed: 01/18/2023]
Abstract
Objectives We investigated the impact of clinical guidelines for the management of minor head injury on utilization and diagnostic yield of head CT over two decades. Methods Retrospective before-after study using multiple electronic health record data sources. Natural language processing algorithms were developed to rapidly extract indication, Glasgow Coma Scale, and CT outcome from clinical records, creating two datasets: one based on all head injury CTs from 1997 to 2009 (n = 9109), for which diagnostic yield of intracranial traumatic findings was calculated. The second dataset (2009–2014) used both CT reports and clinical notes from the emergency department, enabling selection of minor head injury patients (n = 4554) and calculation of both CT utilization and diagnostic yield. Additionally, we tested for significant changes in utilization and yield after guideline implementation in 2011, using chi-square statistics and logistic regression. Results The yield was initially nearly 60%, but in a decreasing trend dropped below 20% when CT became routinely used for head trauma. Between 2009 and 2014, of 4554 minor head injury patients overall, 85.4% underwent head CT. After guideline implementation in 2011, CT utilization significantly increased from 81.6 to 87.6% (p = 7 × 10−7), while yield significantly decreased from 12.2 to 9.6% (p = 0.029). Conclusions The number of CTs performed for head trauma gradually increased over two decades, while the yield decreased. In 2011, despite implementation of a guideline aiming to improve selective use of CT in minor head injury, utilization significantly increased. Key Points • Over two decades, the number of head CTs performed for minor, moderate, and severe head injury gradually increased, while the diagnostic yield for intracranial findings showed a decreasing trend. • Despite the implementation of a guideline in 2011, aiming to improve selective use of CT in minor head injury, utilization significantly increased, while diagnostic yield significantly decreased. • Natural language processing is a valuable tool to monitor the utilization and diagnostic yield of imaging as a potential quality-of-care indicator. Electronic supplementary material The online version of this article (10.1007/s00330-018-5954-5) contains supplementary material, which is available to authorized users.
Collapse
|
6
|
Oris C, Pereira B, Durif J, Simon-Pimmel J, Castellani C, Manzano S, Sapin V, Bouvier D. The Biomarker S100B and Mild Traumatic Brain Injury: A Meta-analysis. Pediatrics 2018; 141:peds.2018-0037. [PMID: 29716980 DOI: 10.1542/peds.2018-0037] [Citation(s) in RCA: 49] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/21/2018] [Indexed: 11/24/2022] Open
Abstract
CONTEXT The usefulness of S100B has been noted as a biomarker in the management of mild traumatic brain injury (mTBI) in adults. However, S100B efficacy as a biomarker in children has previously been relatively unclear. OBJECTIVE A meta-analysis is conducted to assess the prognostic value of S100B in predicting intracerebral lesions in children after mTBI. DATA SOURCES Medline, Embase, the Cochrane Central Register of Controlled Trials (CENTRAL), Web of Science, Scopus, and Google Scholar. STUDY SELECTION Studies including children suffering mTBI who underwent S100B measurement and computed tomography (CT) scans were included. DATA EXTRACTION Of 1030 articles screened, 8 studies met the inclusion criteria. RESULTS The overall pooled sensitivity and specificity were 100% (95% confidence interval [CI]: 98%-100%) and 34% (95% CI: 30%-38%), respectively. A second analysis was based on the collection of 373 individual data points from 4 studies. Sensitivity and specificity results, obtained from reference ranges in children with a sampling time <3 hours posttrauma, were 97% (95% CI: 84.2%-99.9%) and 37.5% (95% CI: 28.8%-46.8%), respectively. Only 1 child had a low S100B level and a positive CT scan result without clinically important traumatic brain injury. LIMITATIONS Only patients undergoing both a CT scan and S100B testing were selected for evaluation. CONCLUSIONS S100B serum analysis as a part of the clinical routine could significantly reduce the number of CT scans performed on children with mTBI. Sampling should take place within 3 hours of trauma. Cutoff levels should be based on pediatric reference ranges.
Collapse
Affiliation(s)
| | - Bruno Pereira
- Biostatistics Unit, Direction de la Recherche Clinique, University Hospital of Clermont-Ferrand, Clermont-Ferrand, France
| | - Julie Durif
- Department of Biochemistry and Molecular Biology, and
| | - Jeanne Simon-Pimmel
- Department of Pediatric Emergency Medicine, University Hospital, Nantes, France
| | - Christoph Castellani
- Department of Paediatric and Adolescent Surgery, Medical University of Graz, Graz, Austria
| | - Sergio Manzano
- Department of Pediatric Emergency Medicine, University Hospital, Geneva, Switzerland; and
| | - Vincent Sapin
- Department of Biochemistry and Molecular Biology, and.,GReD, Université Clermont Auvergne, Centre National de la Recherche Scientifique, Institut National de la Santé et de la Recherche Médicale, Clermont-Ferrand, France
| | - Damien Bouvier
- Department of Biochemistry and Molecular Biology, and .,GReD, Université Clermont Auvergne, Centre National de la Recherche Scientifique, Institut National de la Santé et de la Recherche Médicale, Clermont-Ferrand, France
| |
Collapse
|
7
|
Mehta H, Acharya J, Mohan AL, Tobias ME, LeCompte L, Jeevan D. Minimizing Radiation Exposure in Evaluation of Pediatric Head Trauma: Use of Rapid MR Imaging. AJNR Am J Neuroradiol 2015; 37:11-8. [PMID: 26381555 DOI: 10.3174/ajnr.a4464] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2015] [Accepted: 05/20/2015] [Indexed: 02/03/2023]
Abstract
BACKGROUND AND PURPOSE With >473,000 annual emergency department visits for children with traumatic brain injuries in the United States, the risk of ionizing radiation exposure during CT examinations is a real concern. The purpose of this study was to assess the validity of rapid MR imaging to replace CT in the follow-up imaging of patients with head trauma. MATERIALS AND METHODS A retrospective review of 103 pediatric patients who underwent initial head CT and subsequent follow-up rapid MR imaging between January 2010 and July 2013 was performed. Patients had minor head injuries (Glasgow Coma Scale, >13) that required imaging. Initial head CT was performed, with follow-up rapid MR imaging completed within 48 hours. A board-certified neuroradiologist, blinded to patient information and scan parameters, then independently interpreted the randomized cases. RESULTS There was almost perfect agreement in the ability to detect extra-axial hemorrhage on rapid MR imaging and CT (κ = 0.84, P < .001). Evaluation of hemorrhagic contusion/intraparenchymal hemorrhage demonstrated a moderate level of agreement between MR imaging and CT (κ = 0.61, P < .001). The ability of MR imaging to detect a skull fracture also showed a substantial level of agreement with CT (κ = 0.71, P < .001). Detection of diffuse axonal injury demonstrated a slight level of agreement between MR imaging and CT (κ = 0.154, P = .04). However, the overall predictive agreement for the detection of an axonal injury was 91%. CONCLUSIONS Rapid MR imaging is a valid technique for detecting traumatic cranial injuries and an adequate examination for follow-up imaging in lieu of repeat CT.
Collapse
Affiliation(s)
- H Mehta
- From the Departments of Radiology (H.M., J.A., L.L.)
| | - J Acharya
- From the Departments of Radiology (H.M., J.A., L.L.)
| | - A L Mohan
- Neurosurgery (A.L.M., M.E.T., D.J.), New York Medical College, Valhalla, New York
| | - M E Tobias
- Neurosurgery (A.L.M., M.E.T., D.J.), New York Medical College, Valhalla, New York
| | - L LeCompte
- From the Departments of Radiology (H.M., J.A., L.L.)
| | - D Jeevan
- Neurosurgery (A.L.M., M.E.T., D.J.), New York Medical College, Valhalla, New York
| |
Collapse
|
8
|
Alali AS, Burton K, Fowler RA, Naimark DMJ, Scales DC, Mainprize TG, Nathens AB. Economic Evaluations in the Diagnosis and Management of Traumatic Brain Injury: A Systematic Review and Analysis of Quality. VALUE IN HEALTH : THE JOURNAL OF THE INTERNATIONAL SOCIETY FOR PHARMACOECONOMICS AND OUTCOMES RESEARCH 2015; 18:721-734. [PMID: 26297101 DOI: 10.1016/j.jval.2015.04.012] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/03/2014] [Revised: 03/23/2015] [Accepted: 04/12/2015] [Indexed: 06/04/2023]
Abstract
BACKGROUND Economic evaluations provide a unique opportunity to identify the optimal strategies for the diagnosis and management of traumatic brain injury (TBI), for which uncertainty is common and the economic burden is substantial. OBJECTIVE The objective of this study was to systematically review and examine the quality of contemporary economic evaluations in the diagnosis and management of TBI. METHODS Two reviewers independently searched MEDLINE, EMBASE, Cochrane Central Register of Controlled Trials, NHS Economic Evaluation Database, Health Technology Assessment Database, EconLit, and the Tufts CEA Registry for comparative economic evaluations published from 2000 onward (last updated on August 30, 2013). Data on methods, results, and quality were abstracted in duplicate. The results were summarized quantitatively and qualitatively. RESULTS Of 3539 citations, 24 economic evaluations met our inclusion criteria. Nine were cost-utility, five were cost-effectiveness, three were cost-minimization, and seven were cost-consequences analyses. Only six studies were of high quality. Current evidence from high-quality studies suggests the economic attractiveness of the following strategies: a low medical threshold for computed tomography (CT) scanning of asymptomatic infants with possible inflicted TBI, selective CT scanning of adults with mild TBI as per the Canadian CT Head Rule, management of severe TBI according to the Brain Trauma Foundation guidelines, management of TBI in dedicated neurocritical care units, and early transfer of patients with TBI with nonsurgical lesions to neuroscience centers. CONCLUSIONS Threshold-guided CT scanning, adherence to Brain Trauma Foundation guidelines, and care for patients with TBI, including those with nonsurgical lesions, in specialized settings appear to be economically attractive strategies.
Collapse
Affiliation(s)
- Aziz S Alali
- Sunnybrook Research Institute, Sunnybrook Health Sciences Center, Toronto, ON, Canada; Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada; Division of Neurosurgery, University of Ottawa, Ottawa, ON, Canada.
| | - Kirsteen Burton
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada; Department of Medical Imaging, University of Toronto, Toronto, ON, Canada
| | - Robert A Fowler
- Sunnybrook Research Institute, Sunnybrook Health Sciences Center, Toronto, ON, Canada; Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada; Department of Critical Care, Sunnybrook Health Sciences Center, Toronto, ON, Canada; Interdepartmental Division of Critical Care, University of Toronto, Toronto, ON, Canada
| | - David M J Naimark
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada; Department of Medicine, University of Toronto, Toronto, ON, Canada
| | - Damon C Scales
- Sunnybrook Research Institute, Sunnybrook Health Sciences Center, Toronto, ON, Canada; Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada; Department of Critical Care, Sunnybrook Health Sciences Center, Toronto, ON, Canada; Interdepartmental Division of Critical Care, University of Toronto, Toronto, ON, Canada
| | - Todd G Mainprize
- Division of Neurosurgery, Sunnybrook Health Sciences Center, University of Toronto, Toronto, ON, Canada
| | - Avery B Nathens
- Sunnybrook Research Institute, Sunnybrook Health Sciences Center, Toronto, ON, Canada; Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada; Keenan Research Centre of the Li Ka Shing Knowledge Institute, St Michael's Hospital, Toronto, ON, Canada; Department of Surgery, Sunnybrook Health Sciences Center, University of Toronto, Toronto, ON, Canada
| |
Collapse
|
9
|
Kavosi Z, Jafari A, Hatam N, Enaami M. The economic burden of traumatic brain injury due to fatal traffic accidents in shahid rajaei trauma hospital, shiraz, iran. ARCHIVES OF TRAUMA RESEARCH 2015; 4:e22594. [PMID: 25834791 PMCID: PMC4377539 DOI: 10.5812/atr.22594] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 08/20/2014] [Revised: 02/13/2015] [Accepted: 02/17/2015] [Indexed: 11/16/2022]
Abstract
BACKGROUND Traumatic Brain Injuries (TBIs) as a result of traffic accidents are one of the major causes of deaths, which lead to the loss of individuals' productive and working years of life. OBJECTIVES This study aimed to calculate the economic burden of traumatic brain injuries in fatal crashes at Shahid Rajaei Trauma Hospital, Shiraz, Iran for a period of five years. PATIENTS AND METHODS In this descriptive, cross-sectional study the population included people who had died as a result of TBIs during 2009 to 2013 in Shiraz Shahid Rajaei Trauma Hospital. Cost and demographic data were obtained from the participants' medical records using data gathering forms, and some other information was also collected via telephone calls to the victims' families. Economic burden of TBIs due to traffic accidents, which led to death, was estimated using the human capital as direct costs of treatment, and the number of potential years of life lost and lost productivity as indirect costs. RESULTS Deaths resulting from TBIs due to traffic accidents in Shiraz imposed 6.2 billion Rials (511000 USD) of hospital costs, 6390 potential years of life lost, and 506 billion Rials (20 million USD) of productivity lost. In the present study, the mean age of the individuals who died was 38.4 ± 19.41 and the productivity lost per capita was 1.8 billion Rials (73000 USD). CONCLUSIONS The findings of this study indicated that the economic burden of TBIs was high in fatal accidents in Fars Province so that it was equivalent to 0.00011% of Iran's Gross Domestic Product (GDP) in 2013. Therefore, more attention has to be paid to the rules to prevent the fatal accidents.
Collapse
Affiliation(s)
- Zahra Kavosi
- Social Determinants of Health Research Center, School of Management and Information Sciences, Shiraz University of Medical Sciences, Shiraz, IR Iran
| | - Abdosaleh Jafari
- Health Economics Department, School of Management and Medical Information, Shiraz University of Medical Sciences, Shiraz, IR Iran
| | - Nahid Hatam
- School of Management and Medical Information, Shiraz University of Medical Sciences, Shiraz, IR Iran
| | - Meysam Enaami
- Student Research Committee, School of Management and Medical Information, Shiraz University of Medical Sciences, Shiraz, IR Iran
| |
Collapse
|
10
|
Chern JJ, Sarda S, Howard BM, Jea A, Tubbs RS, Brahma B, Wrubel DM, Reisner A, Boydston W. Utility of surveillance imaging after minor blunt head trauma. J Neurosurg Pediatr 2014; 14:306-10. [PMID: 25014322 DOI: 10.3171/2014.6.peds13682] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT Nonoperative blunt head trauma is a common reason for admission in a pediatric hospital. Adverse events, such as growing skull fracture, are rare, and the incidence of such morbidity is not known. As a result, optimal follow-up care is not clear. METHODS Patients admitted after minor blunt head trauma between May 1, 2009, and April 30, 2013, were identified at a single institution. Demographic, socioeconomic, and clinical characteristics were retrieved from administrative and outpatient databases. Clinical events within the 180-day period following discharge were reviewed and analyzed. These events included emergency department (ED) visits, need for surgical procedures, clinic visits, and surveillance imaging utilization. Associations among these clinical events and potential contributing factors were analyzed using appropriate statistical methods. RESULTS There were 937 admissions for minor blunt head trauma in the 4-year period. Patients who required surgical interventions during the index admission were excluded. The average age of the admitted patients was 5.53 years, and the average length of stay was 1.7 days; 15.7% of patients were admitted for concussion symptoms with negative imaging findings, and 26.4% of patients suffered a skull fracture without intracranial injury. Patients presented with subdural, subarachnoid, or intraventricular hemorrhage in 11.6%, 9.19%, and 0.53% of cases, respectively. After discharge, 672 patients returned for at least 1 follow-up clinic visit (71.7%), and surveillance imaging was obtained at the time of the visit in 343 instances. The number of adverse events was small and consisted of 34 ED visits and 3 surgeries. Some of the ED visits could have been prevented with better discharge instructions, but none of the surgery was preventable. Furthermore, the pattern of postinjury surveillance imaging utilization correlated with physician identity but not with injury severity. Because the number of adverse events was small, surveillance imaging could not be shown to positively influence outcomes. CONCLUSIONS Adverse events after nonoperative mild traumatic injury are rare. The routine use of postinjury surveillance imaging remains controversial, but these data suggest that such imaging does not effectively identify those who require operative intervention.
Collapse
Affiliation(s)
- Joshua J Chern
- Pediatric Neurosurgery Associates, Children's Healthcare of Atlanta
| | | | | | | | | | | | | | | | | |
Collapse
|
11
|
Vestergaard V, Astrand R, Romner B. A survey of the management of paediatric minor head injury. Acta Neurol Scand 2014; 129:168-72. [PMID: 23763509 DOI: 10.1111/ane.12158] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/07/2013] [Indexed: 11/30/2022]
Abstract
OBJECTIVES To investigate present established routines and standards in managing minor head-injured children in Danish hospitals, a survey of present management practice was conducted. MATERIALS AND METHODS A cross-sectional mail survey, detailing clinical and radiological examinations, in-hospital observation, discharge criteria and follow-up, was performed on all 46 hospitals treating children with minor head injury in Denmark. RESULTS Of the 46 hospitals, 33% report having established written criteria for the referral and management of children with minor head injury. Ten (22%) of the 46 hospitals are so-called injury clinics, where only nurses are employed. All state that they use the Glasgow Coma Scale (GCS) and/or the paediatric GCS to assess the level of consciousness; 15% use the paediatric GCS exclusively. None perform routine radiological examinations. Criteria for early discharge are established in 98% of the hospitals. All hospitals provide written instructions for observations at home before discharge. CONCLUSION The management of children with minor head injury varies between hospitals in Denmark. Local management guidelines are either lacking or mainly based on those of adults. Hence, there is a need for the development of minor head injury guidelines specifically designed for the management of children.
Collapse
Affiliation(s)
- V. Vestergaard
- Department of Neurosurgery; Rigshospitalet; Copenhagen Denmark
| | - R. Astrand
- Department of Neurosurgery; Rigshospitalet; Copenhagen Denmark
| | - B. Romner
- Department of Neurosurgery; Rigshospitalet; Copenhagen Denmark
| |
Collapse
|
12
|
Abstract
Mild traumatic brain injury (mTBI) is the commonest form of TBI. Though the name implies, it may not be mild in certain cases. There is a lot of heterogeneity in nomenclature, classification, evaluation and outcome of mTBI. We have reviewed the relevant articles on mTBI in adults, particularly its definition, evaluation and outcome, published in the last decade. The aspects of mTBI like pediatric age group, sports concussion, and postconcussion syndrome were not reviewed. There is general agreement that Glasgow coma score (GCS) of 13 should not be considered as mTBI as the risk of intracranial lesion is higher than in patients with GCS 14-15. All patients with GCS of <15 should be evaluated with a computed tomography (CT) scan. Patients with GCS 15 and risk factors or neurological symptoms should also be evaluated with CT scan. The outcome of mTBI depends on the combination of preinjury, injury and postinjury factors. Overall outcome of mTBI is good with mortality around 0.1% and disability around 10%.
Collapse
Affiliation(s)
- Dhaval Shukla
- Department of Neurosurgery, National Institute of Mental Health and Neurosciences (NIMHANS), Hosur Road, Bangalore - 560 029, India
| | | |
Collapse
|
13
|
Smits M, Dippel DWJ, Nederkoorn PJ, Dekker HM, Vos PE, Kool DR, van Rijssel DA, Hofman PAM, Twijnstra A, Tanghe HLJ, Hunink MGM. Minor Head Injury: CT-based Strategies for Management—A Cost-effectiveness Analysis. Radiology 2010; 254:532-40. [DOI: 10.1148/radiol.2541081672] [Citation(s) in RCA: 68] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
|
14
|
Ruan S, Noyes K, Bazarian JJ. The economic impact of S-100B as a pre-head CT screening test on emergency department management of adult patients with mild traumatic brain injury. J Neurotrauma 2010; 26:1655-64. [PMID: 19413465 DOI: 10.1089/neu.2009.0928] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Recent research suggests that serum S-100B may serve as a good pre-head computed tomography (CT) screening test because of its high sensitivity for abnormal head CT scans. The potential economic impact of using S-100B in the emergency department setting for management of adult patients with isolated mild traumatic brain injury (mTBI) has not been evaluated despite its clinical implementation in Europe. Using evidence from the literature, we constructed a decision tree to compare the average cost per patient of using S-100B as a pre-head CT screening test to the current practice of ordering CT scans based on patients' presenting symptoms without the aid of S-100B. When compared to scanning 45-77% of isolated mTBI patients based upon their presenting symptoms, using S-100B as a pre-head CT screen does not lower hospital costs ($281 versus $160), primarily due to its low specificity for abnormal head CT scans. Sensitivity analyses showed, however, that S-100B becomes cost-lowering when the proportion of mTBI patients being scanned exceeds 78%, or when final CT scan results require 96 min or more than the wait for blood test results. Generally speaking, if blood test results require less time than imaging, and if head CT scan rates for patients with isolated mTBI are relatively high, using S-100B will lower costs. Recommendations for using S-100B as a screening tool should account for setting-specific characteristics and their consequent economic impacts. Despite its high sensitivity and excellent negative predictive value, serum S-100B has low specificity and low positive predictive value, limiting its ability to reduce numbers of CT scans and hospital costs.
Collapse
Affiliation(s)
- Shuolun Ruan
- Department of Community and Preventive Medicine, University of Rochester School of Medicine and Dentistry, Rochester, New York 14642, USA.
| | | | | |
Collapse
|
15
|
Sadowski-Cron C, Schneider J, Senn P, Radanov BP, Ballinari P, Zimmermann H. Patients with mild traumatic brain injury: Immediate and long-term outcome compared to intra-cranial injuries on CT scan. Brain Inj 2009; 20:1131-7. [PMID: 17123929 DOI: 10.1080/02699050600832569] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
BACKGROUND Mild traumatic brain injury (MTBI) defined as Glasgow Coma Scale (GCS) 14 or 15 has shown contradictory short- and long-term outcomes. The objective of this study was to correlate intra-cranial injuries (ICI) on CT scan to neurocognitive tests at admission and to complaints after 1 year. METHODS Two hundred and five patients with MTBI underwent a CT scan and were examined with neurocognitive tests. After 1 year complaints were assessed by phone interviews. RESULTS The neurocognitive tests in 51% of the patients showed significant deficits; there was no difference for patients with GCS 14-15, nor was there a difference between patients with ICI to patients without. After 1 year patients with ICI had significantly more complaints than patients without ICI, the most frequent complaint was headache and memory deficits. CONCLUSIONS No correlation was found between GCS or ICI and the neurocognitive tests upon admission. After 1 year, patients with ICI have significantly more complaints than patients without ICI. No cost savings resulted by doing immediate CT scan on all.
Collapse
Affiliation(s)
- Charlotte Sadowski-Cron
- Department of Accident and Emergency Medicine, University of Bern, Inselspital, Bern, Switzerland
| | | | | | | | | | | |
Collapse
|
16
|
Kerr J, Beard D, Smith R, Gray S, Robertson CE, Dunn LT. Implications of full compliance with the computed tomography scanning recommendations of the National Institute for Clinical Excellence and Scottish Intercollegiate Guidelines Network guidelines for the management of head injury. Eur J Emerg Med 2007; 14:147-50. [PMID: 17473608 DOI: 10.1097/mej.0b013e3280b17e25] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
A prospective study was conducted to examine clinical practices in the management of head-injured patients preinception and postinception of the Scottish Intercollegiate Guidelines Network guidelines. Comparison was made between the Scottish Intercollegiate Guidelines Network and National Institute for Clinical Excellence guidelines on their indications for computed tomography scanning. Information was available on 2827 adult patients. Two hundred and thirty-two patients satisfied one or more Scottish Intercollegiate Guidelines Network criteria for computed tomography scanning. Four hundred and seventy-eight patients fulfilled one or more National Institute for Clinical Excellence criteria for scanning. No patient with Scottish Intercollegiate Guidelines Network or National Institute for Clinical Excellence indications for computed tomography scanning and who was not scanned, subsequently required neurosurgical treatment for a complication related to their injury. Full compliance with the scanning recommendations in the Scottish Intercollegiate Guidelines Network and National Institute for Clinical Excellence guidelines will require a significant increase in scanning resource and is unlikely to lead to the identification of a significant additional number of patients with intracranial lesions requiring neurosurgical intervention.
Collapse
Affiliation(s)
- Jacques Kerr
- Scottish Trauma Audit Group, Royal Infirmary of Edinburgh, Little France Crescent, Edinburgh cInstitute of Neurological Sciences, University of Glasgow, Southern General Hospital, Govan Road, Glasgow, UK.
| | | | | | | | | | | |
Collapse
|
17
|
Syed AT, Lone NA, Wani MA, Bhat AS. Clinical management of patients with minor head injuries. Int J Health Sci (Qassim) 2007; 1:131-140. [PMID: 21475463 PMCID: PMC3068669] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/30/2023] Open
Abstract
BACKGROUND Injuries are a focus of public health practice because they pose a serious health threat, occur frequently, and are preventable. Globally, thousands of people attend their local Emergency Department daily after suffering a head injury. Early diagnosis and appropriate management improves outcomes but is sometimes more difficult to achieve than might be imagined. Of all types of injury, those to the brain are among the most likely to result in death or permanent disability. Estimates of traumatic brain injury (TBI) incidence, severity, and cost reflect the enormous losses to individuals, their families, and society. The reduction in the number and severity of injuries offers a cost-effective manner in which to improve the health status of populations. METHODS We prospectively studied 485 consecutive patients of traumatic brain injury out of which 280 with GCS of 13, 14, and 15 were subjected to routine early CT scan of head after 4 hours of reporting to Emergency Department. Patients with penetrating head injury were excluded. RESULTS 15 % of patients had abnormal CT Scans and only 4% needed surgical intervention. Though a small number of patients harbour potentially lethal intracranial lesions yet, most of these cases are salvageable if diagnosed early and proper treatment. CONCLUSION This study reveals that the current practice in the some countries of risk stratification of adult MHI based on skull radiography need to be replaced by slightly modified versions of the Canadian CT rule/NICE guidelines. This will result in a large reduction in skull radiography and will be associated with modest increases in CT and admissions rates. The authors also believe that early CT Scanning can detect intracranial lesions and will reduce unnecessary hospital admissions.
Collapse
Affiliation(s)
- A. T Syed
- Correspondence:Dr. Syed A. T., Head, Accident & Emergency Department, Sher-e-Kashmir Institute of Medical Sciences, Post Box: 826, GPO, Srinagar – 190001, (India)
| | | | | | | |
Collapse
|
18
|
Falk AC, Klang B, Paavonen EJ, von Wendt L. Current incidence and management of children with traumatic head injuries: the Stockholm experience. Dev Neurorehabil 2007; 10:49-55. [PMID: 17608326 DOI: 10.1080/13638490600864066] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
PURPOSE A traumatic head injury is one of the most common causes of morbidity and mortality among children, however few population-based studies in this area have been reported. Therefore, the aim of this study was to evaluate the incidence and management of traumatic head injuries in children at a level-one trauma centre in Stockholm, Sweden. PARTICIPANTS All children (n = 3168) who visited the emergency department with a history of head injury during 1 year were included. METHOD The required information was collected retrospectively and the children's medical records were reviewed. RESULTS The overall incidences of head injury were 865 per 100 000 children with the highest incidence (2379/10(5) children) occurring among children younger than 18 months of age. Twelve per cent (n = 396) were admitted to a hospital ward and CT scans were performed in 13% (n = 412) of all children. During this year, 0.3% required a neurosurgical intervention and only 1% of all children had documentation of a planned follow-up appointment. CONCLUSION The findings indicate that clinical documentation as a part of the early management in children with a head injury is inconsistent and suffers from lack of valid criteria. Implementation of clinical guidelines during emergency care would help improve subsequent hospital care, as well as the planning of health care services for these children.
Collapse
Affiliation(s)
- Ann-Charlotte Falk
- Department of Women and Child Health-Neuropediatrics, Astrid Lindgren's Hospital for Children, Karolinska Institut, Stockholm, Sweden.
| | | | | | | |
Collapse
|
19
|
Norlund A, Marké LA, af Geijerstam JL, Oredsson S, Britton M. Immediate computed tomography or admission for observation after mild head injury: cost comparison in randomised controlled trial. BMJ 2006; 333:469. [PMID: 16895945 PMCID: PMC1557926 DOI: 10.1136/bmj.38918.659120.4f] [Citation(s) in RCA: 60] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
OBJECTIVE To compare the costs of immediate computed tomography during triage for admission with those of observation in hospital in patients with mild head injury. DESIGN Prospective cost effectiveness analysis within a multicentre, pragmatic randomised trial. SETTING 39 acute hospitals in Sweden PARTICIPANTS 2602 patients (aged > or = 6) with mild head injury. INTERVENTIONS Immediate computed tomography or admission for observation. MAIN OUTCOME MEASURES Direct and indirect costs related to the mild head injury during the acute and three month follow-up period. RESULTS Outcome after three months was similar for both strategies (non-significantly in favour of computed tomography). For the acute stage and complications, the cost was 461 euros (314 pounds sterling, 582 dollars) per patient in the computed tomography group and 677 euros (462 pounds sterling, 854 dollars) in the observation group; an average of 32% less in the computed tomography group (216 euros, 95% confidence interval -272 to -164; P < 0.001). Sensitivity analysis showed that computed tomography was the most cost effective strategy under a broad range of assumptions. After three months, total costs were 718 euros and 914 euros per patient-that is, 196 euros less in the computed tomography group (- 281 to - 114; P < 0.001). The lower cost of the computed tomography strategy at the acute stage thus remained unchanged during follow-up. CONCLUSION Patients with mild head injury attending an emergency department can be managed more cost effectively with computed tomography rather than admission for observation in hospital. TRIAL REGISTRATION ISRCTN81464462.
Collapse
Affiliation(s)
- Anders Norlund
- Department of Medicine, Clinical Epidemiology Unit, Karolinska University Hospital, 171 76 Stockholm, Sweden
| | | | | | | | | |
Collapse
|
20
|
af Geijerstam JL, Oredsson S, Britton M. Medical outcome after immediate computed tomography or admission for observation in patients with mild head injury: randomised controlled trial. BMJ 2006; 333:465. [PMID: 16895944 PMCID: PMC1557917 DOI: 10.1136/bmj.38918.669317.4f] [Citation(s) in RCA: 70] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
OBJECTIVE To compare immediate computed tomography during triage for admission with observation in hospital in patients with mild head injury. DESIGN Multicentre, pragmatic, non-inferiority randomised trial. SETTING 39 acute hospitals in Sweden. PARTICIPANTS 2602 patients (aged > or = 6) with mild head injury. INTERVENTIONS Immediate computed tomography or admission for observation. MAIN OUTCOME MEASURE Dichotomised extended Glasgow outcome scale (1-7 v 8). The non-inferiority margin was 5 percentage points. RESULTS At three months, 275 patients (21.4%) in the computed tomography group had not recovered completely compared with 300 (24.2%) admitted for observation. The difference was - 2.8 percentage points, non-significantly in favour of computed tomography (95% confidence interval - 6.1% to 0.6%). The worst outcomes (mortality and more severe loss of function) were similar between the groups. In the patients admitted for observation, there was a considerable delay in time to treatment in those who required surgery. None of the patients with normal findings on immediate computed tomography had complications later. Patients' satisfaction with the two strategies was similar. CONCLUSIONS The use of computed tomography in the management of patients with mild head injury is feasible and leads to similar clinical outcomes compared with observation in hospital. TRIAL REGISTRATION ISRCTN81464462.
Collapse
Affiliation(s)
- Jean-Luc af Geijerstam
- Department of Medicine, Clinical Epidemiology Unit, Karolinska University Hospital, 171 76 Stockholm, Sweden.
| | | | | |
Collapse
|
21
|
Bulut M, Koksal O, Dogan S, Bolca N, Ozguc H, Korfali E, Ilcol YO, Parklak M. Tau protein as a serum marker of brain damage in mild traumatic brain injury: preliminary results. Adv Ther 2006; 23:12-22. [PMID: 16644603 DOI: 10.1007/bf02850342] [Citation(s) in RCA: 51] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
The objective of this study was to investigate the diagnostic value of serum tau protein in determining the severity of traumatic brain injury in patients with mild traumatic brain injury (mTBI) and high-risk patients. Adult patients who presented to our emergency department (ED) with mTBI over 1 year were prospectively enrolled. Patients underwent cranial computed tomography (CT) and were subdivided into high- and low-risk groups, according to the probability of resultant intracranial injury. Serum tau levels of 60 patients and 20 healthy volunteers, who served as a control group, were measured. The mean age of the 60 patients (45 males, 15 females) was 32.5 years (range, 15-66 y). Mean Glasgow Coma Scale (GCS) score was 14+/-0.6. CT scans demonstrated intracranial injury in 11 patients (18.3%) and depressed fracture in 4 patients (6.7%). Serum tau levels of patients (188+/-210 pg/mL), compared with those of controls (86+/-48 pg/mL), were relatively higher; however, differences were not statistically significant (P=.445). Also, serum tau levels of high-risk patients (307+/-246 pg/mL) were significantly higher than those of low-risk patients (77+/-61 pg/mL) (P=.001). A total of 48 patients (80%) were accessible for follow-up after 6 months. Postconcussive syndrome was observed in 8 patients, 5 of whom had serum tau protein levels that were higher than those of the other 3 patients. However, no statistically significant difference was observed (P>.05). Investigators of the present study noted that serum tau levels in patients with mTBI were increased. Therefore, it is believed that this biomarker may prove helpful in identifying high-risk patients with mTBI. However, additional studies are needed to establish the diagnostic value of serum tau in detecting traumatic brain injury in patients with mTBI.
Collapse
Affiliation(s)
- M Bulut
- Department of Emergency Medicine, Uludag University Medical School, Bursa, Turkey
| | | | | | | | | | | | | | | |
Collapse
|
22
|
Muthukumar N. Indications and need for neuroimaging and newer developments in brain imaging in mild head injury. INDIAN JOURNAL OF NEUROTRAUMA 2005. [DOI: 10.1016/s0973-0508(05)80021-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
|
23
|
Serum tau protein levels in adult patients with mild head injury. Eur J Emerg Med 2005. [DOI: 10.1097/00063110-200508000-00022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
|
24
|
Jaffres P, Brun J, Declety P, Bosson JL, Fauvage B, Schleiermacher A, Kaddour A, Anglade D, Jacquot C, Payen JF. Transcranial Doppler to detect on admission patients at risk for neurological deterioration following mild and moderate brain trauma. Intensive Care Med 2005; 31:785-90. [PMID: 15834704 DOI: 10.1007/s00134-005-2630-4] [Citation(s) in RCA: 48] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2004] [Accepted: 03/22/2005] [Indexed: 01/30/2023]
Abstract
OBJECTIVE To investigate the contribution of transcranial Doppler measurements obtained in the emergency room for detecting patients with secondary neurological deterioration after mild or moderate brain trauma. DESIGN AND SETTING Prospective cohort study in the emergency room in a university teaching hospital. PATIENTS Seventy-eight adult patients admitted to the emergency room after a traumatic brain injury (TBI), including 42 patients with Glasgow Coma Score 14-15 and 36 with 9-13. MEASUREMENTS AND RESULTS All patients had transcranial Doppler measurements on both middle cerebral arteries and computed tomography on admission. Neurological outcome was assessed 7 days after trauma. Of the patients included 7 and 10 had secondary neurological deterioration after mild and moderate TBI, respectively. On admission these groups of patients had significantly more injuries on computed tomography using the Trauma Coma Data Bank classification and higher pulsatility index using transcranial Doppler than the patients having no subsequent neurological worsening. CONCLUSIONS Increased pulsatility index after mild or moderate TBI is a reason for concern about the possibility of further neurological deterioration. Computed tomography and Doppler measurements could be combined to detect on admission patients at risk for secondary neurological deterioration in order to improve their initial disposition.
Collapse
Affiliation(s)
- Paul Jaffres
- Department of Anaesthesiology and Critical Care Medicine, Albert Michallon Hospital, 38043 Grenoble, France
| | | | | | | | | | | | | | | | | | | |
Collapse
|
25
|
Abstract
PURPOSE OF REVIEW This review on traumatic brain injury consolidates the substantial current literature available on the pathophysiology, mechanisms, developments, and their subsequent effects on outcome. In particular, it tries to conceptualize why our greatly improved understanding of pathophysiology and neurobiology in traumatic brain injury has not translated into clear outcome improvements. RECENT FINDINGS Early cerebral ischaemia has been characterized further, with ischaemic brain volume correlating with 6-month outcome. The Brain Trauma Foundation has revised perfusion pressure targets, and there are additional data on the outcome impact of brain tissue oxygen response and asymmetric patterns of cerebral autoregulation. Mechanistic studies have highlighted the role of inflammation and introduced concepts such as therapeutic vaccination and immune modulation. Experimental neurogenesis and repair strategies show promise. Despite continuing gains in knowledge, the experimental successes have not yet translated to the clinic. Indeed, several major articles have attempted to understand the clinical failure of highly promising strategies such as hypothermia, and set out the framework for further studies (e.g. addressing decompressive craniectomy). High-dose mannitol has shown promise in poor grade patients, while hypertonic saline has shown better intracranial pressure control. Negative results may be the consequence of ineffective therapies. However, there is a gathering body of work that highlights the outcome impact of subtle neurocognitive changes, which may not be quantified adequately by outcome measures used in previous trials. Such knowledge has also informed improved definition of mild traumatic brain injury, and allowed validation of management guidelines. SUMMARY The evidence base for current therapies in this heterogeneous patient group is being refined, with greater emphasis on long-term functional outcomes. Improved monitoring techniques emphasize the need for individualization of therapeutic interventions.
Collapse
Affiliation(s)
- Jurgens Nortje
- Department of Anaesthesia, University of Cambridge, Cambridge CB2 2QQ, UK
| | | |
Collapse
|