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Impact of Fall Risk and Direct Oral Anticoagulant Treatment on Quality-Adjusted Life-Years in Older Adults with Atrial Fibrillation: A Markov Decision Analysis. Drugs Aging 2021; 38:713-723. [PMID: 34235644 DOI: 10.1007/s40266-021-00870-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/22/2021] [Indexed: 01/09/2023]
Abstract
BACKGROUND AND OBJECTIVE The decision to initiate anticoagulation in older adults with atrial fibrillation is complicated by the benefit of ischemic stroke prevention vs the risk of falls resulting in major bleeds. The objective of this study was to assess the impact of different treatments including direct oral anticoagulants on quality-adjusted life-years (QALYs) in patients aged 75 years and older with atrial fibrillation in the context of falls. METHODS A Markov decision process was constructed for older patients with atrial fibrillation taking no anti-thrombotic, aspirin, warfarin, rivaroxaban, and apixaban. Input probabilities for clinical events were estimated from the available literature. One-way and two-way sensitivity analyses were performed by measuring the impact of varying input probabilities of clinical events on QALY outcomes. RESULTS The base-case scenario estimated that older adults treated with no anti-thrombotic, aspirin, warfarin, rivaroxaban, and apixaban had QALYs of 8.03, 8.69, 10.38, 11.02, and 11.56, respectively. The sensitivity analysis estimated that an older adult would need to fall over 45 (rivaroxaban) and 458 (apixaban) times per year for the QALY of a direct oral anticoagulant to be lower than that of aspirin. CONCLUSIONS Older adults with atrial fibrillation benefit from stroke protection of anticoagulants, especially direct oral anticoagulants, even if they are at high risk of falls. Clinicians should not consider fall risk as a deciding factor for withholding anticoagulation in this population of patients.
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de Wit K, Mercuri M, Clayton N, Worster A, Mercier E, Emond M, Varner C, McLeod SL, Eagles D, Stiell I, Barbic D, Morris J, Jeanmonod R, Kagoma Y, Shoamanesh A, Engels PT, Sharma S, Kearon C, Papaioannou A, Parpia S. Which older emergency patients are at risk of intracranial bleeding after a fall? A protocol to derive a clinical decision rule for the emergency department. BMJ Open 2021; 11:e044800. [PMID: 34215600 PMCID: PMC8256748 DOI: 10.1136/bmjopen-2020-044800] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
INTRODUCTION Falling on level ground is now the most common cause of traumatic intracranial bleeding worldwide. Older adults frequently present to the emergency department (ED) after falling. It can be challenging for clinicians to determine who requires brain imaging to rule out traumatic intracranial bleeding, and often head injury decision rules do not apply to older adults who fall. The goal of our study is to derive a clinical decision rule, which will identify older adults who present to the ED after a fall who do not have clinically important intracranial bleeding. METHODS AND ANALYSIS This is a prospective cohort study enrolling patients aged 65 years or older, who present to the ED of 11 hospitals in Canada and the USA within 48 hours of having a fall. Patients are included if they fall on level ground, off a chair, toilet seat or out of bed. The primary outcome is the diagnosis of clinically important intracranial bleeding within 42 days of the index ED visit. An independent adjudication committee will determine the primary outcome, blinded to all other data. We are collecting data on 17 potential predictor variables. The treating physician completes a study data form at the time of initial assessment, prior to brain imaging. Data extraction is supplemented by an independent, structured electronic medical record review. We will perform binary recursive partitioning using Classification and Regression Trees to derive a clinical decision rule. ETHICS AND DISSEMINATION The study was initially approved by the Hamilton Integrated Research Ethics Committee and subsequently approved by the research ethics boards governing all participating sites. We will disseminate our results by journal publication, presentation at international meetings and social media. TRIAL REGISTRATION NUMBER NCT03745755.
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Affiliation(s)
- Kerstin de Wit
- Department of Emergency Medicine, Queen's University, Kingston, Ontario, Canada
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
| | - Mathew Mercuri
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada
- Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
| | - Natasha Clayton
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada
- Emergency Department, Hamilton Health Sciences, Hamilton, Ontario, Canada
| | - Andrew Worster
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
| | - Eric Mercier
- Centre de recherche du CHU de Québec, Université Laval, Québec, Quebec, Canada
- Centre de recherche sur les soins et les services de première ligne, Université Laval, Québec, Québec, Canada
| | - Marcel Emond
- Centre de recherche du CHU de Québec, Université Laval, Québec, Quebec, Canada
- Centre de recherche sur les soins et les services de première ligne, Université Laval, Québec, Québec, Canada
| | - Catherine Varner
- Schwartz/Reisman Emergency Medicine Institute, Sinai Health System, Toronto, Ontario, Canada
- Family and community medicine, University of Toronto, Toronto, Ontario, Canada
| | - Shelley L McLeod
- Schwartz/Reisman Emergency Medicine Institute, Sinai Health System, Toronto, Ontario, Canada
- Family and community medicine, University of Toronto, Toronto, Ontario, Canada
| | - Debra Eagles
- Department of Emergency Medicine, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
- School of Epidemiology and Public Heath, University of Ottawa, Ottawa, Ontario, Canada
| | - Ian Stiell
- Department of Emergency Medicine, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - David Barbic
- Emergency Medicine, University of British Columbia, Vancouver, British Columbia, Canada
- Centre for Health Evaluation Outcome Sciences, St Paul's Hospital, Vancouver, British Columbia, Canada
| | - Judy Morris
- Department of Family Medicine and Emergency Medicine, Université de Montréal, Montreal, Quebec, Canada
- Department of Family Medicine and Emergency Medicine, Université de Montréal, Québec, Québec, Canada
| | - Rebecca Jeanmonod
- Emergency Medicine, St. Luke's University Health Network, Bethlehem, Pennsylvania, USA
| | - Yoan Kagoma
- Department of Radiology, McMaster University, Hamilton, Ontario, Canada
| | - Ashkan Shoamanesh
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Paul T Engels
- Department of Surgery, McMaster University, Hamilton, Ontario, Canada
| | - Sunjay Sharma
- Division of Neurosurgery, Department of Surgery, McMaster University, Hamilton, Ontario, Canada
| | - Clive Kearon
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | | | - Sameer Parpia
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
- Ontario Clinical Oncology Group, McMaster University, Hamilton, Ontario, Canada
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de Wit K, Parpia S, Varner C, Worster A, McLeod S, Clayton N, Kearon C, Mercuri M. Clinical Predictors of Intracranial Bleeding in Older Adults Who Have Fallen: A Cohort Study. J Am Geriatr Soc 2020; 68:970-976. [PMID: 32010977 DOI: 10.1111/jgs.16338] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2019] [Revised: 12/24/2019] [Accepted: 12/27/2019] [Indexed: 01/03/2023]
Abstract
OBJECTIVES Emergency department (ED) visits among older adults are frequently instigated by a fall at home. Some of these patients develop intracranial bleeding. The aim of this study was to identify the incidence of intracranial bleeding and the associated clinical features in older adults who present to the ED after falling. DESIGN Prospective cohort study. SETTING Three Canadian EDs. PARTICIPANTS A total of 2 176 patients age 65 years or older who presented to the ED with a fall were assessed, and 1753 were included. Inclusion criteria were a fall on level ground, off a bed, chair, or toilet, or from one or two steps within 48 hours. MEASUREMENTS Emergency physicians recorded predefined clinical findings on initial assessment. The primary outcome was intracranial bleeding, diagnosed either by computed tomography at the index visit or within 42 days. Associations between baseline clinical findings and the presence of intracranial bleeding were assessed with multivariable logistic regression. RESULTS A total of 1753 patients (median age = 82 y) were enrolled, of whom 39% were male, 35% were on antiplatelet therapy, and 25% were on an anticoagulant. The incidence of intracranial bleeding was 5.0% (95% confidence interval [CI] = 4.1-6.1). Overall, 76 patients were diagnosed at the index ED visit, and 12 were diagnosed during follow-up. Multivariable regression identified four clinical variables that were independently associated with intracranial bleeding: new abnormalities on neurologic examination (odds ratio [OR] = 4.4; 95% CI = 2.4-8.1), bruise or laceration on the head (OR = 4.3; 95% CI = 2.7-7.0), chronic kidney disease (OR = 2.4; 95% CI = 1.3-4.6), and reduced Glasgow Coma Scale from normal (OR = 1.9; 95% CI = 1.0-3.4). CONCLUSION The incidence of intracranial bleeding in our study was 5.0%. We found significant associations between intracranial bleeding and four simple clinical variables. We did not find significant associations between intracranial bleeding and antiplatelet or anticoagulant use. J Am Geriatr Soc 68:970-976, 2020.
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Affiliation(s)
- Kerstin de Wit
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada.,Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Ontario, Canada
| | - Sameer Parpia
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Ontario, Canada
| | - Catherine Varner
- Schwartz/Reisman Emergency Medicine Research Institute, Sinai Health System, Toronto, Ontario, Canada.,Division of Emergency Medicine, Department of Family and Community Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Andrew Worster
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada.,Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Ontario, Canada
| | - Shelley McLeod
- Schwartz/Reisman Emergency Medicine Research Institute, Sinai Health System, Toronto, Ontario, Canada.,Division of Emergency Medicine, Department of Family and Community Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Natasha Clayton
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada.,Emergency Department, Hamilton Health Sciences, Hamilton, Ontario, Canada
| | - Clive Kearon
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Mathew Mercuri
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada
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Hsia RY, Markowitz AJ, Lin F, Guo J, Madhok DY, Manley GT. Ten-year trends in traumatic brain injury: a retrospective cohort study of California emergency department and hospital revisits and readmissions. BMJ Open 2018; 8:e022297. [PMID: 30552250 PMCID: PMC6303631 DOI: 10.1136/bmjopen-2018-022297] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/12/2018] [Revised: 09/21/2018] [Accepted: 10/05/2018] [Indexed: 01/02/2023] Open
Abstract
OBJECTIVE To describe visits and visit rates of adults presenting to emergency departments (EDs) with a diagnosis of traumatic brain injury (TBI). TBI is a major cause of death and disability in the USA; yet, current literature is limited because few studies examine longer-term ED revisits and hospital readmission patterns of TBI patients across a broad spectrum of injury severity, which can help inform potential unmet healthcare needs. DESIGN We performed a retrospective cohort study. SETTING We analysed non-public patient-level data from California's Office of Statewide Health Planning and Development for years 2005 to 2014. PARTICIPANTS We identified 1.2 million adult patients aged ≥18 years presenting to California EDs and hospitals with an index diagnosis of TBI. PRIMARY AND SECONDARY OUTCOME MEASURES Our main outcomes included revisits, readmissions and mortality over time. We also examined demographics, mechanism and severity of injury and disposition at discharge. RESULTS We found a 57.7% increase in the number of TBI ED visits, representing a 40.5% increase in TBI visit rates over the 10-year period (346-487 per 100 000 residents). During this time, there was also a 33.8% decrease in the proportion of patients admitted to the hospital. Older, publicly insured and black populations had the highest visit rates, and falls were the most common mechanism of injury (45.5% of visits). Of all patients with an index TBI visit, 40.5% of them had a revisit during the first year, with 46.7% of them seeking care at a different hospital from their initial hospital or ED visit. Additionally, of revisits within the first year, 13.4% of them resulted in hospital readmission. CONCLUSIONS The large proportion of patients with TBI who are discharged directly from the ED, along with the high rates of revisits and readmissions, suggest a role for an established system for follow-up, treatment and care of TBI.
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Affiliation(s)
- Renee Y Hsia
- Department of Emergency Medicine, University of California, San Francisco, San Francisco, California, USA
- Philip R. Lee Institute for Health Policy Studies, University of California, San Francisco, San Francisco, California, USA
| | - Amy J Markowitz
- Brain and Spinal Injury Center (BASIC), University of California, San Francisco, San Francisco, California, USA
| | - Feng Lin
- Department of Epidemiology and Biostatistics, University of California, San Francisco, San Francisco, California, USA
| | - Joanna Guo
- Department of Emergency Medicine, University of California, San Francisco, San Francisco, California, USA
| | - Debbie Y Madhok
- Department of Emergency Medicine, University of California, San Francisco, San Francisco, California, USA
| | - Geoffrey T Manley
- Department of Neurological Surgery, University of California, San Francisco, San Francisco, California, USA
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Skandsen T, Einarsen CE, Normann I, Bjøralt S, Karlsen RH, McDonagh D, Nilsen TL, Akslen AN, Håberg AK, Vik A. The epidemiology of mild traumatic brain injury: the Trondheim MTBI follow-up study. Scand J Trauma Resusc Emerg Med 2018; 26:34. [PMID: 29703222 PMCID: PMC5921265 DOI: 10.1186/s13049-018-0495-0] [Citation(s) in RCA: 37] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2018] [Accepted: 04/04/2018] [Indexed: 12/27/2022] Open
Abstract
Background Mild traumatic brain injury (MTBI) is a frequent medical condition, and some patients report long-lasting problems after MTBI. In order to prevent MTBI, knowledge of the epidemiology is important and potential bias in studies should be explored. Aims of this study were to describe the epidemiological characteristics of MTBI in a Norwegian area and to evaluate the representativeness of patients successfully enrolled in the Trondheim MTBI follow-up study. Methods During 81 weeks in 2014 and 2015, all persons aged 16–60 years, presenting with possible MTBI to the emergency department (ED) at St. Olavs Hospital, Trondheim University Hospital or to Trondheim municipal outpatient ED, were evaluated for participation in the follow-up study. Patients were identified by CT referrals and patient lists. Patients who were excluded or missed for enrolment in the follow-up study were recorded. Results We identified 732 patients with MTBI. Median age was 28 years, and fall was the most common cause of injury. Fifty-three percent of injuries occurred during the weekend. Only 29% of MTBI patients were hospitalised. Study specific exclusion criteria were present in 23%. We enrolled 379 in the Trondheim MTBI follow-up study. In this cohort, Glasgow Coma Scale score was 15 at presentation in 73%; 45% of patients were injured under the influence of alcohol. Patients missed for inclusion were significantly more often outpatients, females, injured during the weekend, and suffering violent injuries, but differences between enrolled and not enrolled patients were small. Conclusion Two thirds of all patients with MTBI in the 16–60 age group were treated without hospital admission, patients were often young, and half of the patients presented during the weekend. Fall was the most common cause of injury, and patients were commonly injured under the influence of alcohol, which needs to be addressed when considering strategies for prevention. The Trondheim MTBI follow-up study comprised patients who were highly representative for the underlying epidemiology of MTBI.
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Affiliation(s)
- Toril Skandsen
- Department of Neuromedicine and Movement Science, Faculty of Medicine and Health Sciences, Norwegian University of Science and Technology, Trondheim, Norway. .,Department of Physical Medicine and Rehabilitation, St. Olavs Hospital, Trondheim University Hospital, Trondheim, Norway.
| | - Cathrine Elisabeth Einarsen
- Department of Neuromedicine and Movement Science, Faculty of Medicine and Health Sciences, Norwegian University of Science and Technology, Trondheim, Norway.,Department of Physical Medicine and Rehabilitation, St. Olavs Hospital, Trondheim University Hospital, Trondheim, Norway
| | - Ingunn Normann
- Department of Neuromedicine and Movement Science, Faculty of Medicine and Health Sciences, Norwegian University of Science and Technology, Trondheim, Norway
| | - Stine Bjøralt
- Department of Neuromedicine and Movement Science, Faculty of Medicine and Health Sciences, Norwegian University of Science and Technology, Trondheim, Norway
| | - Rune Hatlestad Karlsen
- Department of Neuromedicine and Movement Science, Faculty of Medicine and Health Sciences, Norwegian University of Science and Technology, Trondheim, Norway.,Department of Physical Medicine and Rehabilitation, St. Olavs Hospital, Trondheim University Hospital, Trondheim, Norway
| | - David McDonagh
- Orthopaedic Department, St. Olavs Hospital, Trondheim University Hospital, Trondheim, Norway.,Municipal Emergency Department, Trondheim kommune, Trondheim, Norway
| | - Tom Lund Nilsen
- Department of Public Health and Nursing, NTNU, Faculty of Medicine and Health Sciences, Trondheim, Norway
| | - Andreas Nylenna Akslen
- Department of Neuromedicine and Movement Science, Faculty of Medicine and Health Sciences, Norwegian University of Science and Technology, Trondheim, Norway
| | - Asta Kristine Håberg
- Department of Neuromedicine and Movement Science, Faculty of Medicine and Health Sciences, Norwegian University of Science and Technology, Trondheim, Norway.,Department of Radiology and Nuclear Medicine, St. Olavs Hospital, Trondheim University Hospital, Trondheim, Norway
| | - Anne Vik
- Department of Neuromedicine and Movement Science, Faculty of Medicine and Health Sciences, Norwegian University of Science and Technology, Trondheim, Norway.,Department of Neurosurgery, St. Olavs Hospital, Trondheim University Hospital, Trondheim, Norway
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Kucera KL, Fortington LV, Wolff CS, Marshall SW, Finch CF. Estimating the international burden of sport-related death: a review of data sources. Inj Prev 2018; 25:83-89. [PMID: 29437783 DOI: 10.1136/injuryprev-2017-042642] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2017] [Revised: 01/12/2018] [Accepted: 01/18/2018] [Indexed: 11/03/2022]
Abstract
INTRODUCTION Despite detailed recommendations for sports injury data capture provided since the mid-1990s, international data collection efforts for sport-related death remains limited in scope. The purpose of this paper was to review the data sources available for studying sport-related death and describe their key features, coverage, accessibility and strengths and limitations. METHODS The outcomes of interest for this review was death occurring as a result of participation in organised sport-related activity. Data sources used to enumerate death in sport were identified, drawing from the authors' knowledge/experience and review of key references from international organisations. The general purpose, case identification, structure, strengths and limitations of each source in relation to collection of data for sport-related death were summarised, drawing on examples from the international published literature to illustrate this application. RESULTS Seven types of resources were identified for capturing deaths in sport. Data sources varied considerably in their ability to identify: participant status, sport relatedness of the death, types of sport-related deaths they capture, level of detail provided about the circumstances and medical care received. The most detailed sources were those that were dedicated to sports surveillance. Sport relatedness and type of sport may not be reliably captured by systems not dedicated to sports injury surveillance. Only one source permitted international comparisons and was limited to one sport (soccer). CONCLUSION Data on sport-related death are currently collected across a wide variety of data sources. This review highlights the need for robust, comprehensive approaches with standardised methodologies enabling linkage between sources and international comparisons.
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Affiliation(s)
- Kristen L Kucera
- Department of Exercise and Sport Science, National Center for Catastrophic Sport Injury Research, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Lauren V Fortington
- Australian Centre for Research into Injury in Sport and its Prevention (ACRISP), Federation University Australia, Ballarat, Victoria, Australia
| | - Catherine S Wolff
- Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Stephen W Marshall
- Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA.,Injury Prevention Research Center, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Caroline F Finch
- Australian Centre for Research into Injury in Sport and its Prevention (ACRISP), Federation University Australia, Ballarat, Victoria, Australia
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Hassan WMNW, Nasir YM, Zaini RHM, Shukeri WFWM. Target-controlled Infusion Propofol Versus Sevoflurane Anaesthesia for Emergency Traumatic Brain Surgery: Comparison of the Outcomes. Malays J Med Sci 2017; 24:73-82. [PMID: 29386974 DOI: 10.21315/mjms2017.24.5.8] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2017] [Accepted: 08/22/2017] [Indexed: 10/18/2022] Open
Abstract
Background The choice of anaesthetic techniques is important for the outcome of traumatic brain injury (TBI) emergency surgery. The objective of this study was to compare patient outcomes for target-controlled infusion (TCI) of propofol and sevoflurane anaesthesia. Methods A total of 110 severe TBI patients, aged 18-60, who underwent emergency brain surgery were randomised into Group T (TCI) (n = 55) and Group S (sevoflurane) (n = 55). Anaesthesia was maintained in Group T with propofol target plasma concentration of 3-6 μg/mL and in Group S with minimum alveolar concentration (MAC) of sevoflurane 1.0-1.5. Both groups received TCI remifentanil 2-8 ng/mL for analgesia. After the surgery, patients were managed in the intensive care unit and were followed up until discharge for the outcome parameters. Results Demographic characteristics were comparable in both groups. Differences in Glasgow Outcome Scale (GOS) score at discharge were not significant between Group T and Group S (P = 0.25): the percentages of mortality (GOS 1) [27.3% versus 16.4%], vegetative and severe disability (GOS 2-3) [29.1% versus 41.8%] and good outcome (GOS 4-5) [43.6% versus 41.8%] were comparable in both groups. There were no significant differences in other outcome parameters. Conclusion TCI propofol and sevoflurane anaesthesia were comparable in the outcomes of TBI patients after emergency surgery.
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Affiliation(s)
- Wan Mohd Nazaruddin Wan Hassan
- Department of Anaesthesiology, School of Medical Sciences, Jalan Sultanah Zainab II, Universiti Sains Malaysia, 16150 Kubang Kerian, Kelantan, Malaysia
| | - Yusnizah Mohd Nasir
- Department of Anaesthesiology, School of Medical Sciences, Jalan Sultanah Zainab II, Universiti Sains Malaysia, 16150 Kubang Kerian, Kelantan, Malaysia
| | - Rhendra Hardy Mohamad Zaini
- Department of Anaesthesiology, School of Medical Sciences, Jalan Sultanah Zainab II, Universiti Sains Malaysia, 16150 Kubang Kerian, Kelantan, Malaysia
| | - Wan Fadzlina Wan Muhd Shukeri
- Department of Anaesthesiology, School of Medical Sciences, Jalan Sultanah Zainab II, Universiti Sains Malaysia, 16150 Kubang Kerian, Kelantan, Malaysia
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Validation of Acoustic Wave Induced Traumatic Brain Injury in Rats. Brain Sci 2017; 7:brainsci7060059. [PMID: 28574429 PMCID: PMC5483632 DOI: 10.3390/brainsci7060059] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2017] [Revised: 05/17/2017] [Accepted: 05/25/2017] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND This study looked to validate the acoustic wave technology of the Storz-D-Actor that inflicted a consistent closed-head, traumatic brain injury (TBI) in rats. We studied a range of single pulse pressures administered to the rats and observed the resulting decline in motor skills and memory. Histology was observed to measure and confirm the injury insult. METHODS Four different acoustic wave pressures were studied using a single pulse: 0, 3.4, 4.2 and 5.0 bar (n = 10 rats per treatment group). The pulse was administered to the left frontal cortex. Rotarod tests were used to monitor the rats' motor skills while the water maze test was used to monitor memory deficits. The rats were then sacrificed ten days post-treatment for histological analysis of TBI infarct size. RESULTS The behavioral tests showed that acoustic wave technology administered an effective insult causing significant decreases in motor abilities and memory. Histology showed dose-dependent damage to the cortex infarct areas only. CONCLUSIONS This study illustrates that the Storz D-Actor effectively induces a repeatable TBI infarct, avoiding the invasive procedure of a craniotomy often used in TBI research.
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Hoffer ME, Balaban C, Szczupak M, Buskirk J, Snapp H, Crawford J, Wise S, Murphy S, Marshall K, Pelusso C, Knowles S, Kiderman A. The use of oculomotor, vestibular, and reaction time tests to assess mild traumatic brain injury (mTBI) over time. Laryngoscope Investig Otolaryngol 2017; 2:157-165. [PMID: 28894835 PMCID: PMC5562938 DOI: 10.1002/lio2.74] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2016] [Revised: 01/15/2017] [Accepted: 02/16/2017] [Indexed: 11/27/2022] Open
Abstract
Objectives The objective of this work is to examine the outcomes of a set of objective measures for evaluating individuals with minor traumatic brain injury (mTBI) over the sub‐acute time period. These methods involve tests of oculomotor, vestibular, and reaction time functions. This work expands upon published work examining these test results at the time of presentation. Study Design This study is a prospective age‐ and sex‐matched controlled study. Materials and Methods The subject group was composed of 106 individuals with mTBI and 300 age‐ and sex‐matched controls without a history of mTBI. All individuals agreeing to participate in the study underwent a battery of oculomotor, vestibular, and reaction time tests (OVRT). Those subjects with mTBI underwent these tests at presentation (within 6 days of injury) and 1 and 2weeks post injury. These outcomes were compared to each other over time as well as to results from the controls that underwent 1 test session. Results Six measures from 5 tests can classify the control and mTBI during Session 1 with a true positive rate (sensitivity) of 84.9% and true negative rate (specificity) of 97.0%. Patterns of abnormalities changed over time in the mTBI group and overall normalized in a subset of individuals at the third (final) testing session. Conclusions We describe an objective and effective second generation testing algorithm for diagnosing and following the prognosis of mTBI/concussion. This testing paradigm will allow investigators to institute better treatments and provide more accurate return to activity advice. Level of Evidence 3
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Affiliation(s)
- Michael E Hoffer
- Department of Otolaryngology Miami Florida U.S.A.,Department of Neurological Surgery Miller School of Medicine, University of Miami Miami Florida U.S.A.,University of Miami Sports Performance and Wellness Institute Miami Florida U.S.A
| | - Carey Balaban
- Department of Otolaryngology University of Pittsburgh Pittsburgh Pennsylvania U.S.A
| | - Mikhaylo Szczupak
- Department of Otolaryngology Miami Florida U.S.A.,University of Miami Sports Performance and Wellness Institute Miami Florida U.S.A
| | - James Buskirk
- Department of Otolaryngology Miami Florida U.S.A.,University of Miami Sports Performance and Wellness Institute Miami Florida U.S.A
| | | | - James Crawford
- Department of Otolaryngology Madigan Army Medical Center Tacoma Washington U.S.A
| | - Sean Wise
- Naval Medical Center, San Diego San Diego California U.S.A
| | - Sara Murphy
- Department of Otolaryngology Miami Florida U.S.A.,Naval Medical Center, San Diego San Diego California U.S.A
| | - Kathryn Marshall
- Department of Otolaryngology Madigan Army Medical Center Tacoma Washington U.S.A
| | - Constanza Pelusso
- Department of Otolaryngology Miami Florida U.S.A.,University of Miami Sports Performance and Wellness Institute Miami Florida U.S.A
| | - Sean Knowles
- Department of Otolaryngology Miami Florida U.S.A
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10
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Acetazolamide Mitigates Astrocyte Cellular Edema Following Mild Traumatic Brain Injury. Sci Rep 2016; 6:33330. [PMID: 27623738 PMCID: PMC5022024 DOI: 10.1038/srep33330] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2016] [Accepted: 08/25/2016] [Indexed: 12/31/2022] Open
Abstract
Non-penetrating or mild traumatic brain injury (mTBI) is commonly experienced in accidents, the battlefield and in full-contact sports. Astrocyte cellular edema is one of the major factors that leads to high morbidity post-mTBI. Various studies have reported an upregulation of aquaporin-4 (AQP4), a water channel protein, following brain injury. AZA is an antiepileptic drug that has been shown to inhibit AQP4 expression and in this study we investigate the drug as a therapeutic to mitigate the extent of mTBI induced cellular edema. We hypothesized that mTBI-mediated astrocyte dysfunction, initiated by increased intracellular volume, could be reduced when treated with AZA. We tested our hypothesis in a three-dimensional in vitro astrocyte model of mTBI. Samples were subject to no stretch (control) or one high-speed stretch (mTBI) injury. AQP4 expression was significantly increased 24 hours after mTBI. mTBI resulted in a significant increase in the cell swelling within 30 min of mTBI, which was significantly reduced in the presence of AZA. Cell death and expression of S100B was significantly reduced when AZA was added shortly before mTBI stretch. Overall, our data point to occurrence of astrocyte swelling immediately following mTBI, and AZA as a promising treatment to mitigate downstream cellular mortality.
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Hånell A, Greer JE, Jacobs KM. Increased Network Excitability Due to Altered Synaptic Inputs to Neocortical Layer V Intact and Axotomized Pyramidal Neurons after Mild Traumatic Brain Injury. J Neurotrauma 2015; 32:1590-8. [PMID: 25789412 DOI: 10.1089/neu.2014.3592] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Mild traumatic brain injury (mTBI) can produce long lasting cognitive dysfunction. There is typically no cell death and only diffuse structural injury after mTBI. Thus, functional changes in intact neurons may contribute to symptoms. We have previously shown altered intrinsic properties of axotomized and intact neurons within 2 d after a central fluid percussion injury in mice expressing yellow fluorescent protein (YFP) that allow identification of axonal state prior to recording. Here, whole-cell patch clamp recordings were used to examine synaptic properties of YFP(+) layer V pyramidal neurons. An increased frequency of spontaneous and miniature excitatory postsynaptic currents (EPSCs) was recorded from axotomized neurons at 1 d and intact neurons at 2 d after injury, likely reflecting an increased number of afferents. This also was reflected in the increased amplitude of the EPSC evoked by local extracellular stimulation for all neurons from injured cortex and increased likelihood of producing an action potential for intact cells. Field potentials recorded in superficial layers after online deep layer stimulation contained a single negative peak in controls but multiple negative peaks in injured tissue. The amplitude of this evoked negativity was significantly larger than controls over a series of stimulus intensities at both the 1 d and 2 d survival times. Interictal-like spikes never occurred in the field potential recordings from controls but were observed in 20-80% of stimulus presentations in injured cortex. Together, these results suggest an overall increase in network excitability and the production of particularly powerful (intact) neurons that have both increased intrinsic and synaptic excitability.
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Affiliation(s)
- Anders Hånell
- 1 Department of Anatomy and Neurobiology, Virginia Commonwealth University , Richmond, Virginia
| | - John E Greer
- 2 Department of Neurosurgery, Virginia Commonwealth University , Richmond, Virginia
| | - Kimberle M Jacobs
- 1 Department of Anatomy and Neurobiology, Virginia Commonwealth University , Richmond, Virginia
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