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Schneider H, Meis J, Klose C, Ratzka P, Niesen WD, Seder DB, Bösel J. Surgical Versus Dilational Tracheostomy in Patients with Severe Stroke: A SETPOINT2 Post hoc Analysis. Neurocrit Care 2024:10.1007/s12028-023-01933-9. [PMID: 38291277 DOI: 10.1007/s12028-023-01933-9] [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: 09/28/2023] [Accepted: 12/21/2023] [Indexed: 02/01/2024]
Abstract
BACKGROUND Tracheostomy in mechanically ventilated patients with severe stroke can be performed surgically or dilationally. Prospective data comparing both methods in patients with stroke are scarce. The randomized Stroke-Related Early Tracheostomy vs Prolonged Orotracheal Intubation in Neurocritical Care Trial2 (SETPOINT2) assigned 382 mechanically ventilated patients with stroke to early tracheostomy versus extubation or standard tracheostomy. Surgical tracheostomy (ST) was performed in 41 of 307 SETPOINT2 patients, and the majority received dilational tracheostomy (DT). We aimed to compare ST and DT in these patients with patients. METHODS All SETPOINT2 patients with ST were compared with a control group of patients with stroke undergoing DT (1:2), selected by propensity score matching that included the factors stroke type, SETPOINT2 randomization group, Stroke Early Tracheostomy score, patient age, and premorbid functional status. Successful decannulation was the primary outcome, and secondary outcome parameters included functional outcome at 6 months and adverse events attributable to tracheostomy. Potential predictors of decannulation were evaluated by regression analysis. RESULTS Baseline characteristics were comparable in the two groups of patients with stroke undergoing ST (n = 41) and matched patients with stroke undergoing DT (n = 82). Tracheostomy was performed significantly later in the ST group than in the DT group (median 9 [interquartile range {IQR} 5-12] vs. 9 [IQR 4-11] days after intubation, p = 0.025). Patients with ST were mechanically ventilated longer (median 19 [IQR 17-24] vs.14 [IQR 11-19] days, p = 0.008) and stayed in the intensive care unit longer (median 23 [IQR 16-27] vs. 17 [IQR 13-24] days, p = 0.047), compared with patients with DT. The intrahospital infection rate was significantly higher in the ST group compared to the DT group (14.6% vs. 1.2%, p = 0.002). At 6 months, decannulation rates (56% vs. 61%), functional outcomes, and mortality were not different. However, decannulation was performed later in the ST group compared to the DT group (median 81 [IQR 66-149] vs. 58 [IQR 32-77] days, p = 0.004). Higher baseline Stroke Early Tracheostomy score negatively predicted decannulation. CONCLUSIONS In ventilated patients with severe stroke in need of tracheostomy, surgical and dilational methods are associated with comparable decannulation rate and functional outcome at 6 months. However, ST was associated with longer time to decannulation and higher rates of early infections, supporting the dilational approach to tracheostomy in ventilated patients with stroke.
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Affiliation(s)
- Hauke Schneider
- Department of Neurology, University Hospital Augsburg, Stenglinstr. 2, 86156, Augsburg, Germany.
- Medical Faculty, University of Dresden, Dresden, Germany.
| | - Jan Meis
- Institute of Medical Biometry, University of Heidelberg, Heidelberg, Germany
| | - Christina Klose
- Institute of Medical Biometry, University of Heidelberg, Heidelberg, Germany
| | - Peter Ratzka
- Department of Neurology, University Hospital Augsburg, Stenglinstr. 2, 86156, Augsburg, Germany
| | - Wolf-Dirk Niesen
- Department of Neurology and Neurophysiology, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - David B Seder
- Department of Critical Care Services, Maine Medical Center, Portland, ME, USA
| | - Julian Bösel
- University of Heidelberg, Heidelberg, Germany
- Johns Hopkins University Hospital, Baltimore, MD, USA
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2
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Alkhachroum A, Zhou L, Asdaghi N, Gardener H, Ying H, Gutierrez CM, Manolovitz BM, Samano D, Bass D, Foster D, Sur NB, Rose DZ, Jameson A, Massad N, Kottapally M, Merenda A, Starke RM, O'Phelan K, Romano JG, Claassen J, Sacco RL, Rundek T. Predictors and Temporal Trends of Withdrawal of Life-Sustaining Therapy After Acute Stroke in the Florida Stroke Registry. Crit Care Explor 2023; 5:e0934. [PMID: 37378082 PMCID: PMC10292735 DOI: 10.1097/cce.0000000000000934] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/29/2023] Open
Abstract
Temporal trends and factors associated with the withdrawal of life-sustaining therapy (WLST) after acute stroke are not well determined. DESIGN Observational study (2008-2021). SETTING Florida Stroke Registry (152 hospitals). PATIENTS Acute ischemic stroke (AIS), intracerebral hemorrhage (ICH), and subarachnoid hemorrhage (SAH) patients. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Importance plots were performed to generate the most predictive factors of WLST. Area under the curve (AUC) for the receiver operating curve were generated for the performance of logistic regression (LR) and random forest (RF) models. Regression analysis was applied to evaluate temporal trends. Among 309,393 AIS patients, 47,485 ICH patients, and 16,694 SAH patients; 9%, 28%, and 19% subsequently had WLST. Patients who had WLST were older (77 vs 70 yr), more women (57% vs 49%), White (76% vs 67%), with greater stroke severity on the National Institutes of Health Stroke Scale greater than or equal to 5 (29% vs 19%), more likely hospitalized in comprehensive stroke centers (52% vs 44%), had Medicare insurance (53% vs 44%), and more likely to have impaired level of consciousness (38% vs 12%). Most predictors associated with the decision to WLST in AIS were age, stroke severity, region, insurance status, center type, race, and level of consciousness (RF AUC of 0.93 and LR AUC of 0.85). Predictors in ICH included age, impaired level of consciousness, region, race, insurance status, center type, and prestroke ambulation status (RF AUC of 0.76 and LR AUC of 0.71). Factors in SAH included age, impaired level of consciousness, region, insurance status, race, and stroke center type (RF AUC of 0.82 and LR AUC of 0.72). Despite a decrease in the rates of early WLST (< 2 d) and mortality, the overall rates of WLST remained stable. CONCLUSIONS In acute hospitalized stroke patients in Florida, factors other than brain injury alone contribute to the decision to WLST. Potential predictors not measured in this study include education, culture, faith and beliefs, and patient/family and physician preferences. The overall rates of WLST have not changed in the last 2 decades.
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Affiliation(s)
| | - Lili Zhou
- Department of Neurology, University of Miami, Miami, FL
| | - Negar Asdaghi
- Department of Neurology, University of Miami, Miami, FL
| | | | - Hao Ying
- Department of Neurology, University of Miami, Miami, FL
| | | | | | - Daniel Samano
- Department of Neurology, University of Miami, Miami, FL
| | - Danielle Bass
- Department of Neurology, University of Miami, Miami, FL
| | - Dianne Foster
- Regional Director Quality Improvement, American Heart Association, Dallas, TX
| | - Nicole B Sur
- Department of Neurology, University of Miami, Miami, FL
| | - David Z Rose
- Department of Neurology, Morsani College of Medicine, University of South Florida, Tampa, FL
| | - Angus Jameson
- Department of Emergency Medicine, Pinellas County Emergency Medical Services, Largo, FL
| | - Nina Massad
- Department of Neurology, University of Miami, Miami, FL
| | | | | | - Robert M Starke
- Department of Neurological Surgery, University of Miami, Miami, FL
| | | | - Jose G Romano
- Department of Neurology, University of Miami, Miami, FL
| | - Jan Claassen
- Department of Neurology, Columbia University, New York, NY
| | - Ralph L Sacco
- Department of Neurology, University of Miami, Miami, FL
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3
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Feng C, Lv C, Zhang X, Guo Y, Li X. Effect of 1 + N Extended Nursing Service on Functional Recovery of Colostomy Patients. COMPUTATIONAL INTELLIGENCE AND NEUROSCIENCE 2022; 2022:2645528. [PMID: 36072734 PMCID: PMC9444352 DOI: 10.1155/2022/2645528] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/24/2022] [Revised: 07/12/2022] [Accepted: 07/21/2022] [Indexed: 11/17/2022]
Abstract
To many hospitals' management as well as to patients, the nursing service is one of the most important aspects. Many diseases like sugar, blood pressure, urine passage, and gas are a little bit dangerous to handle by patients themselves. The earlier stage models are unable to give good services to patients; therefore, an advanced JHE: Effect of 1 + N extended nursing service is necessary to crossover the above limitations. Colostomy and colorectal cancers are very dangerous syndromes thus, disease monitoring is so difficult. In this research work, an extended JHE: Effect of 1 + N extended nursing service modeling is discussed with experimental modeling. Apart from conventional nursing care provided by the observation group, it was given online training as well as service providing. Self-efficacy and self-care competence were assessed in both groups 6 months after the discharge. Quality of life and mental health were also assessed. Besides, their dimensional and total self-care ability scores, and the observation group's self-efficacy ratings were substantially higher than those of the control group (P 0.05) after the intervention. It was observed that the intervention group's 6-month adjustment to the stoma was statistically more favorable than the control group's (P 0.001), and only the intervention group showed a significantly major change (P 0.001) between their two evaluations. This proposed methodology can improve the accuracy rate by 93.23%, and succussive treatment rate of 92.14% had been attained.
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Affiliation(s)
- Chunlan Feng
- Department of Nursing, Wuwei Cancer Hospital, Wuwei 733000, Gansu, China
| | - Caixia Lv
- Department of Nursing, Heavy Ion Center of Wuwei Cancer Hospital, Wuwei 733000, Gansu, China
| | - Xia Zhang
- Department of Nursing, Heavy Ion Center of Wuwei Cancer Hospital, Wuwei 733000, Gansu, China
| | - Yumei Guo
- Department of Nursing, Wuwei Cancer Hospital, Wuwei 733000, Gansu, China
| | - Xiaojun Li
- Department of Nursing, Heavy Ion Center of Wuwei Cancer Hospital, Wuwei 733000, Gansu, China
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4
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Lee EY, Sohn MK, Lee JM, Kim DY, Shin YI, Oh GJ, Lee YS, Lee SY, Song MK, Han JH, Ahn JH, Lee YH, Chang WH, Choi SM, Lee SK, Joo MC, Kim YH. Changes in Long-Term Functional Independence in Patients with Moderate and Severe Ischemic Stroke: Comparison of the Responsiveness of the Modified Barthel Index and the Functional Independence Measure. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:9612. [PMID: 35954971 PMCID: PMC9367998 DOI: 10.3390/ijerph19159612] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/26/2022] [Revised: 07/25/2022] [Accepted: 07/31/2022] [Indexed: 11/26/2022]
Abstract
This study investigated the long-term functional changes in patients with moderate-to-severe ischemic stroke. In addition, we investigated whether there was a difference between the modified Barthel Index (MBI) and Functional Independence Measure (FIM) according to severity. To evaluate the changes in the long-term functional independence of the subjects, six evaluations were conducted over 2 years, and the evaluation was performed using MBI and FIM. A total of 798 participants participated in this study, of which 673 were classified as moderate and 125 as severe. During the first 3 months, the moderate group showed greater recovery than the severe group. The period of significant change in the National Institutes of Health Stroke Scale (NIHSS) score was up to 6 months after onset in the moderate group, and up to 3 months after onset in the severe group. In the severe group, MBI evaluation showed significant changes up to 6 months after onset, whereas FIM showed significant changes up to 18-24 months. Our results showed that functional recovery of patients with ischemic stroke in the 3 months after onset was greater in the moderate group than in the severe group. FIM is more appropriate than MBI for evaluating the functional status of patients with severe stroke.
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Affiliation(s)
- Eun Young Lee
- Department of Rehabilitation Medicine, Institute of Brain Science Research, Wonkwang University School of Medicine, Iksan 54538, Korea
| | - Min Kyun Sohn
- Department of Rehabilitation Medicine, College of Medicine, Chungnam National University, Daejeon 35015, Korea
| | - Jong Min Lee
- Department of Rehabilitation Medicine, Konkuk University School of Medicine, Seoul 05030, Korea
| | - Deog Young Kim
- Department and Research Institute of Rehabilitation Medicine, Yonsei University College of Medicine, Seoul 03722, Korea
| | - Yong Il Shin
- Department of Rehabilitation Medicine, Pusan National University Yangsan Hospital, Pusan National University School of Medicine, Yangsan 50612, Korea
| | - Gyung Jae Oh
- Department of Preventive Medicine, Wonkwang University, School of Medicine, Iksan 54538, Korea
| | - Yang Soo Lee
- Department of Rehabilitation Medicine, Kyungpook National University Hospital, Kyungpook National University School of Medicine, Daegu 41566, Korea
| | - So Young Lee
- Department of Rehabilitation Medicine, Jeju National University Hospital, Jeju National University School of Medicine, Jeju 63241, Korea
| | - Min Keun Song
- Department of Physical and Rehabilitation Medicine, Chunnam National University Medical School, Kwangju 61469, Korea
| | - Jun Hee Han
- Department of Statistics, Hallym University, Chuncheon 24252, Korea
| | - Jeong Hoon Ahn
- Department of Health Convergence, Ewha Womans University, Seoul 03760, Korea
| | - Young Hoon Lee
- Department of Rehabilitation Medicine, Kyungpook National University Hospital, Kyungpook National University School of Medicine, Daegu 41566, Korea
| | - Won Hyuk Chang
- Department of Physical and Rehabilitation Medicine, Center for Prevention and Rehabilitation, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul 06351, Korea
| | - Soo Mi Choi
- Division of Chronic Disease Prevention, Korea Centers for Disease Control and Prevention, Center for Disease, Cheongju 28159, Korea
| | - Seon Kui Lee
- Division of Chronic Disease Prevention, Korea Centers for Disease Control and Prevention, Center for Disease, Cheongju 28159, Korea
| | - Min Cheol Joo
- Department of Rehabilitation Medicine, Institute of Wonkwang Medical Science, Wonkwang University School of Medicine, Iksan 54538, Korea
| | - Yun Hee Kim
- Department of Physical and Rehabilitation Medicine, Center for Prevention and Rehabilitation, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul 06351, Korea
- Department of Health Science and Technology, SAIHST, Sungkyunkwan University, Seoul 06351, Korea
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5
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Mostert CQB, Singh RD, Gerritsen M, Kompanje EJO, Ribbers GM, Peul WC, van Dijck JTJM. Long-term outcome after severe traumatic brain injury: a systematic literature review. Acta Neurochir (Wien) 2022; 164:599-613. [PMID: 35098352 DOI: 10.1007/s00701-021-05086-6] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2021] [Accepted: 12/07/2021] [Indexed: 12/28/2022]
Abstract
BACKGROUND Expectation of long-term outcome is an important factor in treatment decision-making after severe traumatic brain injury (sTBI). Conclusive long-term outcome data substantiating these decisions is nowadays lacking. This systematic review aimed to provide an overview of the scientific literature on long-term outcome after sTBI. METHODS A systematic search was conducted using PubMed from 2008 to 2020. Studies were included when reporting long-term outcome ≥ 2 years after sTBI (GCS 3-8 or AIS head score ≥ 4), using standardized outcome measures. Study quality and risk of bias were assessed using the QUIPS tool. RESULTS Twenty observational studies were included. Studies showed substantial variation in study objectives and study methodology. GOS-E (n = 12) and GOS (n = 8) were the most frequently used outcome measures. Mortality was reported in 46% of patients (range 18-75%). Unfavourable outcome rates ranged from 29 to 100% and full recovery was seen in 21-27% of patients. Most surviving patients reported SF-36 scores lower than the general population. CONCLUSION Literature on long-term outcome after sTBI was limited and heterogeneous. Mortality and unfavourable outcome rates were high and persisting sequelae on multiple domains common. Nonetheless, a considerable proportion of survivors achieved favourable outcome. Future studies should incorporate standardized multidimensional and temporal long-term outcome measures to strengthen the evidence-base for acute and subacute decision-making. HIGHLIGHTS 1. Expectation of long-term outcome is an important factor in treatment decision-making for patients with severe traumatic brain injury (sTBI). 2. Favourable outcome and full recovery after sTBI are possible, but mortality and unfavourable outcome rates are high. 3. sTBI survivors are likely to suffer from a wide range of long-term consequences, underscoring the need for long-term and multi-modality outcome assessment in future studies. 4. The quality of the scientific literature on long-term outcome after sTBI can and should be improved to advance treatment decision-making.
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Affiliation(s)
- Cassidy Q B Mostert
- University Neurosurgical Center Holland, Leiden University Medical Center & Haaglanden Medical Center & Haga Teaching Hospital, Leiden The Hague, Albinusdreef 2, J-11-R-83, 2333 ZA, Leiden, The Netherlands.
| | - Ranjit D Singh
- University Neurosurgical Center Holland, Leiden University Medical Center & Haaglanden Medical Center & Haga Teaching Hospital, Leiden The Hague, Albinusdreef 2, J-11-R-83, 2333 ZA, Leiden, The Netherlands
| | - Maxime Gerritsen
- University Neurosurgical Center Holland, Leiden University Medical Center & Haaglanden Medical Center & Haga Teaching Hospital, Leiden The Hague, Albinusdreef 2, J-11-R-83, 2333 ZA, Leiden, The Netherlands
| | - Erwin J O Kompanje
- Department of Intensive Care Medicine, Erasmus Medical Centre, Rotterdam, The Netherlands
| | - Gerard M Ribbers
- Department of Rehabilitation Medicine, Erasmus Medical Centre, Rotterdam, The Netherlands
- Rijndam Rehabilitation, Rotterdam, The Netherlands
| | - Wilco C Peul
- University Neurosurgical Center Holland, Leiden University Medical Center & Haaglanden Medical Center & Haga Teaching Hospital, Leiden The Hague, Albinusdreef 2, J-11-R-83, 2333 ZA, Leiden, The Netherlands
| | - Jeroen T J M van Dijck
- University Neurosurgical Center Holland, Leiden University Medical Center & Haaglanden Medical Center & Haga Teaching Hospital, Leiden The Hague, Albinusdreef 2, J-11-R-83, 2333 ZA, Leiden, The Netherlands
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6
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Alkhachroum A, Bustillo AJ, Asdaghi N, Marulanda-Londono E, Gutierrez CM, Samano D, Sobczak E, Foster D, Kottapally M, Merenda A, Koch S, Romano JG, O’Phelan K, Claassen J, Sacco RL, Rundek T. Withdrawal of Life-Sustaining Treatment Mediates Mortality in Patients With Intracerebral Hemorrhage With Impaired Consciousness. Stroke 2021; 52:3891-3898. [PMID: 34583530 PMCID: PMC8608746 DOI: 10.1161/strokeaha.121.035233] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND AND PURPOSE Impaired level of consciousness (LOC) on presentation at hospital admission in patients with intracerebral hemorrhage (ICH) may affect outcomes and the decision to withhold or withdraw life-sustaining treatment (WOLST). METHODS Patients with ICH were included across 121 Florida hospitals participating in the Florida Stroke Registry from 2010 to 2019. We studied the effect of LOC on presentation on in-hospital mortality (primary outcome), WOLST, ambulation status on discharge, hospital length of stay, and discharge disposition. RESULTS Among 37 613 cases with ICH (mean age 71, 46% women, 61% White, 20% Black, 15% Hispanic), 12 272 (33%) had impaired LOC at onset. Compared with cases with preserved LOC, patients with impaired LOC were older (72 versus 70 years), more women (49% versus 45%), more likely to have aphasia (38% versus 16%), had greater ICH score (3 versus 1), greater risk of WOLST (41% versus 18%), and had an increased in-hospital mortality (32% versus 12%). In the multivariable-logistic regression with generalized estimating equations accounting for basic demographics, comorbidities, ICH severity, hospital size and teaching status, impaired LOC was associated with greater mortality (odds ratio, 3.7 [95% CI, 3.1-4.3], P<0.0001) and less likely discharged home or to rehab (odds ratio, 0.3 [95% CI, 0.3-0.4], P<0.0001). WOLST significantly mediated the effect of impaired LOC on mortality (mediation effect, 190 [95% CI, 152-229], P<0.0001). Early WOLST (<2 days) occurred among 51% of patients. A reduction in early WOLST was observed in patients with impaired LOC after the 2015 American Heart Association/American Stroke Association ICH guidelines recommending aggressive treatment and against early do-not-resuscitate. CONCLUSIONS In this large multicenter stroke registry, a third of ICH cases presented with impaired LOC. Impaired LOC was associated with greater in-hospital mortality and worse disposition at discharge, largely influenced by early decision to withhold or WOLST.
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Affiliation(s)
- Ayham Alkhachroum
- Department of Neurology, University of Miami, Miami, Florida, USA
- Department of Neurology, Jackson Memorial Hospital, Miami, Florida, USA
| | - Antonio J Bustillo
- Department of Neurology, University of Miami, Miami, Florida, USA
- Department of Neurology, Jackson Memorial Hospital, Miami, Florida, USA
| | - Negar Asdaghi
- Department of Neurology, University of Miami, Miami, Florida, USA
- Department of Neurology, Jackson Memorial Hospital, Miami, Florida, USA
| | - Erika Marulanda-Londono
- Department of Neurology, University of Miami, Miami, Florida, USA
- Department of Neurology, Jackson Memorial Hospital, Miami, Florida, USA
| | - Carolina M Gutierrez
- Department of Neurology, University of Miami, Miami, Florida, USA
- Department of Neurology, Jackson Memorial Hospital, Miami, Florida, USA
| | - Daniel Samano
- Department of Neurology, University of Miami, Miami, Florida, USA
- Department of Neurology, Jackson Memorial Hospital, Miami, Florida, USA
| | - Evie Sobczak
- Department of Neurology, University of Miami, Miami, Florida, USA
- Department of Neurology, Jackson Memorial Hospital, Miami, Florida, USA
| | - Dianne Foster
- Regional Director Quality Improvement, American Heart Association, USA
| | - Mohan Kottapally
- Department of Neurology, University of Miami, Miami, Florida, USA
- Department of Neurology, Jackson Memorial Hospital, Miami, Florida, USA
| | - Amedeo Merenda
- Department of Neurology, University of Miami, Miami, Florida, USA
- Department of Neurology, Jackson Memorial Hospital, Miami, Florida, USA
| | - Sebastian Koch
- Department of Neurology, University of Miami, Miami, Florida, USA
- Department of Neurology, Jackson Memorial Hospital, Miami, Florida, USA
| | - Jose G. Romano
- Department of Neurology, University of Miami, Miami, Florida, USA
- Department of Neurology, Jackson Memorial Hospital, Miami, Florida, USA
| | - Kristine O’Phelan
- Department of Neurology, University of Miami, Miami, Florida, USA
- Department of Neurology, Jackson Memorial Hospital, Miami, Florida, USA
| | - Jan Claassen
- Department of Neurology, Columbia University, New York, NY, USA
| | - Ralph L. Sacco
- Department of Neurology, University of Miami, Miami, Florida, USA
- Department of Neurology, Jackson Memorial Hospital, Miami, Florida, USA
| | - Tatjana Rundek
- Department of Neurology, University of Miami, Miami, Florida, USA
- Department of Neurology, Jackson Memorial Hospital, Miami, Florida, USA
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Neurotrophins Time Point Intervention after Traumatic Brain Injury: From Zebrafish to Human. Int J Mol Sci 2021; 22:ijms22041585. [PMID: 33557335 PMCID: PMC7915547 DOI: 10.3390/ijms22041585] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2021] [Revised: 01/25/2021] [Accepted: 02/02/2021] [Indexed: 12/14/2022] Open
Abstract
Traumatic brain injury (TBI) remains the leading cause of long-term disability, which annually involves millions of individuals. Several studies on mammals reported that neurotrophins could play a significant role in both protection and recovery of function following neurodegenerative diseases such as stroke and TBI. This protective role of neurotrophins after an event of TBI has also been reported in the zebrafish model. Nevertheless, reparative mechanisms in mammalian brain are limited, and newly formed neurons do not survive for a long time. In contrast, the brain of adult fish has high regenerative properties after brain injury. The evident differences in regenerative properties between mammalian and fish brain have been ascribed to remarkable different adult neurogenesis processes. However, it is not clear if the specific role and time point contribution of each neurotrophin and receptor after TBI is conserved during vertebrate evolution. Therefore, in this review, I reported the specific role and time point of intervention for each neurotrophic factor and receptor after an event of TBI in zebrafish and mammals.
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Wahlster S, Sharma M, Chu F, Granstein JH, Johnson NJ, Longstreth WT, Creutzfeldt CJ. Outcomes After Tracheostomy in Patients with Severe Acute Brain Injury: A Systematic Review and Meta-Analysis. Neurocrit Care 2020; 34:956-967. [PMID: 33033959 PMCID: PMC8363498 DOI: 10.1007/s12028-020-01109-9] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2020] [Accepted: 09/09/2020] [Indexed: 12/13/2022]
Abstract
OBJECTIVE To synthesize reported long-term outcomes in patients undergoing tracheostomy after severe acute brain injury (SABI). METHODS We systematically searched PubMed, EMBASE, and Cochrane Library for studies in English, German, and Spanish between 1990 and 2019, reporting outcomes in patients with SABI who underwent tracheostomy. We adhered to the preferred reporting items for systematic reviews and meta-analyses guidelines and the meta-analyses of observational studies in epidemiology guidelines. We excluded studies reporting on less than 10 patients, mixed populations with other neurological diseases, or studies assessing highly select subgroups defined by age or procedures. Data were extracted independently by two investigators. Results were pooled using random effects modeling. The primary outcome was long-term functional outcome (mRS or GOS) at 6-12 months. Secondary outcomes included hospital and long-term mortality, decannulation rates, and discharge home rates. RESULTS Of 1405 studies identified, 61 underwent full manuscript review and 19 studies comprising 35,362 patients from 10 countries were included in the meta-analysis. The primary outcome was available from five studies with 451 patients. At 6-12 months, about one-third of patients (30%; 95% confidence interval [CI] 17-48) achieved independence, and about one-third survived in a dependent state (36%, 95% CI 28-46%). The pooled short-term mortality for 19,048 patients was 12%, (95% CI 9-17%) with no significant difference between stroke (10%) and TBI patients (13%), and the pooled long-term mortality was 21% (95% CI 11-36). Decannulation occurred in 79% (95% CI 51-93%) of survivors. Heterogeneity was high for most outcome assessments (I2 > 75%). CONCLUSIONS Our findings suggest that about one in three patients with SABI who undergo tracheostomy may eventually achieve independence. Future research is needed to understand the reasons for the heterogeneity between studies and to identify those patients with promising outcomes as well as factors influencing outcome.
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Affiliation(s)
- Sarah Wahlster
- Department of Neurology, Harborview Medical Center, University of Washington, 325 9th Ave, Box 359775, Seattle, WA, 98104, USA.
| | - Monisha Sharma
- Department of Global Health, University of Washington, Seattle, WA, USA
| | - Frances Chu
- Health Science Library, University of Washington, Seattle, WA, USA
| | - Justin H Granstein
- Department of Neurological Surgery, Mount Sinai Hospital, New York, NY, USA
| | - Nicholas J Johnson
- Department of Emergency Medicine, University of Washington, Seattle, WA, USA
| | - W T Longstreth
- Department of Neurology, Harborview Medical Center, University of Washington, 325 9th Ave, Box 359775, Seattle, WA, 98104, USA.,Department of Epidemiology, University of Washington, Seattle, WA, USA
| | - Claire J Creutzfeldt
- Department of Neurology, Harborview Medical Center, University of Washington, 325 9th Ave, Box 359775, Seattle, WA, 98104, USA
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Schroeppel TJ, Sharpe JP, Melendez CI, Jepson B, Dunn R, Paige Clement L, Khan AD, Croce MA, Fabian TC. Long-Term Analysis of Functional Outcomes in Traumatic Brain Injury Patients. Am Surg 2020; 86:1124-1128. [PMID: 32841047 DOI: 10.1177/0003134820943648] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
INTRODUCTION Traumatic brain injury (TBI) remains a significant cause of morbidity and mortality. The purpose of this study is to examine outcomes after discharge and identify factors from the index admission that may contribute to long-term mortality. METHODS The study population is composed of patients who survived to discharge from a previously published study examining TBI. Demographics, injury severity, and length of stay were abstracted from the index study. Phone surveys of surviving patients were performed to evaluate each patient's Glasgow Outcome Scale-Extended (GOSE). Patients who were deceased at the time of the survey were compared with those who were alive. RESULTS 1615 patients were alive at the end of the first study period and 211 (13%) comprised the study population. Overall, the median age was 54 years, and the majority were male (74%). The median time to follow-up was 80 months. The population was severely injured, with a median injury severity score (ISS) of 25 and a median head abbreviated injury score (AIS) of 4. Overall mortality was 57%. The group that survived at the time of the survey was younger, more injured, less likely to have received beta-blockers (BB) during the index admission, and had a longer time to follow-up. After adjusting for ISS, age, base deficit, and BB, age was the only variable predictive of mortality (HR 1.03; HL 1.02-1.04). CONCLUSION Despite being more severely injured, younger patients were more likely to survive to follow-up. Further investigation is needed to determine if aggressive care in older TBI patients in the acute phase leads to good long-term outcomes.
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Affiliation(s)
- Thomas J Schroeppel
- 22095 Department of Surgery, University of Colorado Health Memorial Hospital, Colorado Springs, CO, USA
| | - John P Sharpe
- 38667 Department of Surgery, Covenant Healthcare, Saginaw, MI, USA
| | - Claudia I Melendez
- 22095 Department of Surgery, University of Colorado Health Memorial Hospital, Colorado Springs, CO, USA
| | - Brian Jepson
- 22095 Department of Surgery, University of Colorado Health Memorial Hospital, Colorado Springs, CO, USA
| | - Rebekah Dunn
- 22095 Department of Surgery, University of Colorado Health Memorial Hospital, Colorado Springs, CO, USA
| | - L Paige Clement
- Department of Pharmacy, University of Colorado Health Memorial Hospital, Colorado Springs, CO, USA
| | - Abid D Khan
- 22095 Department of Surgery, University of Colorado Health Memorial Hospital, Colorado Springs, CO, USA
| | - Martin A Croce
- 4285 Department of Surgery, University of Tennessee Health Science Center, Memphis, TN, USA
| | - Timothy C Fabian
- 4285 Department of Surgery, University of Tennessee Health Science Center, Memphis, TN, USA
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Karlsson B, Jokura H, Yang HC, Yamamoto M, Martinez R, Kawagishi J, Guo WY, Beute G, Chung WY, Söderman M, Yeo TT. Clinical outcome following cerebral AVM hemorrhage. Acta Neurochir (Wien) 2020; 162:1759-1766. [PMID: 32385636 DOI: 10.1007/s00701-020-04380-z] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2020] [Accepted: 04/29/2020] [Indexed: 12/21/2022]
Abstract
BACKGROUND A significant difference exists between the published results reporting the clinical outcome following brain arteriovenous malformation (AVM) ruptures. Information about the outcome following hemorrhage in an AVM population treated with radiosurgery could provide additional information to assess the risk of mortality and morbidity following an AVM hemorrhage. METHODS Clinical outcome was studied in 383 patients, the largest patient population yet studied, who suffered from a symptomatic hemorrhage after Gamma Knife® surgery (GKS) but before confirmed AVM obliteration. The impact of different patient, AVM, and treatment parameters on the clinical outcome was analyzed. The aim was to generate outcome predictions by comparing our data to and combining them with earlier published results. RESULTS No relation was found between clinical outcome and treatment parameters, indicating that the results are applicable also on untreated AVMs. Twenty-one percent of the patients died, 45% developed or experienced worsening of neurological sequelae, and 35% recovered completely after the hemorrhage. Old age was a predictor of poor outcome. Sex, AVM location, AVM volume, and history of prior hemorrhage did not influence the outcome. The mortality rate was comparable to earlier published prospective data, but higher than that found in retrospective studies. CONCLUSIONS The mortality rates in earlier published retrospective series as well as in studies focusing on clinical outcome following AVM hemorrhage significantly underestimate the risk for a mortal outcome following an AVM hemorrhage. Based on our findings, an AVM rupture has around 20% likelihood to result in mortality, 45% likelihood to result in a minor or major deficit, and 35% likelihood of complete recovery. The findings are probably applicable also for AVM ruptures in general. The cumulative mortality and morbidity rates 25 years after diagnosis were estimated to be around 40% in a patient with a patent AVM.
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Affiliation(s)
- Bengt Karlsson
- Department of Surgery, Div. of Neurosurgery, National University Hospital, 5 Lower Kent Ridge Road, Singapore, 119074, Singapore.
| | - Hidefumi Jokura
- Jiro Suzuki Memorial Gamma House, Furukawa Seiryo Hospital, Furukawa, Osaki, Japan
| | - Huai-Che Yang
- Department of Neurosurgery, Veterans General Hospital, Taipei, Taiwan
- Yang-Ming University, Taipei, Taiwan
| | | | | | - Jun Kawagishi
- Jiro Suzuki Memorial Gamma House, Furukawa Seiryo Hospital, Furukawa, Osaki, Japan
| | - Wan-Yuo Guo
- Department of Radiology, Veterans General Hospital, Taipei, Taiwan
| | - Guus Beute
- St Elizabeth Ziekenhuis, Tilburg, the Netherlands
| | - Wen-Yuh Chung
- Department of Neurosurgery, Veterans General Hospital, Taipei, Taiwan
| | | | - Tseng Tsai Yeo
- Department of Surgery, Div. of Neurosurgery, National University Hospital, 5 Lower Kent Ridge Road, Singapore, 119074, Singapore
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Schieren M, Wappler F, Wafaisade A, Lefering R, Sakka SG, Kaufmann J, Heiroth HJ, Defosse J, Böhmer AB. Impact of blunt chest trauma on outcome after traumatic brain injury- a matched-pair analysis of the TraumaRegister DGU®. Scand J Trauma Resusc Emerg Med 2020; 28:21. [PMID: 32164757 PMCID: PMC7069167 DOI: 10.1186/s13049-020-0708-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2019] [Accepted: 02/05/2020] [Indexed: 12/02/2022] Open
Abstract
Background Traumatic brain injury (TBI) is associated with high rates of long-term disability and mortality. Our aim was to investigate the effects of thoracic trauma on the in-hospital course and outcome of patients with TBI. Methods We performed a matched pair analysis of the multicenter trauma database TraumaRegisterDGU® (TR-DGU) in the 5-year period from 2012 to 2016. We included adult patients (≥18 years of age) with moderate to severe TBI (abbreviated injury scale (AIS)= 3–5). Patients with isolated TBI (group 1) were compared to patients with TBI and varying degrees of additional blunt thoracic trauma (AISThorax= 2–5) (group 2). Matching criteria were gender, age, severity of TBI, initial GCS and presence/absence of shock. The χ2-test was used for comparing categorical variables and the Mann-Whitney-U-test was chosen for continuous parameters. Statistical significance was defined by a p-value < 0.05. Results A total of 5414 matched pairs (10,828 patients) were included. The presence of additional thoracic injuries in patients with TBI was associated with a longer duration of mechanical ventilation and a prolonged ICU and hospital length of stay. Additional thoracic trauma was also associated with higher mortality rates. These effects were most pronounced in thoracic AIS subgroups 4 and 5. Additional thoracic trauma, regardless of its severity (AISThorax ≥2) was associated with significantly decreased rates of good neurologic recovery (GOS = 5) after TBI. Conclusions Chest trauma in general, regardless of its initial severity (AISThorax= 2–5), is associated with decreased chance of good neurologic recovery after TBI. Affected patients should be considered “at risk” and vigilance for the maintenance of optimal neuro-protective measures should be high.
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Affiliation(s)
- Mark Schieren
- Department of Anaesthesiology and Intensive Care Medicine, University Witten/Herdecke, Medical Center Cologne-Merheim, Ostmerheimer Str, 200, 51109, Cologne, Germany.
| | - Frank Wappler
- Department of Anaesthesiology and Intensive Care Medicine, University Witten/Herdecke, Medical Center Cologne-Merheim, Ostmerheimer Str, 200, 51109, Cologne, Germany
| | - Arasch Wafaisade
- Department of Traumatology and Orthopedic Surgery, University Witten/Herdecke, Medical Center Cologne-Merheim, Cologne, Germany
| | - Rolf Lefering
- IFOM - Institute for Research in Operative Medicine, University Witten/Herdecke, Cologne, Germany
| | - Samir G Sakka
- Department of Intensive Care Medicine, University of Mainz, Gemeinschaftsklinikum Mittelrhein, Koblenz, Germany
| | - Jost Kaufmann
- Department of Pediatric Anaesthesiology, University Witten/Herdecke, Children Hospital Amsterdamer Straße, Cologne, Germany
| | - Hi-Jae Heiroth
- Department of Neurosurgery, University Witten/Herdecke, Medical Center Cologne-Merheim, Cologne, Germany
| | - Jerome Defosse
- Department of Anaesthesiology and Intensive Care Medicine, University Witten/Herdecke, Medical Center Cologne-Merheim, Ostmerheimer Str, 200, 51109, Cologne, Germany
| | - Andreas B Böhmer
- Department of Anaesthesiology and Intensive Care Medicine, University Witten/Herdecke, Medical Center Cologne-Merheim, Ostmerheimer Str, 200, 51109, Cologne, Germany
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Minimum Competency Recommendations for Programs That Provide Rehabilitation Services for Persons With Disorders of Consciousness: A Position Statement of the American Congress of Rehabilitation Medicine and the National Institute on Disability, Independent Living and Rehabilitation Research Traumatic Brain Injury Model Systems. Arch Phys Med Rehabil 2020; 101:1072-1089. [PMID: 32087109 DOI: 10.1016/j.apmr.2020.01.013] [Citation(s) in RCA: 33] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2020] [Revised: 01/27/2020] [Accepted: 01/28/2020] [Indexed: 11/24/2022]
Abstract
Persons who have disorders of consciousness (DoC) require care from multidisciplinary teams with specialized training and expertise in management of the complex needs of this clinical population. The recent promulgation of practice guidelines for patients with prolonged DoC by the American Academy of Neurology, American Congress of Rehabilitation Medicine (ACRM), and National Institute on Disability, Independent Living, and Rehabilitation Research (NIDILRR) represents a major advance in the development of care standards in this area of brain injury rehabilitation. Implementation of these practice guidelines requires explication of the minimum competencies of clinical programs providing services to persons who have DoC. The Brain Injury Interdisciplinary Special Interest Group of the ACRM, in collaboration with the Disorders of Consciousness Special Interest Group of the NIDILRR-Traumatic Brain Injury Model Systems convened a multidisciplinary panel of experts to address this need through the present position statement. Content area-specific workgroups reviewed relevant peer-reviewed literature and drafted recommendations which were then evaluated by the expert panel using a modified Delphi voting process. The process yielded 21 recommendations on the structure and process of essential services required for effective DoC-focused rehabilitation, organized into 4 categories: diagnostic and prognostic assessment (4 recommendations), treatment (11 recommendations), transitioning care/long-term care needs (5 recommendations), and management of ethical issues (1 recommendation). With few exceptions, these recommendations focus on infrastructure requirements and operating procedures for the provision of DoC-focused neurorehabilitation services across subacute and postacute settings.
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