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Iderdar Y, Marzouk S, Wachami NA, Arraji M, Boumendil K, Mourajid Y, Aquil A, Saad E, Chahboune M. Translation and interrater reliability of the structured interview for the extended glasgow outcome scale among Moroccan patients with traumatic brain injury. Neurochirurgie 2025; 71:101658. [PMID: 40021118 DOI: 10.1016/j.neuchi.2025.101658] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2024] [Revised: 01/12/2025] [Accepted: 02/23/2025] [Indexed: 03/03/2025]
Abstract
OBJECTIVE The Extended Glasgow Outcome Scale (GOSE) is a commonly used assessment tool to evaluate the outcome following traumatic brain injury (TBI). This study aims to evaluate the applicability of the GOSE structured interview in the Moroccan context and to examine its reliability. METHODS In this prospective validation study, we assessed the inter-rater reliability of GOSE scoring for 123 TBI patients who attended Avicenna University Hospital's outpatient unit. Interrater agreement of the GOSE was assessed, with Cohen's weighted κ, between the rater with the structured interview and the rater without the structured interview and between the rater specialized in TBI and the non-specialized rater. RESULTS The findings demonstrated a high level of agreement (weighted kappa = 0.96) between the rater specialized in TBI and the non-specialized rater with (p < 0.001) and a high level of agreement (weighted kappa = 0.85) between the rater with the structured interview and the neurosurgeon without the structured interview. The Moroccan version is capable of assessing the GOSE Score at a level similar to the original version. CONCLUSION The use of this version has the potential to expedite the process of evaluating outcomes in patients with TBI in both clinical practice and research settings.
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Affiliation(s)
- Younes Iderdar
- Hassan First University of Settat, Higher Institute of Health Sciences, Laboratory of Health Sciences and Technologies, Settat 26000, Morocco.
| | - Soumia Marzouk
- Hassan First University of Settat, Higher Institute of Health Sciences, Laboratory of Health Sciences and Technologies, Settat 26000, Morocco
| | - Nadia Al Wachami
- Hassan First University of Settat, Higher Institute of Health Sciences, Laboratory of Health Sciences and Technologies, Settat 26000, Morocco
| | - Maryem Arraji
- Hassan First University of Settat, Higher Institute of Health Sciences, Laboratory of Health Sciences and Technologies, Settat 26000, Morocco
| | - Karima Boumendil
- Hassan First University of Settat, Higher Institute of Health Sciences, Laboratory of Health Sciences and Technologies, Settat 26000, Morocco
| | - Yassmine Mourajid
- Hassan First University of Settat, Higher Institute of Health Sciences, Laboratory of Health Sciences and Technologies, Settat 26000, Morocco
| | - Amina Aquil
- Hassan First University of Settat, Higher Institute of Health Sciences, Laboratory of Health Sciences and Technologies, Settat 26000, Morocco
| | - Elmadani Saad
- Hassan First University of Settat, Higher Institute of Health Sciences, Laboratory of Health Sciences and Technologies, Settat 26000, Morocco
| | - Mohamed Chahboune
- Hassan First University of Settat, Higher Institute of Health Sciences, Laboratory of Health Sciences and Technologies, Settat 26000, Morocco
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Eagle SR, Temkin N, Barber JK, McCrea M, Giacino JT, Okonkwo D, Manley GT, Nelson L. Association of Subacute Mild Traumatic Brain Injury Symptoms With Long-Term Persistent Symptoms, Functional Limitations, and Quality of Life. Neurology 2025; 104:e213427. [PMID: 40168631 PMCID: PMC11966525 DOI: 10.1212/wnl.0000000000213427] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2024] [Accepted: 02/03/2025] [Indexed: 04/03/2025] Open
Abstract
BACKGROUND AND OBJECTIVES The objective was to evaluate the association of subacute postconcussion symptoms (with the total Rivermead Post-Concussion Questionnaire [RPQ] score) with persistent symptoms, functional limitations, and quality of life at 6 months in patients with mild traumatic brain injury (mTBI). METHODS This was a secondary analysis of the Transforming Research and Clinical Knowledge of Traumatic Brain Injury, which was a prospective cohort study of patients with TBI and admission Glasgow Coma Scale score between 13 and 15 at 18 US Level 1 trauma centers through 2014-2018. Participants were included in the study if presenting within 24 hours of external force trauma to the head and met the American Congress of Rehabilitation Medicine's criteria for TBI. Participants completed the RPQ, Glasgow Outcome Scale-Extended (GOSE), and Quality of Life after Brain Injury Overall Scale (QOLIBRI-OS). Primary outcomes were persistent symptoms (≥3 individual RPQ symptoms higher than preinjury level), incomplete recovery (GOSE score <8), and lower quality of life (QOLIBRI-OS score ≤51) at 6 months. Multivariable regression models were developed including RPQ clinical cutoffs at 2 weeks and 3 months and risk factors. Adjusted odds ratios (aORs) and 95% CI are reported for multivariable models. Receiver operating characteristic curves were built to identify discriminative ability of the cutoffs with area under the curve (AUC). RESULTS The age of the study cohort (n = 2,000) was 41.1 ± 17.3 years; 33% were female (n = 669), 67% male, 57% White (n = 1,141), and 20% Hispanic (n = 408). RPQ total score ≥14 was associated with higher odds of persistent symptoms (aOR 7.25, 95% CI 5.51-9.54), incomplete recovery (aOR 4.85, 95% CI 3.69-6.39), and lower quality of life (aOR 5.31, 95% CI 3.82-7.40) at 6 months compared with patients below the cutoff. AUC for RPQ total score ≥14 at 2 weeks was 0.76-0.81 across outcomes. RPQ total score ≥12 at 3 months was associated with higher odds of persistent symptoms (aOR 18.22, 95% CI 13.09-25.35), incomplete recovery (aOR 8.44, 95% CI 6.18-11.51), and lower quality of life (aOR 7.45, 95% CI 5.40-10.26) at 6 months compared with patients below the cutoff, with AUCs of 0.80-0.88 across outcomes. DISCUSSION Clinical cutoffs for a commonly used TBI symptom questionnaire had acceptable-to-excellent discrimination for 6-month outcomes and can be used by clinicians at 2 weeks after injury to identify patients at risk of chronic impairments and refer for targeted rehabilitation. CLASSIFICATION OF EVIDENCE This study provides Class III evidence that overall TBI symptoms at 2 weeks are predictive of 6-month clinical outcomes.
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Eagle SR, Barber J, Temkin N, McCrea MA, Giacino JT, Okonkwo DO, Madhok D, Yue JK, Zerbato JM, Manley GT, Nelson LD. Follow up rates and patient interest in clinical care after mild traumatic brain injury presenting to a level 1 trauma center: a TRACK-TBI prospective cohort study. Front Neurol 2025; 16:1558204. [PMID: 40242629 PMCID: PMC12002085 DOI: 10.3389/fneur.2025.1558204] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2025] [Accepted: 03/12/2025] [Indexed: 04/18/2025] Open
Abstract
Study objective To evaluate the rates of clinical follow-up and patient interest in clinical follow-up within the first year of traumatic brain injury (TBI) with presenting Glasgow Coma Scale (GCS) score between 13 and 15. Methods This is a secondary analysis of a prospective cohort study which enrolled patients with TBI first evaluated at a 1 of 23 level 1 trauma centers (n = 1,916). At 2 weeks and 3 months, the participants were asked "have you seen any healthcare provider for your TBI?" and "if so, did it help?." Participants also completed the Rivermead Post-Concussion Questionnaire (RPQ), Quality of Life after Brain Injury- Overall Scale (QOLIBRI-OS), and Glasgow Outcome Scale Extended for TBI (GOSE-TBI) at 2 weeks, 3-, 6-, and 12-months. Persistent symptoms were defined as 3+ symptoms worse than pre-injury levels. QOLIBRI-OS≤51 was defined as lower quality of life. GOSE<8 was defined as incomplete recovery. Results By 2 weeks, 43% of participants had followed up with a clinical provider; cumulative follow-up within the first year was 63%. Overall, 61% of participants interested in clinical follow-up care reported receiving clinical follow-up care. Participants who received follow-up care reported that it helped at an 86% rate. Of those not interested in follow-up care, 42% reported receiving clinical follow-up care and 86% of those receiving care reported that it helped. Approximately 44% of participants who reported "I did not think I need follow-up" at 2 weeks had incomplete recovery (GOSE<8), 40% had persistent symptoms, and 19% had lower quality of life at 12-months post-injury. Conclusion Participants not interested in follow-up care had high rates of poor functional recovery, persistent symptoms and lower quality-of-life at 12 months following traumatic brain injury with GCS 13-15. Education and provider emphasis on the importance of clinical follow-up after hospital discharge with TBI need to be enhanced. Prioritizing timely clinical follow-up for adult patients with TBI with GCS 13 to 15 is critical for improving rates of long-term recovery in this population.
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Affiliation(s)
- Shawn R. Eagle
- Department of Neurological Surgery, University of Pittsburgh, Pittsburgh, PA, United States
| | - Jason Barber
- Department of Neurological Surgery, University of Washington, Seattle, WA, United States
| | - Nancy Temkin
- Department of Neurological Surgery, University of Washington, Seattle, WA, United States
| | | | - Joseph T. Giacino
- Department of Physical Medicine and Rehabilitation, Harvard University, Cambridge, MA, United States
| | - David O. Okonkwo
- Department of Neurological Surgery, University of Pittsburgh, Pittsburgh, PA, United States
| | - Debbie Madhok
- Department of Neurological Surgery, University of California, San Francisco, San Francisco, CA, United States
| | - John K. Yue
- Department of Neurological Surgery, University of California, San Francisco, San Francisco, CA, United States
| | - Jennifer M. Zerbato
- Department of Neurological Surgery, University of Pittsburgh, Pittsburgh, PA, United States
| | - Geoffrey T. Manley
- Department of Neurological Surgery, University of California, San Francisco, San Francisco, CA, United States
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Gerhalter T, Chen AM, Dehkharghani S, Peralta R, Gajdosik M, Zarate A, Bushnik T, Silver JM, Im BS, Wall SP, Madelin G, Kirov II. Longitudinal changes in sodium concentration and in clinical outcome in mild traumatic brain injury. Brain Commun 2024; 6:fcae229. [PMID: 39035416 PMCID: PMC11258572 DOI: 10.1093/braincomms/fcae229] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2024] [Revised: 06/10/2024] [Accepted: 07/09/2024] [Indexed: 07/23/2024] Open
Abstract
Ionic imbalances and sodium channel dysfunction, well-known sequelae of traumatic brain injury (TBI), promote functional impairment in affected subjects. Therefore, non-invasive measurement of sodium concentrations using 23Na MRI has the potential to detect clinically relevant injury and predict persistent symptoms. Recently, we reported diffusely lower apparent total sodium concentrations (aTSC) in mild TBI patients compared to controls, as well as correlations between lower aTSC and worse clinical outcomes. The main goal of this study was to determine whether these aTSC findings, and their changes over time, predict outcomes at 3- and 12-month from injury. Twenty-seven patients previously studied with 23Na MRI and outcome measures at 22 ± 10 days (average ± standard deviation) after injury (visit-1, v1) were contacted at 3- (visit-2, v2) and 12-month after injury (visit-3, v3) to complete the Rivermead post-concussion symptoms questionnaire (RPQ), the extended Glasgow outcome scale (GOSE), and the brief test of adult cognition by telephone (BTACT). Follow-up 1H and 23Na MRI were additionally scheduled at v2. Linear regression was used to calculate aTSC in global grey and white matters. Six hypotheses were tested in relation to the serial changes in outcome measures and in aTSC, and in relation to the cross-sectional and serial relationships between aTSC and outcome. Twenty patients contributed data at v2 and fifteen at v3. Total RPQ and composite BTACT z-scores differed significantly for v2 and v3 in comparison to v1 (each P < 0.01), reflecting longitudinally reduced symptomatology and improved performance on cognitive testing. No associations between aTSC and outcome were observed at v2. Previously lower grey and white matter aTSC normalized at v2 in comparison to controls, in line with a statistically detectable longitudinal increase in grey matter aTSC between v1 and v2 (P = 0.0004). aTSC values at v1 predicted a subset of future BTACT subtest scores, but not future RPQ scores nor GOSE-defined recovery status. Similarly, aTSC rates of change correlated with BTACT rates of change, but not with those of RPQ. Tissue aTSC, previously shown to be diffusely decreased compared to controls at v1, was no longer reduced by v2, suggesting normalization of the sodium ionic equilibrium. These changes were accompanied by marked improvement in outcome. The results support the notion that early aTSC from 23Na MRI predicts future BTACT, but not RPQ scores, nor future GOSE status.
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Affiliation(s)
- Teresa Gerhalter
- Bernard and Irene Schwartz Center for Biomedical Imaging, Department of Radiology, New York University Grossman School of Medicine, New York, NY 10016, USA
- Center for Advanced Imaging Innovation and Research (CAIR), Department of Radiology, New York University Grossman School of Medicine, New York, NY 10016, USA
| | - Anna M Chen
- Bernard and Irene Schwartz Center for Biomedical Imaging, Department of Radiology, New York University Grossman School of Medicine, New York, NY 10016, USA
- Center for Advanced Imaging Innovation and Research (CAIR), Department of Radiology, New York University Grossman School of Medicine, New York, NY 10016, USA
- Vilcek Institute of Graduate Biomedical Sciences, New York University Grossman School of Medicine, New York, NY 10016, USA
| | - Seena Dehkharghani
- Bernard and Irene Schwartz Center for Biomedical Imaging, Department of Radiology, New York University Grossman School of Medicine, New York, NY 10016, USA
- Center for Advanced Imaging Innovation and Research (CAIR), Department of Radiology, New York University Grossman School of Medicine, New York, NY 10016, USA
- Department of Neurology, New York University Grossman School of Medicine, New York, NY 10016, USA
| | - Rosemary Peralta
- Bernard and Irene Schwartz Center for Biomedical Imaging, Department of Radiology, New York University Grossman School of Medicine, New York, NY 10016, USA
- Center for Advanced Imaging Innovation and Research (CAIR), Department of Radiology, New York University Grossman School of Medicine, New York, NY 10016, USA
| | - Mia Gajdosik
- Bernard and Irene Schwartz Center for Biomedical Imaging, Department of Radiology, New York University Grossman School of Medicine, New York, NY 10016, USA
- Center for Advanced Imaging Innovation and Research (CAIR), Department of Radiology, New York University Grossman School of Medicine, New York, NY 10016, USA
| | - Alejandro Zarate
- Department of Rehabilitation Medicine, New York University Grossman School of Medicine, New York, NY 10016, USA
| | - Tamara Bushnik
- Department of Rehabilitation Medicine, New York University Grossman School of Medicine, New York, NY 10016, USA
| | - Jonathan M Silver
- Department of Psychiatry, New York University Grossman School of Medicine, New York, NY 10016, USA
| | - Brian S Im
- Department of Rehabilitation Medicine, New York University Grossman School of Medicine, New York, NY 10016, USA
| | - Stephen P Wall
- Ronald O. Perelman Department of Emergency Medicine, New York University Grossman School of Medicine, New York, NY 10016, USA
| | - Guillaume Madelin
- Bernard and Irene Schwartz Center for Biomedical Imaging, Department of Radiology, New York University Grossman School of Medicine, New York, NY 10016, USA
- Center for Advanced Imaging Innovation and Research (CAIR), Department of Radiology, New York University Grossman School of Medicine, New York, NY 10016, USA
- Vilcek Institute of Graduate Biomedical Sciences, New York University Grossman School of Medicine, New York, NY 10016, USA
| | - Ivan I Kirov
- Bernard and Irene Schwartz Center for Biomedical Imaging, Department of Radiology, New York University Grossman School of Medicine, New York, NY 10016, USA
- Center for Advanced Imaging Innovation and Research (CAIR), Department of Radiology, New York University Grossman School of Medicine, New York, NY 10016, USA
- Vilcek Institute of Graduate Biomedical Sciences, New York University Grossman School of Medicine, New York, NY 10016, USA
- Department of Neurology, New York University Grossman School of Medicine, New York, NY 10016, USA
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Iderdar Y, Arraji M, Wachami NA, Guennouni M, Boumendil K, Mourajid Y, Elkhoudri N, Saad E, Chahboune M. Predictors of outcomes 3 to 12 months after traumatic brain injury: a systematic review and meta-analysis. Osong Public Health Res Perspect 2024; 15:3-17. [PMID: 38481046 PMCID: PMC10982655 DOI: 10.24171/j.phrp.2023.0288] [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: 10/08/2023] [Revised: 12/25/2023] [Accepted: 12/28/2023] [Indexed: 04/04/2024] Open
Abstract
The exact factors predicting outcomes following traumatic brain injury (TBI) remain elusive. In this systematic review and meta-analysis, we examined factors influencing outcomes in adult patients with TBI, from 3 months to 1 year after injury. A search of four electronic databases-PubMed, Scopus, Web of Science, and ScienceDirect-yielded 29 studies for review and 16 for meta-analysis, in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines. In patients with TBI of any severity, mean differences were observed in age (8.72 years; 95% confidence interval [CI], 4.77-12.66 years), lymphocyte count (-0.15 109/L; 95% CI, -0.18 to -0.11), glucose levels (1.20 mmol/L; 95% CI, 0.73-1.68), and haemoglobin levels (-0.91 g/dL; 95% CI, -1.49 to -0.33) between those with favourable and unfavourable outcomes. The prevalence rates of unfavourable outcomes were as follows: abnormal cisterns, 65.7%; intracranial pressure above 20 mmHg, 52.9%; midline shift of 5 mm or more, 63%; hypotension, 71%; hypoxia, 86.8%; blood transfusion, 70.3%; and mechanical ventilation, 90%. Several predictors were strongly associated with outcome. Specifically, age, lymphocyte count, glucose level, haemoglobin level, severity of TBI, pupillary reaction, and type of injury were identified as potential predictors of long-term outcomes.
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Affiliation(s)
- Younes Iderdar
- Hassan First University of Settat, Higher Institute of Health Sciences, Laboratory of Health Sciences and Technologies, Settat, Morocco
| | - Maryem Arraji
- Hassan First University of Settat, Higher Institute of Health Sciences, Laboratory of Health Sciences and Technologies, Settat, Morocco
| | - Nadia Al Wachami
- Hassan First University of Settat, Higher Institute of Health Sciences, Laboratory of Health Sciences and Technologies, Settat, Morocco
| | - Morad Guennouni
- Hassan First University of Settat, Higher Institute of Health Sciences, Laboratory of Health Sciences and Technologies, Settat, Morocco
- Science and Technology Team, Higher School of Education and Training, Chouaîb Doukkali University of El Jadida, El Jadida, Morocco
| | - Karima Boumendil
- Hassan First University of Settat, Higher Institute of Health Sciences, Laboratory of Health Sciences and Technologies, Settat, Morocco
| | - Yassmine Mourajid
- Hassan First University of Settat, Higher Institute of Health Sciences, Laboratory of Health Sciences and Technologies, Settat, Morocco
| | - Noureddine Elkhoudri
- Hassan First University of Settat, Higher Institute of Health Sciences, Laboratory of Health Sciences and Technologies, Settat, Morocco
| | - Elmadani Saad
- Hassan First University of Settat, Higher Institute of Health Sciences, Laboratory of Health Sciences and Technologies, Settat, Morocco
| | - Mohamed Chahboune
- Hassan First University of Settat, Higher Institute of Health Sciences, Laboratory of Health Sciences and Technologies, Settat, Morocco
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Ichwan K, Gazali S, Suherman S, Desiana D, Nurjannah N. Plasma interleukin 6 as an outcome predictor of traumatic brain injury patients. NARRA J 2023; 3:e234. [PMID: 38455629 PMCID: PMC10919736 DOI: 10.52225/narra.v3i3.234] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/05/2023] [Accepted: 09/26/2023] [Indexed: 03/09/2024]
Abstract
Traumatic brain injury is one of the leading causes of death and disability in young adults. Previous studies have suggested that neuroinflammatory process involves the overexpression of interleukin 6 (IL-6); however, data on the predictive ability of IL-6 is limited and conflicting in traumatic head injury patients. The aim of this study was to assess the ability of plasma IL-6 as a predictor of outcome in head injury patients. A cross-sectional study was conducted between June and December 2020 among traumatic head injury patients admitted to Dr. Zainoel Abidin Hospital, Banda Aceh, Indonesia. Demographic, clinical data, and IL-6 level were collected and measured on admission. The outcome was assessed by the Glasgow outcome scale extended (GOSE) in the first- and third-month of post-injury. A total of 50 traumatic brain injury patients were recruited of which 54% were male, 64% had mild head injury, 82% had leukocytosis, and 60% had non-bleeding head CT scan. The mean of IL-6 level was 79.32 pg/mL while the GOSE scores ranged from 1 (death) to 8 (upper good recovery). Early IL-6 level (<24 hours post-injury) was significantly correlated with worse outcome in traumatic head injury, though the correlation strength was moderate (p<0.001; r=-0.42). As a predictor, IL-6 yielded the area under curve (AUC) value of 93.5% (p<0.001) and a cut-off point of 46.33 pg/mL. The sensitivity and specificity of this predictor were 87.5% and 95.24%, respectively. In conclusion, early IL-6 level can be used as a predictor for traumatic head injury. Nevertheless, further multi-center study with a bigger sample size is needed to confirm this finding.
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Affiliation(s)
- Khairunnisa Ichwan
- Department of Neurology, Faculty of Medicine, Universitas Syiah Kuala, Banda Aceh, Indonesia
- Department of Neurology, Dr. Zainoel Abidin Hospital, Banda Aceh, Indonesia
| | - Syahrul Gazali
- Department of Neurology, Faculty of Medicine, Universitas Syiah Kuala, Banda Aceh, Indonesia
- Department of Neurology, Dr. Zainoel Abidin Hospital, Banda Aceh, Indonesia
| | - Suherman Suherman
- Department of Neurology, Faculty of Medicine, Universitas Syiah Kuala, Banda Aceh, Indonesia
- Department of Neurology, Dr. Zainoel Abidin Hospital, Banda Aceh, Indonesia
| | - Desiana Desiana
- Department of Clinical Pathology, Faculty of Medicine, Universitas Syiah Kuala, Banda Aceh, Indonesia
- Department of Clinical Pathology, Dr. Zainoel Abidin Hospital, Banda Aceh, Indonesia
| | - Nurjannah Nurjannah
- Department of Public Health, Faculty of Medicine, Universitas Syiah Kuala, Banda Aceh, Indonesia
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Mikolić A, Steyerberg EW, Polinder S, Wilson L, Zeldovich M, von Steinbuechel N, Newcombe VF, Menon DK, van der Naalt J, Lingsma HF, Maas AI, van Klaveren D. Prognostic Models for Global Functional Outcome and Post-Concussion Symptoms Following Mild Traumatic Brain Injury: A Collaborative European NeuroTrauma Effectiveness Research in Traumatic Brain Injury (CENTER-TBI) Study. J Neurotrauma 2023; 40:1651-1670. [PMID: 37078144 PMCID: PMC10458380 DOI: 10.1089/neu.2022.0320] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/21/2023] Open
Abstract
After mild traumatic brain injury (mTBI), a substantial proportion of individuals do not fully recover on the Glasgow Outcome Scale Extended (GOSE) or experience persistent post-concussion symptoms (PPCS). We aimed to develop prognostic models for the GOSE and PPCS at 6 months after mTBI and to assess the prognostic value of different categories of predictors (clinical variables; questionnaires; computed tomography [CT]; blood biomarkers). From the Collaborative European NeuroTrauma Effectiveness Research in Traumatic Brain Injury (CENTER-TBI) study, we included participants aged 16 or older with Glasgow Coma Score (GCS) 13-15. We used ordinal logistic regression to model the relationship between predictors and the GOSE, and linear regression to model the relationship between predictors and the Rivermead Post-concussion Symptoms Questionnaire (RPQ) total score. First, we studied a pre-specified Core model. Next, we extended the Core model with other clinical and sociodemographic variables available at presentation (Clinical model). The Clinical model was then extended with variables assessed before discharge from hospital: early post-concussion symptoms, CT variables, biomarkers, or all three categories (extended models). In a subset of patients mostly discharged home from the emergency department, the Clinical model was extended with 2-3-week post-concussion and mental health symptoms. Predictors were selected based on Akaike's Information Criterion. Performance of ordinal models was expressed as a concordance index (C) and performance of linear models as proportion of variance explained (R2). Bootstrap validation was used to correct for optimism. We included 2376 mTBI patients with 6-month GOSE and 1605 patients with 6-month RPQ. The Core and Clinical models for GOSE showed moderate discrimination (C = 0.68 95% confidence interval 0.68 to 0.70 and C = 0.70[0.69 to 0.71], respectively) and injury severity was the strongest predictor. The extended models had better discriminative ability (C = 0.71[0.69 to 0.72] with early symptoms; 0.71[0.70 to 0.72] with CT variables or with blood biomarkers; 0.72[0.71 to 0.73] with all three categories). The performance of models for RPQ was modest (R2 = 4% Core; R2 = 9% Clinical), and extensions with early symptoms increased the R2 to 12%. The 2-3-week models had better performance for both outcomes in the subset of participants with these symptoms measured (C = 0.74 [0.71 to 0.78] vs. C = 0.63[0.61 to 0.67] for GOSE; R2 = 37% vs. 6% for RPQ). In conclusion, the models based on variables available before discharge have moderate performance for the prediction of GOSE and poor performance for the prediction of PPCS. Symptoms assessed at 2-3 weeks are required for better predictive ability of both outcomes. The performance of the proposed models should be examined in independent cohorts.
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Affiliation(s)
- Ana Mikolić
- Department of Public Health, Erasmus MC-University Medical Center Rotterdam, Rotterdam, the Netherlands
| | - Ewout W. Steyerberg
- Department of Public Health, Erasmus MC-University Medical Center Rotterdam, Rotterdam, the Netherlands
- Department of Biomedical Data Sciences, Leiden University Medical Center, Leiden, the Netherlands
| | - Suzanne Polinder
- Department of Public Health, Erasmus MC-University Medical Center Rotterdam, Rotterdam, the Netherlands
| | - Lindsay Wilson
- Division of Psychology, University of Stirling, Stirling, United Kingdom
| | - Marina Zeldovich
- Institute of Medical Psychology and Medical Sociology, University Medical Center Göttingen, Georg-August-University, Göttingen, Germany
| | - Nicole von Steinbuechel
- Institute of Medical Psychology and Medical Sociology, University Medical Center Göttingen, Georg-August-University, Göttingen, Germany
| | - Virginia F.J. Newcombe
- Division of Anesthesia, Department of Medicine, University of Cambridge, Cambridge, United Kingdom
| | - David K. Menon
- Division of Anesthesia, Department of Medicine, University of Cambridge, Cambridge, United Kingdom
| | - Joukje van der Naalt
- Department of Neurology, University of Groningen, University Medical Center Groningen, the Netherlands
| | - Hester F. Lingsma
- Department of Public Health, Erasmus MC-University Medical Center Rotterdam, Rotterdam, the Netherlands
| | - Andrew I.R. Maas
- Department of Neurosurgery, Antwerp University Hospital and University of Antwerp, Edegem, Belgium
| | - David van Klaveren
- Department of Public Health, Erasmus MC-University Medical Center Rotterdam, Rotterdam, the Netherlands
- Predictive Analytics and Comparative Effectiveness Center, Institute for Clinical Research and Health Policy Studies/Tufts Medical Center, Boston, Massachusetts, USA
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Malik S, Alnaji O, Malik M, Gambale T, Farrokhyar F, Rathbone MP. Inflammatory cytokines associated with mild traumatic brain injury and clinical outcomes: a systematic review and meta-analysis. Front Neurol 2023; 14:1123407. [PMID: 37251220 PMCID: PMC10213278 DOI: 10.3389/fneur.2023.1123407] [Citation(s) in RCA: 16] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2022] [Accepted: 04/26/2023] [Indexed: 05/31/2023] Open
Abstract
Mild traumatic brain injuries (mTBIs) trigger a neuroinflammatory response, which leads to perturbations in the levels of inflammatory cytokines, resulting in a distinctive profile. A systematic review and meta-analysis were conducted to synthesize data related to levels of inflammatory cytokines in patients with mTBI. The electronic databases EMBASE, MEDLINE, and PUBMED were searched from January 2014 to December 12, 2021. A total of 5,138 articles were screened using a systematic approach based on the PRISMA and R-AMSTAR guidelines. Of these articles, 174 were selected for full-text review and 26 were included in the final analysis. The results of this study demonstrate that within 24 hours, patients with mTBI have significantly higher levels of Interleukin-6 (IL-6), Interleukin-1 Receptor Antagonist (IL-1RA), and Interferon-γ (IFN-γ) in blood, compared to healthy controls in majority of the included studies. Similarly one week following the injury, patients with mTBI have higher circulatory levels of Monocyte Chemoattractant Protein-1/C-C Motif Chemokine Ligand 2 (MCP-1/CCL2), compared to healthy controls in majority of the included studies. The results of the meta-analysis also confirmed these findings by demonstrating significantly elevated blood levels of IL-6, MCP-1/CCL2, and Interleukin-1 beta (IL-1β) in the mTBI population compared to healthy controls (p < 0.0001), particularly in the acute stages (<7 days). Furthermore, it was found that IL-6, Tumor Necrosis Factor-alpha (TNF-α), IL-1RA, IL-10, and MCP-1/CCL2 were associated with poor clinical outcomes following the mTBI. Finally, this research highlights the lack of consensus in the methodology of mTBI studies that measure inflammatory cytokines in the blood, and also provides direction for future mTBI research.
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Affiliation(s)
- Shazia Malik
- Neurosciences Graduate Program, McMaster University, Hamilton, ON, Canada
| | - Omar Alnaji
- Faculty of Life Sciences, McMaster University, Hamilton, ON, Canada
| | - Mahnoor Malik
- Bachelor of Health Sciences Program, McMaster University, Hamilton, ON, Canada
| | - Teresa Gambale
- Division of Neurology, Department of Medicine, McMaster University, Hamilton, ON, Canada
| | - Forough Farrokhyar
- Department of Surgery and Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
| | - Michel P. Rathbone
- Division of Neurology, Department of Medicine, McMaster University, Hamilton, ON, Canada
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9
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de Neeling M, Liessens D, Depreitere B. Relationship between psychosocial and psychiatric risk factors and poor long-term outcome following mild traumatic brain injury: A systematic review. Eur J Neurol 2023; 30:1540-1550. [PMID: 36708085 DOI: 10.1111/ene.15713] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2022] [Revised: 12/21/2022] [Accepted: 01/07/2023] [Indexed: 01/29/2023]
Abstract
BACKGROUND AND PURPOSE Mild traumatic brain injury (mTBI) has an estimated worldwide incidence of >60 million per year, and long-term persistent postconcussion symptoms (PPCS) are increasingly recognized as being predicted by psychosocial variables. Patients at risk for PPCS may be amenable to closer follow-up to treat modifiable symptoms and prevent chronicity. In this regard, similarities seem to exist with psychosocial risk factors for chronicity in other health-related conditions. However, as opposed to other conditions, no screening instruments exist for mTBI. METHODS A systematic search of the literature on psychological and psychiatric predictors of long-term symptoms in mTBI was performed by two independent reviewers using PubMed, Embase, and Web of Science. RESULTS Fifty papers were included in the systematic analysis. Anxiety, depressive symptoms, and emotional distress early after injury predict PPCS burden and functional outcome up to 1 year after injury. In addition, coping styles and preinjury psychiatric disorders and mental health also correlate with PPCS burden and functional outcome. Associations between PPCS and personality and beliefs were reported, but either these effects were small or evidence was limited. CONCLUSIONS Early psychological and psychiatric factors may negatively interact with recovery potential to increase the risk of chronicity of PPCS burden after mTBI. This opens opportunities for research on screening tools and early intervention in patients at risk.
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Affiliation(s)
| | - Dirk Liessens
- Saint Camillus Psychiatric Center, Bierbeek, Belgium
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10
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Chen AM, Gerhalter T, Dehkharghani S, Peralta R, Gajdošík M, Gajdošík M, Tordjman M, Zabludovsky J, Sheriff S, Ahn S, Babb JS, Bushnik T, Zarate A, Silver JM, Im BS, Wall SP, Madelin G, Kirov II. Replicability of proton MR spectroscopic imaging findings in mild traumatic brain injury: Implications for clinical applications. Neuroimage Clin 2023; 37:103325. [PMID: 36724732 PMCID: PMC9898311 DOI: 10.1016/j.nicl.2023.103325] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2022] [Revised: 11/06/2022] [Accepted: 01/16/2023] [Indexed: 01/20/2023]
Abstract
PURPOSE Proton magnetic resonance spectroscopy (1H MRS) offers biomarkers of metabolic damage after mild traumatic brain injury (mTBI), but a lack of replicability studies hampers clinical translation. In a conceptual replication study design, the results reported in four previous publications were used as the hypotheses (H1-H7), specifically: abnormalities in patients are diffuse (H1), confined to white matter (WM) (H2), comprise low N-acetyl-aspartate (NAA) levels and normal choline (Cho), creatine (Cr) and myo-inositol (mI) (H3), and correlate with clinical outcome (H4); additionally, a lack of findings in regional subcortical WM (H5) and deep gray matter (GM) structures (H6), except for higher mI in patients' putamen (H7). METHODS 26 mTBI patients (20 female, age 36.5 ± 12.5 [mean ± standard deviation] years), within two months from injury and 21 age-, sex-, and education-matched healthy controls were scanned at 3 Tesla with 3D echo-planar spectroscopic imaging. To test H1-H3, global analysis using linear regression was used to obtain metabolite levels of GM and WM in each brain lobe. For H4, patients were stratified into non-recovered and recovered subgroups using the Glasgow Outcome Scale Extended. To test H5-H7, regional analysis using spectral averaging estimated metabolite levels in four GM and six WM structures segmented from T1-weighted MRI. The Mann-Whitney U test and weighted least squares analysis of covariance were used to examine mean group differences in metabolite levels between all patients and all controls (H1-H3, H5-H7), and between recovered and non-recovered patients and their respectively matched controls (H4). Replicability was defined as the support or failure to support the null hypotheses in accordance with the content of H1-H7, and was further evaluated using percent differences, coefficients of variation, and effect size (Cohen's d). RESULTS Patients' occipital lobe WM Cho and Cr levels were 6.0% and 4.6% higher than controls', respectively (Cho, d = 0.37, p = 0.04; Cr, d = 0.63, p = 0.03). The same findings, i.e., higher patients' occipital lobe WM Cho and Cr (both p = 0.01), but with larger percent differences (Cho, 8.6%; Cr, 6.3%) and effect sizes (Cho, d = 0.52; Cr, d = 0.88) were found in the comparison of non-recovered patients to their matched controls. For the lobar WM Cho and Cr comparisons without statistical significance (frontal, parietal, temporal), unidirectional effect sizes were observed (Cho, d = 0.07 - 0.37; Cr, d = 0.27 - 0.63). No differences were found in any metabolite in any lobe in the comparison between recovered patients and their matched controls. In the regional analyses, no differences in metabolite levels were found in any GM or WM region, but all WM regions (posterior, frontal, corona radiata, and the genu, body, and splenium of the corpus callosum) exhibited unidirectional effect sizes for Cho and Cr (Cho, d = 0.03 - 0.34; Cr, d = 0.16 - 0.51). CONCLUSIONS We replicated findings of diffuse WM injury, which correlated with clinical outcome (supporting H1-H2, H4). These findings, however, were among the glial markers Cho and Cr, not the neuronal marker NAA (not supporting H3). No differences were found in regional GM and WM metabolite levels (supporting H5-H6), nor in putaminal mI (not supporting H7). Unidirectional effect sizes of higher patients' Cho and Cr within all WM analyses suggest widespread injury, and are in line with the conclusion from the previous publications, i.e., that detection of WM injury may be more dependent upon sensitivity of the 1H MRS technique than on the selection of specific regions. The findings lend further support to the corollary that clinic-ready 1H MRS biomarkers for mTBI may best be achieved by using high signal-to-noise-ratio single-voxels placed anywhere within WM. The biochemical signature of the injury, however, may differ and therefore absolute levels, rather than ratios may be preferred. Future replication efforts should further test the generalizability of these findings.
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Affiliation(s)
- Anna M Chen
- Bernard and Irene Schwartz Center for Biomedical Imaging, Department of Radiology, New York University Grossman School of Medicine, New York, NY, USA
| | - Teresa Gerhalter
- Bernard and Irene Schwartz Center for Biomedical Imaging, Department of Radiology, New York University Grossman School of Medicine, New York, NY, USA
| | - Seena Dehkharghani
- Bernard and Irene Schwartz Center for Biomedical Imaging, Department of Radiology, New York University Grossman School of Medicine, New York, NY, USA; Department of Neurology, New York University Grossman School of Medicine, New York, NY, USA
| | - Rosemary Peralta
- Bernard and Irene Schwartz Center for Biomedical Imaging, Department of Radiology, New York University Grossman School of Medicine, New York, NY, USA
| | - Mia Gajdošík
- Bernard and Irene Schwartz Center for Biomedical Imaging, Department of Radiology, New York University Grossman School of Medicine, New York, NY, USA
| | - Martin Gajdošík
- Bernard and Irene Schwartz Center for Biomedical Imaging, Department of Radiology, New York University Grossman School of Medicine, New York, NY, USA
| | - Mickael Tordjman
- Bernard and Irene Schwartz Center for Biomedical Imaging, Department of Radiology, New York University Grossman School of Medicine, New York, NY, USA; Department of Radiology, Hôpital Cochin, Paris, France
| | - Julia Zabludovsky
- Bernard and Irene Schwartz Center for Biomedical Imaging, Department of Radiology, New York University Grossman School of Medicine, New York, NY, USA
| | - Sulaiman Sheriff
- Department of Radiology, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Sinyeob Ahn
- Siemens Medical Solutions USA Inc., Malvern, PA, USA
| | - James S Babb
- Bernard and Irene Schwartz Center for Biomedical Imaging, Department of Radiology, New York University Grossman School of Medicine, New York, NY, USA
| | - Tamara Bushnik
- Department of Rehabilitation Medicine, New York University Grossman School of Medicine, New York, NY, USA
| | - Alejandro Zarate
- Department of Rehabilitation Medicine, New York University Grossman School of Medicine, New York, NY, USA
| | - Jonathan M Silver
- Department of Psychiatry, New York University Grossman School of Medicine, New York, NY, USA
| | - Brian S Im
- Department of Rehabilitation Medicine, New York University Grossman School of Medicine, New York, NY, USA
| | - Stephen P Wall
- Ronald O. Perelman Department of Emergency Medicine, New York University Grossman School of Medicine, New York, NY, USA
| | - Guillaume Madelin
- Bernard and Irene Schwartz Center for Biomedical Imaging, Department of Radiology, New York University Grossman School of Medicine, New York, NY, USA
| | - Ivan I Kirov
- Bernard and Irene Schwartz Center for Biomedical Imaging, Department of Radiology, New York University Grossman School of Medicine, New York, NY, USA; Department of Neurology, New York University Grossman School of Medicine, New York, NY, USA; Center for Advanced Imaging Innovation and Research, Department of Radiology, New York University Grossman School of Medicine, New York, NY, USA.
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11
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Coffeng SM, Jacobs B, Kim LJ, Ter Maaten JC, van der Naalt J. Incomplete recovery in patients with minor head injury directly discharged home from the emergency department: a prospective cohort follow-up study. BMJ Open 2022; 12:e057308. [PMID: 35768088 PMCID: PMC9244716 DOI: 10.1136/bmjopen-2021-057308] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/02/2022] Open
Abstract
OBJECTIVES To determine the frequency of post-traumatic complaints and recovery rate of non-hospitalised patients with minor head injury (MHI) and their relationship with demographic and injury characteristics. We also evaluated the differences between patient groups in this least severe category of brain and head injury. DESIGN Prospective cohort follow-up study. SETTING Patients admitted to the emergency department (ED) of a tertiary hospital in the Netherlands. PARTICIPANTS 242 patients with MHI (n=100 with head injury only and n=142 with mild traumatic brain injury (mTBI)) discharged home directly after evaluation at the ED. OUTCOME MEASURES The primary outcome measure was incomplete recovery at 3 months measured by the Glasgow Outcome Scale-Extended score <8. Secondary outcome measures were number of post-traumatic complaints assessed 2 weeks and 3 months postinjury by a standardised questionnaire. Also the number of patients that visited their general practitioner because of persistent complaints was determined. RESULTS Three months postinjury 48% of patients reported more than one post-traumatic complaint. Half (51%) of patients showed incomplete recovery. Incomplete recovery was associated with headache directly postinjury (OR 3.27, 95% CI 1.28 to 8.34), age (OR 1.02, 95% CI 1.00 to 1.05) and the number of post-traumatic complaints (OR 1.24, 95% CI 1.09 to 1.40) and depression (OR 6.31, 95% CI 1.24 to 32.00) 2 weeks postinjury. Incomplete recovery was comparable between the head injury only and mTBI group (55% vs 50%, 95% CI -12.5 to -23.0). In total 36 MHI patients (28%) visited their general practitioner because of complaints related to their head injury. CONCLUSION Half of the non-hospitalised patients with MHI experienced incomplete recovery after 3 months without differences between head injury only and mTBI patients. Therefore, early identification of patients at risk for incomplete recovery must be started at the ED to provide appropriate aftercare to avoid long-term post-traumatic complaints.
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Affiliation(s)
- Sophie Maria Coffeng
- Department of Emergency Medicine, University Medical Center Groningen, Groningen, The Netherlands
| | - Bram Jacobs
- Department of Neurology, University Medical Center Groningen, Groningen, The Netherlands
| | - Laura Jane Kim
- Department of Surgery, University Medical Center Groningen, Groningen, The Netherlands
| | - Jan Cornelis Ter Maaten
- Department of Internal Medicine, University Medical Center Groningen, Groningen, The Netherlands
| | - Joukje van der Naalt
- Department of Neurology, University Medical Center Groningen, Groningen, The Netherlands
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12
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Gaudette É, Seabury SA, Temkin N, Barber J, DiGiorgio AM, Markowitz AJ, Manley GT. Employment and Economic Outcomes of Participants With Mild Traumatic Brain Injury in the TRACK-TBI Study. JAMA Netw Open 2022; 5:e2219444. [PMID: 35767257 PMCID: PMC9244609 DOI: 10.1001/jamanetworkopen.2022.19444] [Citation(s) in RCA: 25] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/03/2022] Open
Abstract
IMPORTANCE Mild traumatic brain injury (mTBI) may impair the ability to work. Strategies to facilitate return to work are understudied. OBJECTIVE To assess employment and economic outcomes for employed, working-age adults with mTBI in the 12 months after injury and the association between return to work and employer assistance. DESIGN, SETTING, AND PARTICIPANTS Using data from the Transforming Research and Clinical Knowledge in Traumatic Brain Injury (TRACK-TBI) study, a cohort study of patients with mTBI presenting to emergency departments of 11 level I US trauma centers was performed. Patients with mTBI enrolled in the TRACK-TBI cohort study from February 26, 2014, to May 4, 2016, were followed up at 2 weeks and 3, 6, and 12 months after injury. Work status and income decline of participants were documented in the first year after injury. Associations between work status, injury characteristics, and offer of employer assistance and associations between follow-up care and employer assistance were investigated. Results were adjusted for unobserved outcomes using inverse probability weighting. Data were extracted July 12, 2020; analyses were completed March 24, 2021. Analyses included 435 participants aged 18 to 64 years who were working before the injury, had a Glasgow Coma Scale score of 13 to 15, and completed all postinjury follow-up surveys. MAIN OUTCOMES AND MEASURES Primary outcomes were work status (working or not working) at each study follow-up milestone. Employer assistance included sick leave, reduced hours, modified schedule, transfer to different tasks, assistive technology, and coaching offered during the first 3 months after injury. RESULTS Of 435 participants (147 [34%] female; 320 [74%] White; mean [SD] age 37.3 [12.9] years), 258 (59%) reported not working at 2 weeks after injury and 74 (17%) reported not working at 12 months after injury. More than one-fifth (92 [21%]) experienced a decline in annual income. Work status at 12 months was significantly associated with postconcussion symptoms experienced at 3 months after injury (73% of patients with 3 or more symptoms reported working at 12 months after injury vs 89% of patients with 2 or fewer symptoms; P < .001) but not with other injury characteristics. Participants offered employer assistance in the first 3 months after injury were more likely to report working after injury than those not offered such assistance (at 6 months: 88% vs 78%; P = .02; at 12 months: 86% vs 72%; P = .005). CONCLUSIONS AND RELEVANCE In this cohort study, mTBI was associated with substantial employment and economic consequences for some patients. Clinicians should systematically follow up with patients with mTBI and coordinate with employers to promote successful return to work.
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Affiliation(s)
- Étienne Gaudette
- Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
| | - Seth A. Seabury
- Leonard D. Schaeffer Center for Health Policy & Economics, University of Southern California, Los Angeles
- School of Pharmacy, University of Southern California, Los Angeles
| | - Nancy Temkin
- Department of Neurological Surgery, University of Washington, Seattle
- Department of Biostatistics, University of Washington, Seattle
| | - Jason Barber
- Department of Neurological Surgery, University of Washington, Seattle
| | - Anthony M. DiGiorgio
- Department of Neurological Surgery, University of California, San Francisco
- Zuckerberg San Francisco General Hospital, San Francisco, California
| | - Amy J. Markowitz
- Department of Neurological Surgery, University of California, San Francisco
- Zuckerberg San Francisco General Hospital, San Francisco, California
| | - Geoffrey T. Manley
- Department of Neurological Surgery, University of California, San Francisco
- Zuckerberg San Francisco General Hospital, San Francisco, California
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13
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Giugni A, Gamberini L, Carrara G, Antiga L, Brissy O, Buldini V, Calamai I, Csomos A, De Luca A, Ferri E, Fleming JM, Gradisek P, Kaps R, Kyprianou T, Lagomarsino S, Lazar I, Martino C, Mikaszewska-Sokolewicz M, Montis A, Nardai G, Nattino G, Nattino G, Paci G, Portolani L, Xirouchaki N, Chieregato A, Bertolini G. Hospitals with and without neurosurgery: a comparative study evaluating the outcome of patients with traumatic brain injury. Scand J Trauma Resusc Emerg Med 2021; 29:158. [PMID: 34727955 PMCID: PMC8561979 DOI: 10.1186/s13049-021-00959-2] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2021] [Accepted: 09/22/2021] [Indexed: 01/06/2023] Open
Abstract
BACKGROUND We leveraged the data of the international CREACTIVE consortium to investigate whether the outcome of traumatic brain injury (TBI) patients admitted to intensive care units (ICU) in hospitals without on-site neurosurgical capabilities (no-NSH) would differ had the same patients been admitted to ICUs in hospitals with neurosurgical capabilities (NSH). METHODS The CREACTIVE observational study enrolled more than 8000 patients from 83 ICUs. Adult TBI patients admitted to no-NSH ICUs within 48 h of trauma were propensity-score matched 1:3 with patients admitted to NSH ICUs. The primary outcome was the 6-month extended Glasgow Outcome Scale (GOS-E), while secondary outcomes were ICU and hospital mortality. RESULTS A total of 232 patients, less than 5% of the eligible cohort, were admitted to no-NSH ICUs. Each of them was matched to 3 NSH patients, leading to a study sample of 928 TBI patients where the no-NSH and NSH groups were well-balanced with respect to all of the variables included into the propensity score. Patients admitted to no-NSH ICUs experienced significantly higher ICU and in-hospital mortality. Compared to the matched NSH ICU admissions, their 6-month GOS-E scores showed a significantly higher prevalence of upper good recovery for cases with mild TBI and low expected mortality risk at admission, along with a progressively higher incidence of poor outcomes with increased TBI severity and mortality risk. CONCLUSIONS In our study, centralization of TBI patients significantly impacted short- and long-term outcomes. For TBI patients admitted to no-NSH centers, our results suggest that the least critically ill can effectively be managed in centers without neurosurgical capabilities. Conversely, the most complex patients would benefit from being treated in high-volume, neuro-oriented ICUs.
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Affiliation(s)
- Aimone Giugni
- Anesthesia, Intensive Care and Prehospital Emergency, Maggiore Hospital, Bologna, Italy
| | - Lorenzo Gamberini
- Anesthesia, Intensive Care and Prehospital Emergency, Maggiore Hospital, Bologna, Italy
| | - Greta Carrara
- Laboratory of Clinical Epidemiology, Department of Public Health, Istituto Di Ricerche Farmacologiche Mario Negri IRCCS, Villa Camozzi, Via G.B. Camozzi 3, 24020, Ranica, Bergamo, Italy
| | | | - Obou Brissy
- Laboratory of Clinical Epidemiology, Department of Public Health, Istituto Di Ricerche Farmacologiche Mario Negri IRCCS, Villa Camozzi, Via G.B. Camozzi 3, 24020, Ranica, Bergamo, Italy
| | - Virginia Buldini
- Anesthesia, Intensive Care and Prehospital Emergency, Maggiore Hospital, Bologna, Italy
| | - Italo Calamai
- Anesthesia and Intensive Care Unit, AUSL Toscana Centro, San Giuseppe Hospital, Empoli, Florence, Italy
| | - Akos Csomos
- Hungarian Army Medical Center, Budapest, Hungary
| | - Alessandra De Luca
- Neurointensive Care Unit, Department of Anesthesia and Intensive Care Unit, AOU Careggi, Florence, Italy
| | - Enrico Ferri
- Anesthesia, Intensive Care and Prehospital Emergency, Maggiore Hospital, Bologna, Italy
| | - Joanne M Fleming
- Laboratory of Clinical Epidemiology, Department of Public Health, Istituto Di Ricerche Farmacologiche Mario Negri IRCCS, Villa Camozzi, Via G.B. Camozzi 3, 24020, Ranica, Bergamo, Italy
| | - Primoz Gradisek
- Clinical Department of Anaesthesiology and Intensive Therapy, University Medical Centre Ljubljana, Ljubljana, Slovenia
- Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia
| | - Rafael Kaps
- General Hospital Novo Mesto, Novo Mesto, Slovenia
| | - Theodoros Kyprianou
- University of Nicosia Medical School, Nicosia, Cyprus
- University Hospitals Bristol and Weston NHS Foundation Trust, Bristol, UK
| | - Silvia Lagomarsino
- Neurointensive Care Unit, Department of Anesthesia and Intensive Care Unit, AOU Careggi, Florence, Italy
| | - Isaac Lazar
- Pediatric Intensive Care Unit, Soroka Medical Center and The Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer Sheva, Israel
| | - Costanza Martino
- Anesthesia and Intensive Care Unit, AUSL Romagna, Maurizio Bufalini Hospital, Cesena, Italy
| | | | - Andrea Montis
- Department of Neurorehabilitation, ASSL Oristano, ATS Sardegna, Oristano, Italy
| | - Gabor Nardai
- Department of Anaesthesiology and Intensive Care, Péterfy Hospital and Trauma Centre, Budapest, Hungary
| | - Giovanni Nattino
- Laboratory of Clinical Epidemiology, Department of Public Health, Istituto Di Ricerche Farmacologiche Mario Negri IRCCS, Villa Camozzi, Via G.B. Camozzi 3, 24020, Ranica, Bergamo, Italy.
| | - Giuseppe Nattino
- Intensive Care Unit, Azienda Socio Sanitaria Territoriale di Lecco, Lecco, Italy
| | - Giulia Paci
- Laboratory of Clinical Epidemiology, Department of Public Health, Istituto Di Ricerche Farmacologiche Mario Negri IRCCS, Villa Camozzi, Via G.B. Camozzi 3, 24020, Ranica, Bergamo, Italy
| | - Laila Portolani
- Anesthesia and Intensive Care Unit, AUSL Romagna, Maurizio Bufalini Hospital, Cesena, Italy
| | | | - Arturo Chieregato
- Neurointensive Care Unit, Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | - Guido Bertolini
- Laboratory of Clinical Epidemiology, Department of Public Health, Istituto Di Ricerche Farmacologiche Mario Negri IRCCS, Villa Camozzi, Via G.B. Camozzi 3, 24020, Ranica, Bergamo, Italy
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14
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Falk H, Bechtold KT, Peters ME, Roy D, Rao V, Lavieri M, Sair H, Van Meter TE, Korley F. A Prognostic Model for Predicting One-Month Outcomes among Emergency Department Patients with Mild Traumatic Brain Injury and a Presenting Glasgow Coma Scale of Fifteen. J Neurotrauma 2021; 38:2714-2722. [PMID: 33957761 DOI: 10.1089/neu.2021.0137] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
The lack of well-performing prognostic models for early prognostication of outcomes remains a major barrier to improving the clinical care of patients with mild traumatic brain injury (mTBI). We aimed to derive a prognostic model for predicting incomplete recovery at 1-month in emergency department (ED) patients with mTBI and a presenting Glasgow Coma Scale (GCS) score of 15 who were enrolled in the HeadSMART (Head Injury Serum Markers for Assessing Response to Trauma) study. The derivation cohort included 355 participants with complete baseline (day-of-injury) and follow-up data. The primary outcome measure was the Glasgow Outcome Scale Extended (GOSE) at 1-month and incomplete recovery was defined as a GOSE <8. At 1-month post-injury, incomplete recovery was present in 58% (n = 205) of participants. The final multi-variable logistic regression model included six variables: age in years (odds ratio [OR] = 0.98; 95% confidence interval [CI]: 0.97-1.00), positive head CT (OR = 4.42; 95% CI: 2.21-9.33), history of depression (OR = 2.59; 95% CI: 1.47-4.69), and self-report of moderate or severe headache (OR = 2.49; 95% CI: 1.49-4.18), difficulty concentrating (OR = 3.17; 95% CI: 1.53-7.04), and photophobia (OR = 4.17; 95% CI: 2.08-8.92) on the day-of-injury. The model was validated internally using bootstrap resampling (1000 resamples), which revealed a mean over-optimism value of 0.01 and an optimism-corrected area under the curve (AUC) of 0.79 (95% CI: 0.75-0.85). A prognostic model for predicting incomplete recovery among ED patients with mTBI and a presenting GCS of 15 using easily obtainable clinical and demographic variables has acceptable discriminative accuracy. External validation of this model is warranted.
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Affiliation(s)
- Hayley Falk
- Department of Computational Medicine and Bioinformatics, University of Michigan, Ann Arbor, Michigan, USA
| | - Kathleen T Bechtold
- Department of Physical Medicine and Rehabilitation, Johns Hopkins University, Baltimore, Maryland, USA
| | - Matthew E Peters
- Department of Psychiatry and Behavioral Sciences, Johns Hopkins University, Baltimore, Maryland, USA
| | - Durga Roy
- Department of Psychiatry and Behavioral Sciences, Johns Hopkins University, Baltimore, Maryland, USA
| | - Vani Rao
- Department of Psychiatry and Behavioral Sciences, Johns Hopkins University, Baltimore, Maryland, USA
| | - Mariel Lavieri
- Department of Industrial and Operations Engineering, University of Michigan, Ann Arbor, Michigan, USA
| | - Haris Sair
- Department of Radiology and Radiological Science, Johns Hopkins University, Baltimore, Maryland, USA
| | | | - Frederick Korley
- Department of Emergency Medicine, University of Michigan, Ann Arbor, Michigan, USA
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15
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Varner CE, Thompson C, Wit K, Borgundvaag B, Houston R, McLeod S. A randomized trial comparing prescribed light exercise to standard management for emergency department patients with acute mild traumatic brain injury. Acad Emerg Med 2021; 28:493-501. [PMID: 33481332 DOI: 10.1111/acem.14215] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2020] [Revised: 11/11/2020] [Accepted: 11/11/2020] [Indexed: 01/01/2023]
Abstract
BACKGROUND There is a paucity of effective management strategies to prevent prolonged symptoms following mild traumatic brain injury (mTBI), and emerging evidence suggesting possible benefits of exercise. The objective of this trial was to determine whether adult patients presenting to the emergency department (ED) with a diagnosis of acute mTBI prescribed light exercise were less likely to develop persistent postconcussion symptoms (PCS). METHODS This was a randomized controlled trial conducted in three Canadian EDs. Consecutive, adult (18-64 years) ED patients with an mTBI sustained within the preceding 48 hours were eligible for enrollment. The intervention group received discharge instructions prescribing 30 minutes of daily light exercise, and the control group was given standard mTBI instructions advising gradual return to exercise following symptom resolution. The primary outcome was the proportion of patients with PCS at 30 days, defined as the presence of three or more symptoms on the Rivermead Post-concussion Symptoms Questionnaire (RPQ). RESULTS A total of 367 patients were enrolled (control group, n = 184; intervention, n = 183). Median age was 32 years and 201 (57.6%) were female. There was no difference in the proportion of patients with PCS at 30 days (control, 13.4% vs intervention, 14.6%; ∆1.2%, 95% confidence interval [CI] = -6.2 to 8.5). There were no differences in median change of RPQ scores, median number of return health care provider visits, median number of missed school or work days, or unplanned return ED visits within 30 days. Participants in the control group reported fewer minutes of light exercise at 7 days (30 vs 35; ∆5, 95% CI = 2 to 15). CONCLUSION In this trial of prescribed early light exercise for acute mTBI, there were no differences in recovery or health care utilization outcomes. Results suggest that early light exercise may be encouraged as tolerated at ED discharge following mTBI, but this guidance is not sufficient to prevent PCS.
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Affiliation(s)
- Catherine E. Varner
- Schwartz/Reisman Emergency Medicine Institute Sinai Health Toronto Ontario Canada
- Department of Family and Community Medicine University of Toronto Toronto Ontario Canada
| | - Cameron Thompson
- Schwartz/Reisman Emergency Medicine Institute Sinai Health Toronto Ontario Canada
| | - Kerstin Wit
- Department of Medicine McMaster University Hamilton Ontario Canada
| | - Bjug Borgundvaag
- Schwartz/Reisman Emergency Medicine Institute Sinai Health Toronto Ontario Canada
- Department of Family and Community Medicine University of Toronto Toronto Ontario Canada
| | - Reaves Houston
- Schwartz/Reisman Emergency Medicine Institute Sinai Health Toronto Ontario Canada
| | - Shelley McLeod
- Schwartz/Reisman Emergency Medicine Institute Sinai Health Toronto Ontario Canada
- Department of Family and Community Medicine University of Toronto Toronto Ontario Canada
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Varner C, Thompson C, de Wit K, Borgundvaag B, Houston R, McLeod S. Predictors of persistent concussion symptoms in adults with acute mild traumatic brain injury presenting to the emergency department. CAN J EMERG MED 2021; 23:365-373. [PMID: 33555602 DOI: 10.1007/s43678-020-00076-6] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2020] [Accepted: 12/23/2020] [Indexed: 10/22/2022]
Abstract
OBJECTIVE To identify risk factors associated with persistent concussion symptoms in adults presenting to the emergency department (ED) with acute mild traumatic brain injury (TBI). METHODS This was a secondary analysis of a randomized controlled trial conducted in three Canadian EDs whereby the intervention had no impact on recovery or healthcare utilization outcomes. Adult (18-64 years) patients with a mild TBI sustained within the preceding 48 h were eligible for enrollment. The primary outcome was the presence of persistent concussion symptoms at 30 days, defined as the presence of ≥ 3 symptoms on the Rivermead Post-concussion Symptoms Questionnaire. RESULTS Of the 241 patients who completed follow-up, median (IQR) age was 33 (25 to 50) years, and 147 (61.0%) were female. At 30 days, 49 (20.3%) had persistent concussion symptoms. Using multivariable logistic regression, headache at ED presentation (OR: 7.7; 95% CI 1.6 to 37.8), being under the influence of drugs or alcohol at the time of injury (OR: 5.9; 95% CI 1.8 to 19.4), the injury occurring via bike or motor vehicle collision (OR: 2.9; 95% CI 1.3 to 6.0), history of anxiety or depression (OR: 2.4; 95% CI 1.2 to 4.9), and numbness or tingling at ED presentation (OR: 2.4; 95% CI 1.1 to 5.2), were found to be independently associated with persistent concussion symptoms at 30 days. CONCLUSIONS Five variables were found to be significant predictors of persistent concussion symptoms. Although mild TBI is mostly a self-limited condition, patients with these risk factors should be considered high risk for developing persistent concussion symptoms and flagged for early outpatient follow-up.
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Affiliation(s)
- Catherine Varner
- Faculty of Medicine, University of Toronto, Toronto, ON, Canada. .,Schwartz/Reisman Emergency Medicine Institute, Toronto, ON, Canada. .,Department of Family and Community Medicine, University of Toronto, 206-600 University Avenue, Toronto, ON, M5G 1X5, Canada. .,Sinai Health System, Toronto, ON, Canada.
| | - Cameron Thompson
- Schwartz/Reisman Emergency Medicine Institute, Toronto, ON, Canada.,Sinai Health System, Toronto, ON, Canada
| | - Kerstin de Wit
- Faculty of Health Sciences, McMaster University, Hamilton, ON, Canada
| | - Bjug Borgundvaag
- Faculty of Medicine, University of Toronto, Toronto, ON, Canada.,Schwartz/Reisman Emergency Medicine Institute, Toronto, ON, Canada.,Department of Family and Community Medicine, University of Toronto, 206-600 University Avenue, Toronto, ON, M5G 1X5, Canada.,Sinai Health System, Toronto, ON, Canada
| | - Reaves Houston
- Schwartz/Reisman Emergency Medicine Institute, Toronto, ON, Canada
| | - Shelley McLeod
- Faculty of Medicine, University of Toronto, Toronto, ON, Canada.,Schwartz/Reisman Emergency Medicine Institute, Toronto, ON, Canada.,Department of Family and Community Medicine, University of Toronto, 206-600 University Avenue, Toronto, ON, M5G 1X5, Canada.,Sinai Health System, Toronto, ON, Canada
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