Casemix, management, and mortality of patients rreseceiving emergency neurosurgery for traumatic brain injury in the Global Neurotrauma Outcomes Study: a prospective observational cohort study

BACKGROUND

Traumatic brain injury (TBI) is increasingly recognised as being responsible for a substantial proportion of the global burden of disease. Neurosurgical interventions are an important aspect of care for patients with TBI, but there is little epidemiological data available on this patient population. We aimed to characterise differences in casemix, management, and mortality of patients receiving emergency neurosurgery for TBI across different levels of human development.

METHODS

We did a prospective observational cohort study of consecutive patients with TBI undergoing emergency neurosurgery, in a convenience sample of hospitals identified by open invitation, through international and regional scientific societies and meetings, individual contacts, and social media. Patients receiving emergency neurosurgery for TBI in each hospital's 30-day study period were all eligible for inclusion, with the exception of patients undergoing insertion of an intracranial pressure monitor only, ventriculostomy placement only, or a procedure for drainage of a chronic subdural haematoma. The primary outcome was mortality at 14 days postoperatively (or last point of observation if the patient was discharged before this time point). Countries were stratified according to their Human Development Index (HDI)-a composite of life expectancy, education, and income measures-into very high HDI, high HDI, medium HDI, and low HDI tiers. Mixed effects logistic regression was used to examine the effect of HDI on mortality while accounting for and quantifying between-hospital and between-country variation.

FINDINGS

Our study included 1635 records from 159 hospitals in 57 countries, collected between Nov 1, 2018, and Jan 31, 2020. 328 (20%) records were from countries in the very high HDI tier, 539 (33%) from countries in the high HDI tier, 614 (38%) from countries in the medium HDI tier, and 154 (9%) from countries in the low HDI tier. The median age was 35 years (IQR 24-51), with the oldest patients in the very high HDI tier (median 54 years, IQR 34-69) and the youngest in the low HDI tier (median 28 years, IQR 20-38). The most common procedures were elevation of a depressed skull fracture in the low HDI tier (69 [45%]), evacuation of a supratentorial extradural haematoma in the medium HDI tier (189 [31%]) and high HDI tier (173 [32%]), and evacuation of a supratentorial acute subdural haematoma in the very high HDI tier (155 [47%]). Median time from injury to surgery was 13 h (IQR 6-32). Overall mortality was 18% (299 of 1635). After adjustment for casemix, the odds of mortality were greater in the medium HDI tier (odds ratio [OR] 2·84, 95% CI 1·55-5·2) and high HDI tier (2·26, 1·23-4·15), but not the low HDI tier (1·66, 0·61-4·46), relative to the very high HDI tier. There was significant between-hospital variation in mortality (median OR 2·04, 95% CI 1·17-2·49).

INTERPRETATION

Patients receiving emergency neurosurgery for TBI differed considerably in their admission characteristics and management across human development settings. Level of human development was associated with mortality. Substantial opportunities to improve care globally were identified, including reducing delays to surgery. Between-hospital variation in mortality suggests changes at an institutional level could influence outcome and comparative effectiveness research could identify best practices.

FUNDING

National Institute for Health Research Global Health Research Group.

Caregivers' perspectives of the challenges faced with survivors of traumatic brain injury: A scoping review

INTRODUCTION

Traumatic Brain Injury (TBI) has wide-ranging neuropsychological, physical, social and financial implications. The impact on caregivers of moderate to severe TBI survivors, particularly in low- and middle-income countries, is under-investigated.

AIM

Identify and describe the experiences of caregivers' of moderate to severe TBI survivors postdischarge from healthcare facilities.

METHODS

A scoping review was conducted utilising seven electronic databases. Two reviewers screened articles using eligibly criteria related to setting (postdischarge), caregiving (informal), age of TBI survivors (>  18 years) and injury severity (moderate-severe). Studies published in English between 1999 -2018 were included.

RESULTS

Fourteen articles met the inclusion criteria. Articles reporting on the same sample were merged during data charting. The final analyses included 11 articles comprised of qualitative, quantitative and mixed-methods studies. Ten themes were identified: psychological distress, social functioning, financial burden, family experiences, coping strategies, access to services, time burdens and physical, cognitive and behavioural difficulties. Characteristics of caregivers and TBI survivors were also reported.

CONCLUSION

Caregivers of moderate to severe TBI survivors experience challenges in various life domains, and there is limited research concerning caregivers in low- and middle-income countries. Future research should focus on understanding more nuanced experiences across various environments, which may increase comprehensive, flexible and long-term support.

Hypofractionated image-guided radiotherapy for the treatment of acoustic neuromas: A dosimetrically acceptable alternative to stereotactic radiosurgery in a resource-constrained environment

<strong>Purpose:</strong> Treatment options for acoustic neuromas (ANs) are limited in low- and middle-income countries. The aim of this study was to investigate whether hypofractionated image-guided radiotherapy (IGRT) is a clinically acceptable treatment option for departments where no other radiosurgery options are available.<br /><strong>Methods and materials:</strong> Fifteen dynamic conformal arc plans that had been clinically utilised were evaluated against the Radiation Therapy Oncology Group (RTOG) radiosurgery criteria and published indices. Analysis involved evaluating critical structure doses and the volume of normal tissue receiving 12 and 10 Gy single fraction equivalent dose (V12_{<span style="font-size: small;">Eq</span>} and V10_{<span style="font-size: small;">Eq</span>}).<br /><strong>Results:</strong> Overall, there was only one RTOG protocol deviation in the whole patient group, where quality of coverage was compromised in order to achieve brainstem tolerance. Conformity indices were within clinically acceptable limits (CI_{<span style="font-size: small;">Paddick</span>} ≥ 0.6) despite being inferior to the published Universitair Ziekenhuis Brussel (UZB) Gamma Knife and CyberKnife results (<em>p</em> &lt; 0.0001). Homogeneity was superior to the Gamma Knife (<em>p</em> &lt; 0.0001) and Novalis dynamic conformal arc (<em>p</em> = 0.0002) results. Gradient index results were inferior to all published techniques, but doses to the normal structures were well controlled with the exception of the cochlea. The V10_{<span style="font-size: small;">Eq</span>} data showed increased sensitivity when compared with V12_{<span style="font-size: small;">Eq</span>}.<br /><strong>Conclusion:</strong> Dynamic arc IGRT allows for good coverage of AN lesions, but the dose fall-off is not as steep as that obtained with mainstream radiosurgery systems. Contouring and planning should include detailed critical structures analysis. For normal brain parenchyma analysis, V10_{<span style="font-size: small;">Eq</span>} is a superior risk indicator when compared to V12_{<span style="font-size: small;">Eq</span>} for this technique. Dynamic arc IGRT offers a dosimetrically acceptable treatment alternative for patients without serviceable hearing, in departments where there are no mainstream radiosurgery treatment options available.

Improving Traumatic Brain Injury Outcomes: The Development of an Evaluation and Referral Tool at Groote Schuur Hospital

BACKGROUND

The Western Cape Province of South Africa has a great shortage of diagnostic expertise, rehabilitative infrastructure, and support services for patients with traumatic brain injury (TBI). The neurosurgical outpatient setting is busy and often chaotic, and patients are frequently lost to follow-up. This study sought to continue with the design and development of a comprehensive, yet brief tool to aid patient referrals and ensure that no consequence of TBI is left unidentified and unaddressed.

METHODS

There were 47 patients with TBI (mean age, 35 years; range, 18-75 years) assessed. The study was designed in 3 distinct phases, each representing a different stage in the tool's development.

RESULTS

The Groote Schuur Traumatic Brain Injury Evaluation was shortened and simplified. Overall, 81% of the participants indicated cognitive dysfunction. There was a high prevalence of psychological/psychiatric sequelae, with 85% of participants reporting at least 1 such problem.

CONCLUSIONS

The findings further highlight the prevalence of the cognitive, behavioral, and psychological consequences of TBI and shed additional light on the particular types of problems that patients with TBI face. Following the identified changes, the questionnaire and algorithm combination are now ready to be validated in the neurosurgical clinical setting.

Sweating away depression? The impact of intensive exercise on depression

BACKGROUND

In periods of prolonged stress and pain the body produces endorphins to help endure pain. The PANIC system is built on the same pathways as the pain system and is characterized by behaviour that looks like depression. The term 'mental pain' in the context of feelings of loss is arguably justified in light of this relationship between the physical pain and social loss systems. It is reasonable to expect that endorphin release ameliorates depression.

METHODS

Moderately depressed males (n=30) were randomly assigned to one of three groups of varying exercise intensity. Each underwent a six-week exercise programme for three days per week, one hour per day. The HAM-D, MADRS, and ANPS were administered weekly and β-endorphin levels measured.

RESULTS

Moderate- and high-intensity exercise improved depression levels, while very-low intensity exercise did not have as beneficial an effect. β-endorphin results were inconclusive. Participants showed a slight decrease in PANIC and FEAR, and increased SEEKING.

LIMITATIONS

The potential insensitivity of the assays that were utilized, and the known problems with measuring β-endorphins, may have contributed to the findings. The lack of a state measure of the basic emotion systems is problematic, as a trait measure has to be relied upon, and this likely affected the ability to accurately detect changes over time.

CONCLUSIONS

The demonstrated improvements in depressive symptoms have important implications for the clinical treatment of patients despite the hypothesis that the PANIC system is involved in the genesis and maintenance of depression not having been conclusively confirmed.

Adaptation of Aphasia Tests for Neurocognitive Screening in South Africa

Two aphasia tests — the Cookie Theft Test and the Boston Naming Test — were adapted to help eliminate western cultural, language and education bias in neurocognitive screening in South Africa. These tests were among the commonly used tests initially chosen for inclusion in a larger neurocognitive screening battery currently being developed and translated for use in South Africa — the Groote Schuur Neurocognitive Battery. The adaptations were made employing quantitative and qualitative converging lines of evidence to evaluate their efficacy. This evidence included consultation with clinicians at Groote Schuur Hospital and translators knowledgeable in Afrikaans and isiXhosa language and culture, qualitative feedback from the research participants, and the results on the tests. The adapted tests were piloted by testing 30 neurocognitively intact controls consisting of equal numbers of Afrikaans, English and isiXhosa speakers, comparing their scores to their performances on the original tests. Three aphasic patients were also briefly tested. Results indicate that the adaptations made to the tests improved the performance of controls over the original versions, and tentatively suggest that the adapted tests should be able to screen for aphasia. This pilot study recommends further changes to the Groote Schuur Naming Test before its introduction into the battery ahead of its validation.