Occurrence and prognostic effect of cervical spine injuries and cervical artery injuries with concomitant severe head injury

Background Blunt cerebrovascular injuries (BCVIs) and cervical spinal injuries (CSIs) are not uncommon injuries in patients with severe head injury and may affect patient recovery. We aimed to assess the independent relationship between BCVI, CSI, and outcome in patients with severe head injury. Methods We identified patients with severe head injury from the Helsinki Trauma Registry treated during 2015-2017 in a large level 1 trauma hospital. We assessed the association between BCVI and SCI using multivariable logistic regression, adjusting for injury severity. Our primary outcome was functional outcome at 6 months, and our secondary outcome was 6-month mortality. Results Of 255 patients with a cervical spine CT, 26 patients (10%) had a CSI, and of 194 patients with cervical CT angiography, 16 patients (8%) had a BCVI. Four of the 16 BCVI patients had a BCVI-related brain infarction, and four of the CSI patients had some form of spinal cord injury. After adjusting for injury severity in multivariable logistic regression analysis, BCVI associated with poor functional outcome (odds ratio [OR] = 6.0, 95% CI [confidence intervals] = 1.4-26.5) and mortality (OR = 7.9, 95% CI 2.0-31.4). We did not find any association between CSI and outcome. Conclusions We found that BCVI with concomitant head injury was an independent predictor of poor outcome in patients with severe head injury, but we found no association between CSI and outcome after severe head injury. Whether the association between BCVI and poor outcome is an indirect marker of a more severe injury or a result of treatment needs further investigations.Peer reviewe

Temporal changes in outcome following intensive care unit treatment after traumatic brain injury : a 17-year experience in a large academic neurosurgical centre

Traumatic brain injury (TBI) is a major cause of morbidity and mortality. However, it remains undetermined whether long-term outcomes after TBI have improved over the past two decades. We conducted a retrospective analysis of consecutive TBI patients admitted to an academic neurosurgical ICU during 1999-2015. Primary outcomes of interest were 6-month all-cause mortality (available for all patients) and 6-month Glasgow Outcome Scale (GOS, available from 2005 onwards). GOS was dichotomized to favourable and unfavourable functional outcome. Temporal changes in outcome were assessed using multivariate logistic regression analysis, adjusting for age, sex, GCS motor score, pupillary light responsiveness, Marshall CT classification and major extracranial injury. Altogether, 3193 patients were included. During the study period, patient age and admission Glasgow Coma Scale score increased, while the overall TBI severity did not change. Overall unadjusted 6-month mortality was 25% and overall unadjusted unfavourable outcome (2005-2015) was 44%. There was no reduction in the adjusted odds of 6-month mortality (OR 0.98; 95% CI 0.96-1.00), but the adjusted odds of favourable functional outcome significantly increased (OR 1.08; 95% CI 1.04-1.11). Subgroup analysis showed outcome improvements only in specific subgroups (conservatively treated patients, moderate-to-severe TBI patients, middle-aged patients). During the past two decades, mortality after significant TBI has remained largely unchanged, but the odds of favourable functional outcome have increased significantly in specific subgroups, implying an improvement in quality of care. These developments have been paralleled by notable changes in patient characteristics, emphasizing the importance of continuous epidemiological monitoring.Peer reviewe

Prognostic performance of computerized tomography scoring systems in civilian penetrating traumatic brain injury : an observational study

Background The prognosis of penetrating traumatic brain injury (pTBI) is poor yet highly variable. Current computerized tomography (CT) severity scores are commonly not used for pTBI prognostication but may provide important clinical information in these cohorts. Methods All consecutive pTBI patients from two large neurotrauma databases (Helsinki 1999-2015, Stockholm 2005-2014) were included. Outcome measures were 6-month mortality and unfavorable outcome (Glasgow Outcome Scale 1-3). Admission head CT scans were assessed according to the following: Marshall CT classification, Rotterdam CT score, Stockholm CT score, and Helsinki CT score. The discrimination (area under the receiver operating curve, AUC) and explanatory variance (pseudo-R-2) of the CT scores were assessed individually and in addition to a base model including age, motor response, and pupil responsiveness. Results Altogether, 75 patients were included. Overall 6-month mortality and unfavorable outcome were 45% and 61% for all patients, and 31% and 51% for actively treated patients. The CT scores' AUCs and pseudo-R(2)s varied between 0.77-0.90 and 0.35-0.60 for mortality prediction and between 0.85-0.89 and 0.50-0.57 for unfavorable outcome prediction. The base model showed excellent performance for mortality (AUC 0.94, pseudo-R-2 0.71) and unfavorable outcome (AUC 0.89, pseudo-R-2 0.53) prediction. None of the CT scores increased the base model's AUC (p > 0.05) yet increased its pseudo-R-2 (0.09-0.15) for unfavorable outcome prediction. Conclusion Existing head CT scores demonstrate good-to-excellent performance in 6-month outcome prediction in pTBI patients. However, they do not add independent information to known outcome predictors, indicating that a unique score capturing the intracranial severity in pTBI may be warranted.Peer reviewe

Trends in mortality after intensive care of patients with traumatic brain injury in Finland from 2003 to 2019 : a Finnish Intensive Care Consortium study

Background Several studies have suggested no change in the outcome of patients with traumatic brain injury (TBI) treated in intensive care units (ICUs). This is mainly due to the shift in TBI epidemiology toward older and sicker patients. In Finland, the share of the population aged 65 years and over has increased the most in Europe during the last decade. We aimed to assess changes in 12-month and hospital mortality of patients with TBI treated in the ICU in Finland. Methods We used a national benchmarking ICU database (Finnish Intensive Care Consortium) to study adult patients who had been treated for TBI in four tertiary ICUs in Finland during 2003-2019. We divided admission years into quartiles and used multivariable logistic regression analysis, adjusted for case-mix, to assess the association between admission year and mortality. Results A total of 4535 patients were included. Between 2003-2007 and 2016-2019, the patient median age increased from 54 to 62 years, the share of patients having significant comorbidity increased from 8 to 11%, and patients being dependent on help in activities of daily living increased from 7 to 15%. Unadjusted hospital and 12-month mortality decreased from 18 and 31% to 10% and 23%, respectively. After adjusting for case-mix, a reduction in odds of 12-month and hospital mortality was seen in patients with severe TBI, intracranial pressure monitored patients, and mechanically ventilated patients. Despite a reduction in hospital mortality, 12-month mortality remained unchanged in patients aged >= 70 years. Conclusion A change in the demographics of ICU-treated patients with TBI care is evident. The outcome of younger patients with severe TBI appears to improve, whereas long-term mortality of elderly patients with less severe TBI has not improved. This has ramifications for further efforts to improve TBI care, especially among the elderly.Peer reviewe

Trends in mortality after intensive care of patients with traumatic brain injury in Finland from 2003 to 2019: a Finnish Intensive Care Consortium study

Background Several studies have suggested no change in the outcome of patients with traumatic brain injury (TBI) treated in intensive care units (ICUs). This is mainly due to the shift in TBI epidemiology toward older and sicker patients. In Finland, the share of the population aged 65 years and over has increased the most in Europe during the last decade. We aimed to assess changes in 12-month and hospital mortality of patients with TBI treated in the ICU in Finland.Methods We used a national benchmarking ICU database (Finnish Intensive Care Consortium) to study adult patients who had been treated for TBI in four tertiary ICUs in Finland during 2003-2019. We divided admission years into quartiles and used multivariable logistic regression analysis, adjusted for case-mix, to assess the association between admission year and mortality.Results A total of 4535 patients were included. Between 2003-2007 and 2016-2019, the patient median age increased from 54 to 62 years, the share of patients having significant comorbidity increased from 8 to 11%, and patients being dependent on help in activities of daily living increased from 7 to 15%. Unadjusted hospital and 12-month mortality decreased from 18 and 31% to 10% and 23%, respectively. After adjusting for case-mix, a reduction in odds of 12-month and hospital mortality was seen in patients with severe TBI, intracranial pressure monitored patients, and mechanically ventilated patients. Despite a reduction in hospital mortality, 12-month mortality remained unchanged in patients aged >= 70 years.Conclusion A change in the demographics of ICU-treated patients with TBI care is evident. The outcome of younger patients with severe TBI appears to improve, whereas long-term mortality of elderly patients with less severe TBI has not improved. This has ramifications for further efforts to improve TBI care, especially among the elderly.</p

Prognostic performance of computerized tomography scoring systems in civilian penetrating traumatic brain injury : an observational study

Tausta: Lävistävän aivovamman saaneen potilaan ennuste on huono mutta vaihteleva. Nykyaikaisia, pään tie-tokonetomografia(TT)kuvien löydöksiin perustuvia pisteytysjärjestelmiä ei aiemmin ole hyödynnetty lävistä-vien aivovammojen ennustearvioinnissa, vaikka niiden sisältämä informaatio voisi olla hyödyllistä. Menetelmät: Tutkimusaineiston muodostivat kaikki Helsingissä vuosina 1999–2015 ja Tukholmassa vuosina 2005–2014 neurokirurgisella tehovalvontaosastolla hoidetut, lävistävän aivovamman saaneet potilaat. Pääte-muuttujia olivat kuolleisuus ja omatoimisuuden aste 6 kuukautta vammasta. Pään TT-kuvat luokiteltiin neljän pisteytysjärjestelmän (Marshall CT classification, Rotterdam CT score, Stockholm CT score, Helsinki CT sco-re) mukaisesti. Pisteytysjärjestelmien ennustamiskykyä arvioitiin määrittämällä niille erottelukyky (area un-der the receiver operating curve [AUC]) ja selitysaste (pseudo-R2), ja näitä arvioitiin sekä itsenäisinä että osa-na kliinistä (potilaan ikään, tajunnantasoon ja pupillien valoreaktiivisuuteen perustuvaa) vertailumallia. Tulokset: Tutkimusaineisto käsitti 75 potilasta. Koko aineistossa 6 kuukauden kuolleisuus oli 45 % ja ei-omatoimisiksi toipui 61 %; aktiivisesti hoidettujen potilaiden osalta vastaavat prosenttiosuudet olivat 31 % ja 51 %. Eri pisteytysjärjestelmien AUC vaihteli välillä 0.77–0.90 kuolleisuuden ennustamisessa ja välillä 0.85–0.89 ei-omatoimisuuden ennustamisessa, ja pseudo-R2 vaihteli välillä 0.35–0.60 kuolleisuuden ennustamisessa ja välillä 0.50–0.57 ei-omatoimisuuden ennustamisessa. Kliinisen vertailumallin ennustamiskyky oli erin-omainen sekä kuolleisuuden (AUC 0.94; pseudo-R2 0.71) että ei-omatoimisuuden (AUC 0.89; pseudo-R2 0.53) ennustamisessa. Mikään tutkituista pisteytysjärjestelmistä ei merkitsevästi parantanut kliinisen vertailumallin AUC-arvoa (p > 0.05), mutta lisäsivät sen pseudo-R2-arvoa (+0.09–0.15) ei-omatoimisuuden ennustamisessa. Yhteenveto: Nykyaikaisten pään TT-löydöksiin perustuvien pisteytysjärjestelmien tilastollinen ennustamisky-ky lävistävän aivovamman saaneen potilaan toipumisen ennustamisessa vaihtelee hyvän ja erinomaisen välil-lä. Ne eivät kuitenkaan tuo tilastollista lisäarvoa kliiniseen ennustemalliin, viitaten lävistäville vammoille spesifisesti räätälöidyn pisteytysmallin tarpeeseen

In reply : Concomitant cranio-spinal trauma: additional risk from a cerebrovascular injury

Non peer reviewe

The effect of individual short- and long-term psychotherapy on perceived social support: analysis of secondary outcomes of a randomized clinical trial

Purpose: Social support is important for maintaining and restoring psychological well-being but the effects of individual psychotherapies on perceived social support are not well known. In this analysis of secondary outcomes from a randomized clinical study, we compared the effects of long-term psychotherapy and two short-term psychotherapies on social support during a 5-year follow-up. Materials and methods: Altogether 326 adult outpatients suffering from depressive and/or anxiety disorders were randomly assigned to long-term psychodynamic psychotherapy (LPP, n = 126), short-term psychodynamic psychotherapy (SPP, n = 101) and solution-focused therapy (SFT, n = 97). Outcome was measured by the global index and six subscores of the self-reported Brief Inventory of Social Support and Integration scale (BISSI) at baseline and at 1, 2, 3, 4 and 5 years after the beginning of the therapy. Results: Social support improved in all therapy groups and the improvement was relatively stable, lasting several years after the end of therapy. Little difference in improvement was observed either between therapy orientations or durations. Conclusions: While no major differences were observed between treatment groups, the slight differences call for further research to verify these findings and to better understand how different therapies may improve perceived social support.</p

Trends in mortality after intensive care of patients with traumatic brain injury in Finland from 2003 to 2019 : a Finnish Intensive Care Consortium study

Background: Several studies have suggested no change in the outcome of patients with traumatic brain injury (TBI) treated in intensive care units (ICUs). This is mainly due to the shift in TBI epidemiology toward older and sicker patients. In Finland, the share of the population aged 65 years and over has increased the most in Europe during the last decade. We aimed to assess changes in 12-month and hospital mortality of patients with TBI treated in the ICU in Finland. Methods: We used a national benchmarking ICU database (Finnish Intensive Care Consortium) to study adult patients who had been treated for TBI in four tertiary ICUs in Finland during 2003–2019. We divided admission years into quartiles and used multivariable logistic regression analysis, adjusted for case-mix, to assess the association between admission year and mortality. Results: A total of 4535 patients were included. Between 2003–2007 and 2016–2019, the patient median age increased from 54 to 62 years, the share of patients having significant comorbidity increased from 8 to 11%, and patients being dependent on help in activities of daily living increased from 7 to 15%. Unadjusted hospital and 12-month mortality decreased from 18 and 31% to 10% and 23%, respectively. After adjusting for case-mix, a reduction in odds of 12-month and hospital mortality was seen in patients with severe TBI, intracranial pressure monitored patients, and mechanically ventilated patients. Despite a reduction in hospital mortality, 12-month mortality remained unchanged in patients aged ≥ 70 years. Conclusion: A change in the demographics of ICU-treated patients with TBI care is evident. The outcome of younger patients with severe TBI appears to improve, whereas long-term mortality of elderly patients with less severe TBI has not improved. This has ramifications for further efforts to improve TBI care, especially among the elderly.publishedVersionPeer reviewe