Randomized controlled trials in adult traumatic brain injury: A systematic review on the use and reporting of clinical outcome assessments

As part of efforts to improve study design, the use of outcome measures in randomized controlled trials (RCTs) in traumatic brain injury (TBI) is receiving increasing attention. This review aimed to assess how clinical outcome assessments (COAs) have been used and reported in RCTs in adult TBI. Systematic literature searches were conducted to identify medium to large (n ≥ 100) acute and post-acute TBI trials published since 2000. Data were extracted independently by two reviewers using a set of structured templates. Items from the Consolidated Standards of Reporting Trials (CONSORT) 2010 Statement and CONSORT patient-reported outcomes (PRO) extension were used to evaluate reporting quality of COAs. Glasgow Outcome Scale/Extended (GOS/GOSE) data were extracted using a checklist developed specifically for the review. A total of 126 separate COAs were identified in 58 studies. The findings demonstrate heterogeneity in the use of TBI outcomes, limiting comparisons and meta-analyses of RCT findings. The GOS/GOSE was included in 39 studies, but implemented in a variety of ways, which may not be equivalent. Multidimensional outcomes were used in 30 studies, and these were relatively more common in rehabilitation settings. The use of PROs was limited, especially in acute study settings. Quality of reporting was variable, and key information concerning COAs was often omitted, making it difficult to know how precisely outcomes were assessed. Consistency across studies would be increased and future meta-analyses facilitated by (a) using common data elements recommendations for TBI outcomes and (b) following CONSORT guidelines when publishing RCTs

Global functional outcome in traumatic brain injury: Use in clinical trials, approaches to data collection, and role in multi-dimensional outcome assessment

Traumatic brain injury (TBI) affects multiple aspects of health and daily functioning. However, TBI researchers whose primary interest is in the acute care setting have often used single measures of global functional outcome, such as the Glasgow Outcome Scale (GOS), to provide an overall assessment of recovery at follow-up, and have not routinely incorporated measures that capture the multi-dimensional impact of TBI. CENTER-TBI is part of an international initiative towards standardizing and refining outcome assessment in TBI. The aim of this initiative is to promote the use of common measures to provide a multi-dimensional description of TBI outcomes in a range of study contexts. This thesis uses data collected for CENTER-TBI to examine two main issues of relevance to outcome assessment in adult TBI: (1) methods of collecting information about global functional outcome; and (2) implementation of multi-dimensional approaches to outcome assessment in TBI. The systematic review in Chapter 2 examines the patterns of use and reporting quality of outcome measures in clinical trials in adult TBI. The findings from the review demonstrate heterogeneity in the use of outcome measures, limited use of multi-dimensional outcomes, and highlight the issue of incomplete reporting of outcomes in these studies, providing the impetus for the studies in Chapters 4, 5 and 6. Chapters 4 and 5 compare outcomes assigned using clinician ratings and patient reports on the extended GOS (GOSE). The two GOSE approaches were found to be broadly equivalent indicating that, in this context, patient reports generally provide information that is comparable to that obtained via clinician-rated interviews. Chapter 5 demonstrates that the GOSE has significant, but modest, associations with prognostic factors and other outcome measures. The role of the GOSE in implementing multi-dimensional outcome assessment is considered in Chapter 6. Chapter 6 demonstrates that the applicability of individual outcome assessments is strongly driven by level of disability. Thus, a tailored approach to outcome assessment is needed. The studies in this thesis indicate that mixed modes of GOSE data collection can be used to maximise follow-ups in studies with pragmatic constraints. Furthermore, outcome measures need to be carefully selected to capture the multi-dimensional impact of TBI across the spectrum of recovery. The findings have implications for further CENTER-TBI analyses, for selecting outcome measures in future prospective studies, and for pooling data for secondary analyses

The chronic and evolving neurological consequences of traumatic brain injury.

Traumatic brain injury (TBI) can have lifelong and dynamic effects on health and wellbeing. Research on the long-term consequences emphasises that, for many patients, TBI should be conceptualised as a chronic health condition. Evidence suggests that functional outcomes after TBI can show improvement or deterioration up to two decades after injury, and rates of all-cause mortality remain elevated for many years. Furthermore, TBI represents a risk factor for a variety of neurological illnesses, including epilepsy, stroke, and neurodegenerative disease. With respect to neurodegeneration after TBI, post-mortem studies on the long-term neuropathology after injury have identified complex persisting and evolving abnormalities best described as polypathology, which includes chronic traumatic encephalopathy. Despite growing awareness of the lifelong consequences of TBI, substantial gaps in research exist. Improvements are therefore needed in understanding chronic pathologies and their implications for survivors of TBI, which could inform long-term health management in this sizeable patient population

Questionnaires vs Interviews for the Assessment of Global Functional Outcomes After Traumatic Brain Injury

Importance An interview is considered the gold standard method of assessing global functional outcomes in clinical trials among patients with acute traumatic brain injury (TBI). However, several multicenter clinical trials have used questionnaires completed by a patient or caregiver to assess the primary end point. Objective To examine agreement between interview and questionnaire formats for assessing TBI outcomes and to consider whether an interview has advantages. Design, Setting, and Participants This cohort study used data from patients enrolled in the Collaborative European NeuroTrauma Effectiveness Research in TBI (CENTER-TBI) project from December 2014 to December 2017. Data were analyzed from December 2020 to April 2021. Included patients were aged 16 years or older with TBI and a clinical indication for computed tomography imaging. Outcome assessments were completed using both an interview and a questionnaire at follow-up 3 and 6 months after injury. Exposures Traumatic brain injury of all severities. Main Outcomes and Measures Ratings on the Glasgow Outcome Scale–Extended (GOSE) administered as a structured interview rated by an investigator and as a questionnaire completed by patients or caregivers and scored centrally were compared, and the strength of agreement was evaluated using weighted κ statistics. Secondary outcomes included comparison of different sections of the GOSE assessments and the association of GOSE ratings with baseline factors and patient-reported mental health, health-related quality of life, and TBI symptoms. Results Among the 3691 eligible individuals in the CENTER-TBI study, both GOSE assessment formats (interview and questionnaire) were completed by 994 individuals (26.9%) at 3 months after TBI (654 [65.8%] male; median age, 53 years [IQR, 33-66 years]) and 628 (17.0%) at 6 months (409 [65.1%] male; median age, 51 years [IQR, 31-64 years]). Outcomes of the 2 assessment methods agreed well at both 3 months (weighted κ, 0.77; 95% CI, 0.73-0.80) and 6 months (weighted κ, 0.82; 95% CI, 0.78-0.86). Furthermore, item-level agreement between the 2 methods was good for sections regarding independence in everyday activities (κ, 0.70-0.79 across both time points) and moderate for sections regarding subjective aspects of functioning such as relationships and symptoms (κ, 0.41-0.51 across both time points). Compared with questionnaires, interviews recorded more problems with work (294 [30.5%] vs 233 [24.2%] at 3 months and 161 [26.8%] vs 136 [22.7%] at 6 months), fewer limitations in social and leisure activities (330 [33.8%] vs 431 [44.1%] at 3 months and 179 [29.7%] vs 219 [36.4%] at 6 months), and more symptoms (524 [53.6%] vs 324 [33.1%] at 3 months and 291 [48.4%] vs 179 [29.8%] at 6 months). Interviewers sometimes assigned an overall rating based on judgment rather than interview scoring rules, particularly for patients with potentially unfavorable TBI outcomes. However, for both formats, correlations with baseline factors (ρ, −0.13 to 0.42) and patient-reported outcomes (ρ, 0.29 to 0.65) were similar in strength. Conclusions and Relevance In this cohort study, GOSE ratings obtained by questionnaire and interview methods were in good agreement. The similarity of associations of the ratings obtained by both GOSE methods with baseline factors and other TBI outcome measures suggests that despite some apparent differences, the core information collected by both interviews and questionnaires was similar. The findings support the use of questionnaires in studies in which this form of contact may offer substantial practical advantages compared with interviews

A comparison of a structured home-based rehabilitation programme with conventional supervised pulmonary rehabilitation:A randomised non-inferiority trial

Background: Standardised home-based pulmonary rehabilitation (PR) programmes offer an alternative model to centre-based supervised PR for which uptake is currently poor. We determined if a structured home-based unsupervised PR programme was non-inferior to supervised centre-based PR for participants with COPD. Methods: A total of 287 participants with COPD who were referred to PR (187 male, mean (SD) age 68 (8.86) years, FEV1% predicted 48.34 (17.92)) were recruited. They were randomised to either centre-based PR or a structured unsupervised home-based PR programme including a hospital visit with a healthcare professional trained in motivational interviewing, a self-management manual and two telephone calls. Fifty-eight (20%) withdrew from the centre-based group and 51 (18%) from the home group. The primary outcome was dyspnoea domain in the chronic respiratory disease questionnaire (Chronic Respiratory Questionnaire Self-Report; CRQ-SR) at 7 weeks. Measures were taken blinded. We undertook a modified intention-to-treat (mITT) complete case analysis, comparing groups according to original random allocation and with complete data at follow-up. The non-inferiority margin was 0.5 units. Results: There was evidence of significant gains in CRQ-dyspnoea at 7 weeks in both home and centre-based groups. There was inconclusive evidence that home-based PR was non-inferior to PR in dyspnoea (mean group difference, mITT: −0.24, 95% CI −0.61 to 0.12, p=0.18), favouring the centre group at 7 weeks. Conclusions: The standardised home-based programme provides benefits in dyspnoea. Further evidence is needed to definitively determine if the health benefits of the standardised home-based programme are non-inferior or equivalent to supervised centre-based rehabilitation

Ingestion of microplastics by the chironomid Chironomus sancticaroli and effects on the microbiome in the presence of PBDEs

Microplastic particles in the environment can associate with persistent organic pollutants (POPs) due to the hydrophobic nature of plastics and organic chemicals. PBDEs (polybrominated diphenyl ethers) are widely used as flame-retardants in products such as textiles and soft furnishings, with the potential to leach into the environment and be associated with microplastics. If ingested, the gut environment of an organism may favour desorption of adsorbed chemicals due to gut condition. Therefore the ingestion of microplastic particles has implications for uptake and bioaccumulation of these chemicals. Furthermore the presence of microplastics and chemicals in the gut of an organism can also influence the gut environment itself. Gut microbiomes are known to hold a vital role in host metabolism, nutrition and immunity and as such understanding the influence of chemicals and microplastics on the gut microbiota is key

Understanding the relationship between cognitive performance and function in daily life after traumatic brain injury

Objective Cognitive impairment is a key cause of disability after traumatic brain injury (TBI) but relationships with overall functioning in daily life are often modest. The aim is to examine cognition at different levels of function and identify domains associated with disability. Methods 1554 patients with mild-to-severe TBI were assessed at 6 months post injury on the Glasgow Outcome Scale-Extended (GOSE), the Short Form-12v2 and a battery of cognitive tests. Outcomes across GOSE categories were compared using analysis of covariance adjusting for age, sex and education. Results Overall effect sizes were small to medium, and greatest for tests involving processing speed (eta(2)(p) 0.057-0.067) and learning and memory (eta(2)(p) 0.048-0.052). Deficits in cognitive performance were particularly evident in patients who were dependent (GOSE 3 or 4) or who were unable to participate in one or more major life activities (GOSE 5). At higher levels of function (GOSE 6-8), cognitive performance was surprisingly similar across categories. There were decreases in performance even in patients reporting complete recovery without significant symptoms. Medium to large effect sizes were present for summary measures of cognition (eta(2)(p) 0.111), mental health (eta(2)(p) 0.131) and physical health (eta(2)(p) 0.252). Conclusions This large-scale study provides novel insights into cognitive performance at different levels of disability and highlights the importance of processing speed in function in daily life. At upper levels of outcome, any influence of cognition on overall function is markedly attenuated and differences in mental health are salient.Peer reviewe

Podocytes Produce and Secrete Functional Complement C3 and Complement Factor H

Podocytes are an important part of the glomerular filtration barrier and the key player in the development of proteinuria, which is an early feature of complement mediated renal diseases. Complement factors are mainly liver-born and present in circulation. Nevertheless, there is a growing body of evidence for additional sites of complement protein synthesis, including various cell types in the kidney. We hypothesized that podocytes are able to produce complement components and contribute to the local balance of complement activation and regulation. To investigate the relevant balance between inhibiting and activating sides, our studies focused on complement factor H (CFH), an important complement regulator, and on C3, the early key component for complement activation. We characterized human cultured podocytes for the expression and secretion of activating and regulating complement factors, and analyzed the secretion pathway and functional activity. We studied glomerular CFH and C3 expression in puromycin aminonucleoside (PAN) -treated rats, a model for proteinuria, and the physiological mRNA-expression of both factors in murine kidneys. We found, that C3 and CFH were expressed in cultured podocytes and expression levels differed from those in cultivated glomerular endothelial cells. The process of secretion in podocytes was stimulated with interferon gamma and located in the Golgi apparatus. Cultured podocytes could initiate the complement cascade by the splitting of C3, which can be shown by the generation of C3a, a functional C3 split product. C3 contributed to external complement activation. Podocyte-secreted CFH, in conjunction with factor I, was able to split C3b. Podocytes derived from a patient with a CFH mutation displayed impaired cell surface complement regulation. CFH and C3 were synthesized in podocytes of healthy C57Bl/6-mice and were upregulated in podocytes of PAN treated rats. These data show that podocytes produce functionally active complement components, and could therefore influence the local glomerular complement activation and regulation. This modulating effect should therefore be considered in all diseases where glomerular complement activation occurs. Furthermore, our data indicate a potential novel role of podocytes in the innate immune system

A novel topographic parameterization scheme indicates that martian gullies display the signature of liquid water

Martian gullies resemble gullies carved by water on Earth, yet are thought to have formed in an extremely cold (2-driven processes. That this argument persists demonstrates the limitations of morphological interpretations made from 2D images, especially when similar-looking landforms can form by very different processes. To overcome this we have devised a parameterization scheme, based on statistical discriminant analysis and hydrological terrain analysis of meter-scale digital topography data, which can distinguish between dry and wet surface processes acting on a landscape. Applying this approach to new meter-scale topographic datasets of Earth, the Moon and Mars, we demonstrate that martian gullied slopes are dissimilar to dry, gullied slopes on Earth and the Moon, but are similar to both terrestrial debris flows and fluvial gullies. We conclude that liquid water was integral to the process by which martian gullies formed. Finally, our work shows that quantitative 3D analyses of landscape have great potential as a tool in planetary science, enabling remote assessment of processes acting on planetary surfaces

The genome of the protozoan parasite Cystoisospora suis and a reverse vaccinology approach to identify vaccine candidates

Vaccine development targeting protozoan parasites remains challenging, partly due to the complex interactions between these eukaryotes and the host immune system. Reverse vaccinology is a promising approach for direct screening of genome sequence assemblies for new vaccine candidate proteins. Here, we applied this paradigm to Cystoisospora suis, an apicomplexan parasite that causes enteritis and diarrhea in suckling piglets and economic losses in pig production worldwide. Using Next Generation Sequencing we produced an ∼84 Mb sequence assembly for the C. suis genome, making it the first available reference for the genus Cystoisospora. Then, we derived a manually curated annotation of more than 11,000 protein-coding genes and applied the tool Vacceed to identify 1,168 vaccine candidates by screening the predicted C. suis proteome. To refine the set of candidates, we looked at proteins that are highly expressed in merozoites and specific to apicomplexans. The stringent set of candidates included 220 proteins, among which were 152 proteins with unknown function, 17 surface antigens of the SAG and SRS gene families, 12 proteins of the apicomplexan-specific secretory organelles including AMA1, MIC6, MIC13, ROP6, ROP12, ROP27, ROP32 and three proteins related to cell adhesion. Finally, we demonstrated in vitro the immunogenic potential of a C. suis-specific 42 kDa transmembrane protein, which might constitute an attractive candidate for further testing