Predictors of Access to Rehabilitation in the Year Following Traumatic Brain Injury : A European Prospective and Multicenter Study

Background Although rehabilitation is beneficial for individuals with traumatic brain injury (TBI), a significant proportion of them do not receive adequate rehabilitation after acute care. Objective Therefore, the goal of this prospective and multicenter study was to investigate predictors of access to rehabilitation in the year following injury in patients with TBI. Methods Data from a large European study (CENTER-TBI), including TBIs of all severities between December 2014 and December 2017 were used (N = 4498 patients). Participants were dichotomized into those who had and those who did not have access to rehabilitation in the year following TBI. Potential predictors included sociodemographic factors, psychoactive substance use, preinjury medical history, injury-related factors, and factors related to medical care, complications, and discharge. Results In the year following traumatic injury, 31.4% of patients received rehabilitation services. Access to rehabilitation was positively and significantly predicted by female sex (odds ratio [OR] = 1.50), increased number of years of education completed (OR = 1.05), living in Northern (OR = 1.62; reference: Western Europe) or Southern Europe (OR = 1.74), lower prehospital Glasgow Coma Scale score (OR = 1.03), higher Injury Severity Score (OR = 1.01), intracranial (OR = 1.33) and extracranial (OR = 1.99) surgery, and extracranial complication (OR = 1.75). On contrast, significant negative predictors were lack of preinjury employment (OR = 0.80), living in Central and Eastern Europe (OR = 0.42), and admission to hospital ward (OR = 0.47; reference: admission to intensive care unit) or direct discharge from emergency room (OR = 0.24). Conclusions Based on these findings, there is an urgent need to implement national and international guidelines and strategies for access to rehabilitation after TBI.Peer reviewe

Tracheal intubation in traumatic brain injury: a multicentre prospective observational study

Background We aimed to study the associations between pre- and in-hospital tracheal intubation and outcomes in traumatic brain injury (TBI), and whether the association varied according to injury severity. Methods Data from the international prospective pan-European cohort study, Collaborative European NeuroTrauma Effectiveness Research for TBI (CENTER-TBI), were used (n=4509). For prehospital intubation, we excluded self-presenters. For in-hospital intubation, patients whose tracheas were intubated on-scene were excluded. The association between intubation and outcome was analysed with ordinal regression with adjustment for the International Mission for Prognosis and Analysis of Clinical Trials in TBI variables and extracranial injury. We assessed whether the effect of intubation varied by injury severity by testing the added value of an interaction term with likelihood ratio tests. Results In the prehospital analysis, 890/3736 (24%) patients had their tracheas intubated at scene. In the in-hospital analysis, 460/2930 (16%) patients had their tracheas intubated in the emergency department. There was no adjusted overall effect on functional outcome of prehospital intubation (odds ratio=1.01; 95% confidence interval, 0.79–1.28; P=0.96), and the adjusted overall effect of in-hospital intubation was not significant (odds ratio=0.86; 95% confidence interval, 0.65–1.13; P=0.28). However, prehospital intubation was associated with better functional outcome in patients with higher thorax and abdominal Abbreviated Injury Scale scores (P=0.009 and P=0.02, respectively), whereas in-hospital intubation was associated with better outcome in patients with lower Glasgow Coma Scale scores (P=0.01): in-hospital intubation was associated with better functional outcome in patients with Glasgow Coma Scale scores of 10 or lower. Conclusion The benefits and harms of tracheal intubation should be carefully evaluated in patients with TBI to optimise benefit. This study suggests that extracranial injury should influence the decision in the prehospital setting, and level of consciousness in the in-hospital setting. Clinical trial registration NCT02210221

Health-related quality of life after traumatic brain injury : deriving value sets for the QOLIBRI-OS for Italy, The Netherlands and The United Kingdom

Purpose The Quality of Life after Brain Injury overall scale (QOLIBRI-OS) measures health-related quality of life (HRQoL) after traumatic brain injury (TBI). The aim of this study was to derive value sets for the QOLIBRI-OS in three European countries, which will allow calculation of utility scores for TBI health states. Methods A QOLIBRI-OS value set was derived by using discrete choice experiments (DCEs) and visual analogue scales (VAS) in general population samples from the Netherlands, United Kingdom and Italy. A three-stage procedure was used: (1) A selection of health states, covering the entire spectrum of severity, was defined; (2) General population samples performed the health state valuation task using a web-based survey with three VAS questions and an at random selection of sixteen DCEs; (3) DCEs were analysed using a conditional logistic regression and were then anchored on the VAS data. Utility scores for QOLIBRI-OS health states were generated resulting in estimates for all potential health states. Results The questionnaire was completed by 13,623 respondents. The biggest weight increase for all attributes is seen from "slightly" to "not at all satisfied", resulting in the largest impact on HRQoL. "Not at all satisfied with how brain is working" should receive the greatest weight in utility calculations in all three countries. Conclusion By transforming the QOLIBRI-OS into utility scores, we enabled the application in economic evaluations and in summary measures of population health, which may be used to inform decision-makers on the best interventions and strategies for TBI patients.Peer reviewe

Frequency of fatigue and its changes in the first 6 months after traumatic brain injury: results from the CENTER-TBI study

Background Fatigue is one of the most commonly reported subjective symptoms following traumatic brain injury (TBI). The aims were to assess frequency of fatigue over the first 6 months after TBI, and examine whether fatigue changes could be predicted by demographic characteristics, injury severity and comorbidities. Methods Patients with acute TBI admitted to 65 trauma centers were enrolled in the study Collaborative European NeuroTrauma Effectiveness Research in TBI (CENTER-TBI). Subjective fatigue was measured by single item on the Rivermead Post-Concussion Symptoms Questionnaire (RPQ), administered at baseline, three and 6 months postinjury. Patients were categorized by clinical care pathway: admitted to an emergency room (ER), a ward (ADM) or an intensive care unit (ICU). Injury severity, preinjury somatic- and psychiatric conditions, depressive and sleep problems were registered at baseline. For prediction of fatigue changes, descriptive statistics and mixed effect logistic regression analysis are reported. Results Fatigue was experienced by 47% of patients at baseline, 48% at 3 months and 46% at 6 months. Patients admitted to ICU had a higher probability of experiencing fatigue than those in ER and ADM strata. Females and individuals with lower age, higher education, more severe intracranial injury, preinjury somatic and psychiatric conditions, sleep disturbance and feeling depressed postinjury had a higher probability of fatigue. Conclusion A high and stable frequency of fatigue was found during the first 6 months after TBI. Specific socio-demographic factors, comorbidities and injury severity characteristics were predictors of fatigue in this study

Vibrational spectroscopy for the triage of traumatic brain injury computed tomography priority and hospital admissions

Computed tomography (CT) brain imaging is routinely used to support clinical decision-making in patients with traumatic brain injury (TBI). Only 7% of scans, however, demonstrate evidence of TBI. The other 93% of scans contribute a significant cost to the healthcare system and a radiation risk to patients. There may be better strategies to identify which patients, particularly those with mild TBI, are at risk of deterioration and require hospital admission. We introduce a blood serum liquid biopsy that utilizes attenuated total reflectance (ATR)-Fourier transform infrared (FTIR) spectroscopy with machine learning algorithms as a decision-making tool to identify which patients with mild TBI will most likely present with a positive CT scan. Serum samples were obtained from patients (n = 298) patients who had acquired a TBI and were enrolled in CENTER-TBI and from asymptomatic control patients (n = 87). Injury patients (all severities) were stratified against non-injury controls. The cohort with mild TBI was further examined by stratifying those who had at least one CT abnormality against those who had no CT abnormalities. The test performed exceptionally well in classifications of patients with mild injury versus non-injury controls (sensitivity = 96.4% and specificity = 98.0%) and also provided a sensitivity of 80.2% when stratifying mild patients with at least one CT abnormality against those without. The results provided illustrate the test ability to identify four of every five CT abnormalities and show great promise to be introduced as a triage tool for CT priority in patients with mild TBI

A UPFC for voltage regulation in LV distribution feeders with a DC-Link ripple voltage suppression technique

The large-scale integration of distributed photovoltaic generation causes several power quality issues in low voltage (LV) distribution networks. Network voltage profile variations severely affect the LV distribution networks. The four-leg unified power flow controller (4L-UPFC) has series and shunt converters that can address the power quality issues. However, instantaneous power theory shows that second-order harmonic voltage (2ωHV) appears at the dc-link capacitor of the 4L-UPFC during any unbalanced operations. This article proposes control strategies for series and shunt converters that will simultaneously regulate the load voltages of a distribution feeder while suppressing the 2ωHV term on the dc-link of the UPFC. A controlled negative sequence current from the shunt converter is used to suppress the 2ωHV term on the dc-link. The active suppression of the 2ωHV term allows electrolytic capacitors to be replaced with small long life ceramic or film capacitors, and this does not require additional passive compensation. Stability analysis of the control loops demonstrates the overall stability of the converter system. The proposed control methods have been implemented on a Texas DSP (F28377D). An experimental demonstration on a laboratory scale prototype shows that the proposed control methods can effectively regulate the load voltages at LV distribution feeders and suppress the 2ωHV on the dc-link of UPFC during unbalanced loads and supply conditions. © 1972-2012 IEEE

Rhizome, root/sediment interactions, aerenchyma and internal pressure changes in seagrasses

© Springer International Publishing AG, part of Springer Nature 2018. Life in seawater presents several challenges for seagrasses owing to low O 2 and CO 2 solubility and slow gas diffusion rates. Seagrasses have evolved numerous adaptations to these environmental conditions including porous tissue providing low-resistance internal gas channels (aerenchyma) and carbon concentration mechanisms involving the enzyme carbonic anhydrase. Moreover, seagrasses grow in reduced, anoxic sediments, and aerobic metabolism in roots and rhizomes therefore has to be sustained via rapid O 2 transport through the aerenchyma. Tissue aeration is driven by internal concentration gradients between leaves and belowground tissues, where the leaves are the source of O 2 and the rhizomes and roots function as O 2 sinks. Inadequate internal aeration e.g., due to low O 2 availability in the surrounding water during night time, can lead to sulphide intrusion into roots and rhizomes, which has been linked to enhanced seagrass mortality. Under favourable conditions, however, seagrasses leak O 2 and dissolved organic carbon into the rhizosphere, where it maintains oxic microzones protecting the plant against reduced phytotoxic compounds and generates dynamic chemical microgradients that modulate the rhizosphere microenvironment. Local radial O 2 loss from belowground tissues of seagrasses leads to sulphide oxidation in the rhizosphere, which generates protons and results in local acidification. Such low-pH microniches can lead to dissolution of carbonates and protolytic phosphorus solubilisation in carbonate-rich sediments. The seagrass rhizosphere is also characterised by numerous high-pH microniches indicative of local stimulation of proton consuming microbial processes such as sulphate reduction via root/rhizome exudates and/or release of alkaline substances. High sediment pH shifts the sulphide speciation away from H 2 S towards non-tissue-penetrating HS - ions, which can alleviate the belowground tissue exposure to phytotoxic H 2 S. High sulphide production can also lead to iron and phosphorus mobilization through sulphide-induced reduction of insoluble Fe(III)oxyhydroxides to dissolved Fe(II) with concomitant phosphorus release to the porewater. Adequate internal tissue aeration is thus of vital importance for seagrasses as it ensures aerobic metabolism in distal parts of the roots and provides protection against intrusion of phytotoxins from the surrounding sediment