Validation of the Scandinavian guidelines for minor and moderate head trauma in children: protocol for a pragmatic, prospective, observational, multicentre cohort study.

INTRODUCTION: Mild traumatic brain injury is common in children and it can be challenging to accurately identify those in need of urgent medical intervention. The Scandinavian guidelines for management of minor and moderate head trauma in children, the Scandinavian Neurotrauma Committee guideline 2016 (SNC16), were developed to aid in risk stratification and decision-making in Scandinavian emergency departments (EDs). This guideline has been validated externally with encouraging results, but internal validation in the intended healthcare system is warranted prior to broad clinical implementation. OBJECTIVE: We aim to validate the diagnostic accuracy of the SNC16 to predict clinically important intracranial injuries (CIII) in paediatric patients suffering from blunt head trauma, assessed in EDs in Sweden and Norway. METHODS AND ANALYSIS: This is a prospective, pragmatic, observational cohort study. Children (aged 0-17 years) with blunt head trauma, presenting with a Glasgow Coma Scale of 9-15 within 24 hours postinjury at an ED in 1 of the 16 participating hospitals, are eligible for inclusion. Included patients are assessed and managed according to the clinical management routines of each hospital. Data elements for risk stratification are collected in an electronic case report form by the examining doctor. The primary outcome is defined as CIII within 1 week of injury. Secondary outcomes of importance include traumatic CT findings, neurosurgery and 3-month outcome. Diagnostic accuracy of the SNC16 to predict endpoints will be assessed by point estimate and 95% CIs for sensitivity, specificity, likelihood ratio, negative predictive value and positive predictive value. ETHICS AND DISSEMINATION: The study is approved by the ethical board in both Sweden and Norway. Results from this validation will be published in scientific journals, and a tailored development and implementation process will follow if the SNC16 is found safe and effective. TRIAL REGISTRATION NUMBER: NCT05964764.

Management of traumatic brain injury in adult-A cross-sectional national study.

Background: Mild traumatic brain injury (mTBI) is a common cause for seeking care. Previous studies have shown considerable variations in TBI management. New guidelines may have influenced management routines. Methods: This is a descriptive cross-sectional study, collecting data through structured questionnaires. All Swedish emergency hospitals that manage and treat adult patients with mTBI (Reaction Level Scale [RLS] 1-3, Glasgow Coma Scale [GCS] 13-15, age > 18 years) for the initial 24 h after injury were included in this study. Results: The response rate among hospitals fulfilling the study criteria's was 61/67 (91%). We observed a distinct predominance of nonspecialists being responsible for the initial management of these patients, with general surgeons and ED-physicians being the dominating specialties. A total of 45/61 (74%) of the hospitals use a guideline when managing TBI, with 12 hospitals (20%) stating that no guideline was used. Conclusion: In general, established guidelines are used for the management of TBI in Sweden. However, some of these are outdated and several hospitals used local guidelines not based upon reliable evidence-based methodology. Most patients with TBI are managed by nonspecialist doctors, stressing the need of a reliable guideline.

Management of paediatric traumatic brain injury in Sweden: a national cross-sectional survey.

BACKGROUND: Previous studies have shown variations in management routines for children with traumatic brain injury (TBI) in Sweden. It is unknown if this management has changed after the publication of the Scandinavian Neurotrauma Committee guidelines in 2016 (SNC16). Also, knowledge of current practice routines may guide development of an efficient implementation strategy for the guidelines. The aim of this study is therefore to describe current management routines in paediatric TBI on a hospital/organizational level in Sweden. Secondary aims are to analyse differences in management over time, to assess the current dissemination status of the SNC16 guideline and to analyse possible variations between hospitals. METHODS: This is a sequential, cross-sectional, structured survey in five sections, covering initial management routines for paediatric TBI in Sweden. Respondents, with profound knowledge of local management routines and recommendations, were identified for all Swedish hospitals with an emergency department managing children (age 0-17 year) via phone/mail before distribution of the survey. Responses were collected via an on-line survey system during June 2020-March 2021. Data are presented as descriptive statistics and comparisons were made using Fisher exact test, when applicable. RESULTS: 71 of the 76 identified hospitals managed patients with TBI of all ages and 66 responded (response rate 93%). 56 of these managed children and were selected for further analysis. 76% (42/55) of hospitals have an established guideline to aid in clinical decision making. Children with TBI are predominately managed by inexperienced doctors (84%; 47/56), primarily from non-paediatric specialities (75%; 42/56). Most hospitals (75%; 42/56) have the possibility to admit and observe children with TBI of varying degrees and almost all centres have complete access to neuroradiology (96%; 54/56). In larger hospitals, it was more common for nurses to discharge patients without doctor assessment when compared to smaller hospitals (6/9 vs. 9/47; p < 0.001). Presence of established guidelines (14/51 vs. 42/55; p < 0.001) and written observation routines (16/51 vs. 29/42; p < 0.001) in hospitals have increased significantly since 2006. CONCLUSIONS: TBI management routines for children in Sweden still vary, with some differences occurring over time. Use of established guidelines, written observation routines and information for patients/guardians have all improved. These results form a baseline for current management and may also aid in guideline implementation.

Dynamics of IgG-avidity and antibody levels after Covid-19.

BACKGROUND: A potentially important aspect of the humoral immune response to Covid-19 is avidity, the overall binding strength between antibody and antigen. As low avidity is associated with a risk of re- infection in several viral infections, avidity might be of value to predict risk for reinfection with covid-19. OBJECTIVES: The purpose of this study was to describe the maturation of IgG avidity and the antibody-levels over time in patients with PCR-confirmed non-severe covid-19. STUDY DESIGN: Prospective longitudinal cohort study including patients with RT-PCR confirmed covid-19. Blood samples were drawn 1, 3 and 6 months after infection. Antibody levels and IgG-avidity were analysed. RESULTS: The majority had detectable s- and n-antibodies (88,1%, 89,1%, N = 75). The level of total n-antibodies significantly increased from 1 to 3 months (median value 28,3 vs 39,3 s/co, p<0.001) and significantly decreased from 3 to 6 months (median value 39,3 vs 17,1 s/co, p<0.001). A significant decrease in the IgG anti-spike levels (median value 37,6, 24,1 and 18,2 RU/ml, p<0.001) as well as a significant increase in the IgG-avidity index (median values 51,6, 66,0 and 71,0%, p<0.001) were seen from 1 to 3 to 6 months. CONCLUSION: We found a significant ongoing increase in avidity maturation after Covid-19 whilst the levels of antibodies were declining, suggesting a possible aspect of long-term immunity.