RESUMO
PURPOSE: With an increasingly older population and rise in incidence of traumatic brain injury (TBI), end-of-life decisions have become frequent. This study investigated the rate of withdrawal of life sustaining treatment (WLST) and compared treatment outcomes in patients with isolated TBI in two Dutch level-I trauma centers. METHODS: From 2011 to 2016, a retrospective cohort study of patients aged ≥ 18 years with isolated moderate-to-severe TBI (Abbreviated Injury Scale (AIS) head ≥ 3) was conducted at the University Medical Center Rotterdam (UMC-R) and the University Medical Center Utrecht (UMC-U). Demographics, radiologic injury characteristics, clinical outcomes, and functional outcomes at 3-6 months post-discharge were collected. RESULTS: The study population included 596 patients (UMC-R: n = 326; UMC-U: n = 270). There were no statistical differences in age, gender, mechanism of injury, and radiologic parameters between both institutes. UMC-R patients had a higher AIShead (UMC-R: 5 [4-5] vs. UMC-U: 4 [4-5], p < 0.001). There was no difference in the prehospital Glasgow Coma Scale (GCS). However, UMC-R patients had lower GCSs in the Emergency Department and used more prehospital sedation. Total in-hospital mortality was 29% (n = 170), of which 71% (n = 123) occurred after WLST. Two percent (n = 10) remained in unresponsive wakefulness syndrome (UWS) state during follow-up. DISCUSSION: This study demonstrated a high WLST rate among deceased patients with isolated TBI. Demographics and outcomes were similar for both centers even though AIShead was significantly higher in UMC-R patients. Possibly, prehospital sedation might have influenced AIS coding. Few patients persisted in UWS. Further research is needed on WLST patients in a broader spectrum of ethics, culture, and complex medical profiles, as it is a growing practice in modern critical care. LEVEL OF EVIDENCE: Level III, retrospective cohort study.
RESUMO
The aim of this study was to introduce and evaluate a contour segmentation method to extract the interfaces of the intima-media complex in carotid B-mode ultrasound images. The method was applied to assess the temporal variation of intima-media thickness during the cardiac cycle. The main methodological contribution of the proposed approach is the introduction of an augmented dimension to process 2-D images in a 3-D space. The third dimension, which is added to the two spatial dimensions of the image, corresponds to the tentative local thickness of the intima-media complex. The method is based on a dynamic programming scheme that runs in a 3-D space generated with a shape-adapted filter bank. The optimal solution corresponds to a single medial axis representation that fully describes the two anatomical interfaces of the arterial wall. The method is fully automatic and does not require any input from the user. The method was trained on 60 subjects and validated on 184 other subjects from six different cohorts and four different medical centers. The arterial wall was successfully segmented in all analyzed images (average pixel size = 57 ± 20 mm), with average segmentation errors of 47 ± 70 mm for the lumen-intima interface, 55 ± 68 mm for the media-adventitia interface and 66 ± 90 mm for the intima-media thickness. The amplitude of the temporal variations in IMT during the cardiac cycle was significantly higher in the diseased population than in healthy volunteers (106 ± 48 vs. 86 ± 34 mm, p = 0.001). The introduced framework is a promising approach to investigate an emerging functional parameter of the arterial wall by assessing the cyclic compression-decompression pattern of the tissues.
