Liberal or Restrictive Transfusion Strategy in Patients with Traumatic Brain Injury.

BACKGROUND: The effect of a liberal transfusion strategy as compared with a restrictive strategy on outcomes in critically ill patients with traumatic brain injury is unclear. METHODS: We randomly assigned adults with moderate or severe traumatic brain injury and anemia to receive transfusion of red cells according to a liberal strategy (transfusions initiated at a hemoglobin level of ≤10 g per deciliter) or a restrictive strategy (transfusions initiated at ≤7 g per deciliter). The primary outcome was an unfavorable outcome as assessed by the score on the Glasgow Outcome Scale-Extended at 6 months, which we categorized with the use of a sliding dichotomy that was based on the prognosis of each patient at baseline. Secondary outcomes included mortality, functional independence, quality of life, and depression at 6 months. RESULTS: A total of 742 patients underwent randomization, with 371 assigned to each group. The analysis of the primary outcome included 722 patients. The median hemoglobin level in the intensive care unit was 10.8 g per deciliter in the group assigned to the liberal strategy and 8.8 g per deciliter in the group assigned to the restrictive strategy. An unfavorable outcome occurred in 249 of 364 patients (68.4%) in the liberal-strategy group and in 263 of 358 (73.5%) in the restrictive-strategy group (adjusted absolute difference, restrictive strategy vs. liberal strategy, 5.4 percentage points; 95% confidence interval, -2.9 to 13.7). Among survivors, a liberal strategy was associated with higher scores on some but not all the scales assessing functional independence and quality of life. No association was observed between the transfusion strategy and mortality or depression. Venous thromboembolic events occurred in 8.4% of the patients in each group, and acute respiratory distress syndrome occurred in 3.3% and 0.8% of patients in the liberal-strategy and restrictive-strategy groups, respectively. CONCLUSIONS: In critically ill patients with traumatic brain injury and anemia, a liberal transfusion strategy did not reduce the risk of an unfavorable neurologic outcome at 6 months. (Funded by the Canadian Institutes of Health Research and others; HEMOTION ClinicalTrials.gov number, NCT03260478.).

The effectiveness of stimulus control in cognitive behavioural therapy for insomnia in adults: A systematic review and network meta-analysis.

Stimulus control is part of the widely used cognitive behavioural therapy for insomnia. However, there is a lack of knowledge about its mechanisms of action and effectiveness when used alone. This systematic review with network meta-analysis aimed to evaluate stimulus control efficacy when used alone compared with cognitive behavioural therapy for insomnia or its components. The review also documented stimulus control mechanisms of action proposed by the authors. A search was conducted in several bibliographic databases (MEDLINE, PsycINFO, Embase, CINAHL, Psychology Behavioural Sciences Collection, Web of Science, and Cochrane Library) and in two registers from 1972 to June 2022. Randomised studies with adult participants presenting a diagnosis of insomnia and including at least one stimulus control instruction in a treatment group were included. Risk of bias was assessed with the Quality Assessment of Controlled Intervention Studies. Twenty-three studies were included and three network meta-analyses were conducted. The quality of included studies was generally poor. Results indicate that stimulus control is an effective intervention to improve insomnia compared with control conditions. Not all stimulus control instructions seem essential, especially those known to recondition the bedroom for sleep. The review challenges the classical conditioning hypothesis. Results should be interpreted cautiously given the small number of studies included, bias risk, and inconsistencies in the network meta-analysis. Rigorous research is needed in evaluating stimulus control efficacy and mechanisms.

Injury outcomes across Canadian trauma systems: a historical cohort study.

PURPOSE: Most North American trauma systems have designated trauma centres (TCs) including level I (ultraspecialized high-volume metropolitan centres), level II (specialized medium-volume urban centres), and/or level III (semirural or rural centres). Trauma system configuration varies across provinces and it is unclear how these differences influence patient distributions and outcomes. We aimed to compare patient case mix, case volumes, and risk-adjusted outcomes of adults with major trauma admitted to designated level I, II, and III TCs across Canadian trauma systems. METHODS: In a national historical cohort study, we extracted data from Canadian provincial trauma registries on major trauma patients treated between 2013 and 2018 in all designated level I, II, or III TCs in British Columbia, Alberta, Quebec, and Nova Scotia; level I and II TCs in New Brunswick; and four TCs in Ontario. We used multilevel generalized linear models to compare mortality and intensive care unit (ICU) admission and competitive risk models for hospital and ICU length of stay (LOS). Ontario could not be included in outcome comparisons because there were no population-based data from this province. RESULTS: The study sample comprised 50,959 patients. Patient distributions in level I and II TCs were similar across provinces but we observed significant differences in case mix and volumes for level III TCs. There was low variation in risk-adjusted mortality and LOS across provinces and TCs but interprovincial and intercentre variation in risk-adjusted ICU admission was high. CONCLUSIONS: Our results suggest that differences in the functional role of TCs according to their designation level across provinces leads to significant variations in the distribution of patients, case volumes, resource use, and clinical outcomes. These results highlight opportunities to improve Canadian trauma care and underline the need for standardized population-based injury data to support national quality improvement efforts.

RéSUMé: OBJECTIF: La plupart des systèmes de traumatologie nord-américains disposent de centres de traumatologie (CT) désignés, y compris de niveau I (centres métropolitains ultraspécialisés à volume élevé), de niveau II (centres urbains spécialisés à volume moyen) et/ou de niveau III (centres semi-ruraux ou ruraux). La configuration des systèmes de traumatologie varie d'une province à l'autre et nous ne savons pas comment ces différences influent sur la répartition de la patientèle et sur les issues. Notre objectif était de comparer le mélange de cas des patient·es, le volume de cas et les issues ajustées en fonction du risque des adultes ayant subi un traumatisme majeur admis·es dans des CT désignés de niveaux I, II et III dans l'ensemble des systèmes de traumatologie canadiens. MéTHODE: Dans une étude de cohorte historique nationale, nous avons extrait des données des registres provinciaux canadiens de traumatologie sur les patient·es ayant subi un traumatisme majeur traité·es entre 2013 et 2018 dans tous les CT désignés de niveau I, II ou III en Colombie-Britannique, en Alberta, au Québec et en Nouvelle-Écosse, les CT de niveau I et II au Nouveau-Brunswick, et dans quatre CT en Ontario. Nous avons utilisé des modèles linéaires généralisés à plusieurs niveaux pour comparer la mortalité, les admissions en unité de soins intensifs (USI) et les modèles de risque compétitif pour la durée du séjour à l'hôpital et à l'USI. L'Ontario n'a pas pu être inclus dans les comparaisons des devenirs parce qu'il n'y avait pas de données démographiques pour cette province. RéSULTATS: L'échantillon de l'étude comptait 50 959 patient·es. La répartition des patient·es dans les CT de niveaux I et II était similaire d'une province à l'autre, mais nous avons observé des différences significatives dans le mélange des cas et les volumes pour les CT de niveau III. Il y avait une faible variation de la mortalité ajustée en fonction du risque et des durées de séjour entre les provinces et les CT, mais la variation interprovinciale et intercentre des admissions à l'USI ajustées en fonction du risque était élevée. CONCLUSION: Nos résultats suggèrent que les différences dans le rôle fonctionnel des CT selon leur niveau de désignation d'une province à l'autre entraînent des variations importantes dans la répartition des patient·es, le nombre de cas, l'utilisation des ressources et les issues cliniques. Ces résultats mettent en évidence les possibilités d'amélioration des soins de traumatologie au Canada et soulignent la nécessité de disposer de données normalisées sur les blessures dans la population pour appuyer les efforts nationaux d'amélioration de la qualité.

Comparison of trauma care structures, processes and outcomes between the English National Health Service and Quebec, Canada.

BACKGROUND: Comparisons across trauma systems are key to identifying opportunities to improve trauma care. We aimed to compare trauma service structures, processes and outcomes between the English National Health Service (NHS) and the province of Quebec, Canada. METHODS: We conducted a multicentre cohort study including admissions of patients aged older than 15 years with major trauma to major trauma centres (MTCs) from 2014/15 to 2016/17. We compared structures descriptively, and time to MTC and time in the emergency department (ED) using Wilcoxon tests. We compared mortality, and hospital and intensive care unit (ICU) length of stay (LOS) using multilevel logistic regression with propensity score adjustment, stratified by body region of the worst injury. RESULTS: The sample comprised 36 337 patients from the NHS and 6484 patients from Quebec. Structural differences in the NHS included advanced prehospital medical teams (v. "scoop and run" in Quebec), helicopter transport (v. fixed-wing aircraft) and trauma team leaders. The median time to an MTC was shorter in Quebec than in the NHS for direct transports (1 h v. 1.5 h, p < 0.001) but longer for transfers (2.5 h v. 6 h, p < 0.001). Time in the ED was longer in Quebec than in the NHS (6.5 h v. 4.0 h, p < 0.001). The adjusted odds of death were higher in Quebec for head injury (odds ratio [OR] 1.28, 95% confidence interval [CI] 1.09-1.51) but lower for thoracoabdominal injuries (OR 0.69, 95% CI 0.52-0.90). The adjusted median hospital LOS was longer for spine, torso and extremity injuries in the NHS than in Quebec, and the median ICU LOS was longer for spine injuries. CONCLUSION: We observed significant differences in the structure of trauma care, delays in access and risk-adjusted outcomes between Quebec and the NHS. Future research should assess associations between structures, processes and outcomes to identify opportunities for quality improvement.

Development and Validation of a Hospital Indicator of Activity-Based Costs for Injury Admissions.

OBJECTIVES: To develop a hospital indicator of resource use for injury admissions. METHODS: We focused on resource use for acute injury care and therefore adopted a hospital perspective. We included patients ≥16 years old with an Injury Severity Score >9 admitted to any of the 57 trauma centers of an inclusive Canadian trauma system from 2014 to 2018. We extracted data from the trauma registry and hospital financial reports and estimated resource use with activity-based costing. We developed risk-adjustment models by trauma center designation level (I/II and III/IV) for the whole sample, traumatic brain injuries, thoraco-abdominal injuries, orthopedic injuries, and patients ≥65 years old. Candidate variables were selected using bootstrap resampling. We performed benchmarking by comparing the adjusted mean cost in each center, obtained using shrinkage estimates, to the provincial mean. RESULTS: We included 38 713 patients. The models explained between 12% and 36% (optimism-corrected r2) of the variation in resource use. In the whole sample and in all subgroups, we identified centers with higher- or lower-than-expected resource use across level I/II and III/IV centers. CONCLUSIONS: We propose an algorithm to produce the indicator using data routinely collected in trauma registries to prompt targeted exploration of potential areas for improvement in resource use for injury admissions. The r2 of our models suggest that between 64% and 88% of the variation in resource use for injury care is dictated by factors other than patient baseline risk.

Perioperative Use of Gabapentinoids for the Management of Postoperative Acute Pain: A Systematic Review and Meta-analysis.

BACKGROUND: Widely used for acute pain management, the clinical benefit from perioperative use of gabapentinoids is uncertain. The aim of this systematic review was to assess the analgesic effect and adverse events with the perioperative use of gabapentinoids in adult patients. METHODS: Randomized controlled trials studying the use of gabapentinoids in adult patients undergoing surgery were included. The primary outcome was the intensity of postoperative acute pain. Secondary outcomes included the intensity of postoperative subacute pain, incidence of postoperative chronic pain, cumulative opioid use, persistent opioid use, lengths of stay, and adverse events. The clinical significance of the summary estimates was assessed based on established thresholds for minimally important differences. RESULTS: In total, 281 trials (N = 24,682 participants) were included in this meta-analysis. Compared with controls, gabapentinoids were associated with a lower postoperative pain intensity (100-point scale) at 6 h (mean difference, -10; 95% CI, -12 to -9), 12 h (mean difference, -9; 95% CI, -10 to -7), 24 h (mean difference, -7; 95% CI, -8 to -6), and 48 h (mean difference, -3; 95% CI, -5 to -1). This effect was not clinically significant ranging below the minimally important difference (10 points out of 100) for each time point. These results were consistent regardless of the type of drug (gabapentin or pregabalin). No effect was observed on pain intensity at 72 h, subacute and chronic pain. The use of gabapentinoids was associated with a lower risk of postoperative nausea and vomiting but with more dizziness and visual disturbance. CONCLUSIONS: No clinically significant analgesic effect for the perioperative use of gabapentinoids was observed. There was also no effect on the prevention of postoperative chronic pain and a greater risk of adverse events. These results do not support the routine use of pregabalin or gabapentin for the management of postoperative pain in adult patients.

Effect of age of transfused red blood cells on neurologic outcome following traumatic brain injury (ABLE-tbi Study): a nested study of the Age of Blood Evaluation (ABLE) trial.

BACKGROUND: Anemia is common in critically ill patients with traumatic brain injury, and often requires red blood cell transfusion. Studies suggest that prolonged storage causes lesions of the red blood cells, including a decreased ability to carry oxygen. Considering the susceptibility of the brain to hypoxemia, victims of traumatic brain injury may thus be more vulnerable to exposure to older red blood cells. METHODS: Our study aimed to ascertain whether the administration of fresh red blood cells (seven days or less) results in a better neurologic outcome compared with standard red blood cells in critically ill patients with traumatic brain injury requiring transfusion. The Age of Blood Evaluation in traumatic brain injury (ABLE-tbi) study was a nested study within the ABLE study (ISRCTN44878718). Our primary outcome was the extended Glasgow Outcome Scale (GOSe) at six months. RESULTS: In the ABLE study, 217 subjects suffered a traumatic brain injury: 110 in the fresh group, and 107 in the standard group. In the fresh group, 68 (73.1%) of the patients had an unfavourable neurologic outcome (GOSe ≤ 4) compared with 60 (64.5%) in the standard group (P = 0.21). Using a sliding dichotomy approach, we observed no overall effect of fresh red blood cells on neurologic outcome (odds ratio [OR], 1.34; 95% confidence interval [CI], 0.72 to 2.50; P = 0.35) but observed differences across prognostic bands with a decreased odds of unfavourable outcome in patients with the best prognosis at baseline (OR, 0.33; 95% CI, 0.11 to 0.96; P = 0.04) but an increased odds in those with intermediate and worst baseline prognosis (OR, 5.88; 95% CI,1.66 to 20.81; P = 0.006; and OR, 1.67; 95% CI, 0.53 to 5.30; P = 0.38, respectively). CONCLUSION: Overall, transfusion of fresh red blood cells was not associated with a better neurologic outcome at six months in critically ill patients with traumatic brain injury. Nevertheless, we cannot exclude a differential effect according to the patient baseline prognosis. TRIAL REGISTRATION: ABLE study (ISRCTN44878718); registered 22 August, 2008.

Intensity of care and withdrawal of life-sustaining therapies in severe traumatic brain injury patients: a post-hoc analysis of a multicentre retrospective cohort study.

PURPOSE: The intensity of care provided to critically ill patients has been shown to be associated with mortality. In patients with traumatic brain injury (TBI), specialized neurocritical care is often required, but whether it affects clinically significant outcomes is unknown. We aimed to determine the association of the intensity of care on mortality and the incidence of withdrawal of life-sustaining therapies in critically ill patients with severe TBI. METHODS: We conducted a post hoc analysis of a multicentre retrospective cohort study of critically ill adult patients with severe TBI. We defined the intensity of care as a daily cumulative sum of interventions during the intensive care unit stay. Our outcome measures were all-cause hospital mortality and the incidence of withdrawal of life-sustaining therapies. RESULTS: Seven hundred sixteen severe TBI patients were included in our study. Most were male (77%) with a mean (standard deviation) age of 42 (20.5) yr and a median [interquartile range] Glasgow Coma Scale score of 3 [3-6]. Our results showed an association between the intensity of care and mortality (hazard ratio [HR], 0.69; 95% confidence interval [CI], 0.63 to 0.74) and the incidence of withdrawal of life-sustaining therapy (HR, 0.73; 95% CI, 0.67 to 0.79). CONCLUSION: In general, more intense care was associated with fewer deaths and a lower incidence of withdrawal of life-sustaining therapies in critically ill patients with severe TBI.

Timed Up and Go predicts functional decline in older patients presenting to the emergency department following minor trauma†.

Background: there is no standardised test for assessing mobility in the Emergency Department (ED). Objective: we wished to evaluate the relationship between the Timed Up and Go (TUG) and frailty, functional decline and falls in community dwelling elders that present to the ED following minor trauma. Methods: this was a secondary analysis of a prospective cohort study conducted at eight Canadian hospitals. Evaluations included: TUG; Study of Osteoporotic Fractures Frailty Index; Older American Resources and Service Functional Scale; and self-reported falls. Of note, 3- and 6-month follow-up was conducted. Generalised linear model with log-binomial distribution was utilised. Relative risks (RR) and 95% CI were calculated. Results: TUG scores were available for 911/2918 patients, mean age 76.2 (SD 7.8) and 57.9% female. There was an association between TUG scores and frailty (P < 0.05) and functional decline at 3 (P < 0.05) and 6 (P < 0.05) months but not self-reported falls. For TUG scores 10-19 seconds, 20-29 seconds and ≥30 seconds, respectively: (i) frailty RR (95% CI): 1.8 (1.3-2.4), 3.0 (2.2-4.2) and 3.7 (2.6-5.1); (ii) functional decline RR (95% CI): 2.7 (1.1-6.4), 5.5 (2.1-14.3) and 8.9 (3.0-25.8); (iii) falls RR (95% CI): 0.9 (0.5-1.5), 1.3 (0.6-2.5) and 1.1 (0.4-3.5). Conclusion: in community dwelling elders presenting to the ED following minor trauma, TUG scores were associated with frailty and strongly associated with functional decline at 3 and 6 months post injury. TUG scores were not associated with self-reported falls. Use of the TUG in the ED will help identify frail patients at risk of functional decline.

Derivation and validation of a quality indicator of acute care length of stay to evaluate trauma care.

OBJECTIVE: To derive and internally validate a quality indicator (QI) for acute care length of stay (LOS) after admission for injury. BACKGROUND: Unnecessary hospital days represent an estimated 20% of total LOS implying an important waste of resources as well as increased patient exposure to hospital-acquired infections and functional decline. METHODS: This study is based on a multicenter, retrospective cohort from a Canadian provincial trauma system (2005-2010; 57 trauma centers; n = 57,524). Data were abstracted from the provincial trauma registry and the hospital discharge database. Candidate risk factors were identified by expert consensus and selected for model derivation using bootstrap resampling. The validity of the QI was evaluated in terms of interhospital discrimination, construct validity, and forecasting. RESULTS: The risk adjustment model explains 37% of the variation in LOS. The QI discriminates well across trauma centers (coefficient of variation = 0.02, 95% confidence interval: 0.011-0.028) and is correlated with the QI on processes of care (r = -0.32), complications (r = 0.66), unplanned readmissions (r = 0.38), and mortality (r = 0.35). Performance in 2005 to 2007 was predictive of performance in 2008 to 2010 (r = 0.80). CONCLUSIONS: We have developed a QI on the basis of risk-adjusted LOS to evaluate trauma care that can be implemented with routinely collected data. The QI is based on a robust risk adjustment model with good internal and temporal validity, and demonstrates good properties in terms of discrimination, construct validity, and forecasting. This QI can be used to target interventions to reduce LOS, which will lead to more efficient resource use and may improve patient outcomes after injury.

Perioperative Transfusion Practices in Adults Having Noncardiac Surgery.

Surgical patients are often transfused to manage bleeding and anemia. Best practices for red blood cell (RBC) transfusion administration in patient having noncardiac surgery remains controversial and a robust evaluation and description of perioperative transfusion practices is lacking. We characterized perioperative hemoglobin concentrations and transfusion practices from the prospective VISION cohort which included 39,222 patients aged ≥45 years who had inpatient noncardiac surgery. Variations in transfusion practices were analyzed using hierarchical mixed models, and associations with mortality and complications were evaluated using a nested frailty survival model. Within the cohort, 16.1% (n = 6296) were given perioperative RBC transfusions, with the fraction declining from 20% to 13% over the 6-year study period. The proportion of patients transfused varied by surgery type from 6.4% for low-risk operations (i.e., minor surgery) to 31.5% for orthopedic surgeries. Variations were largely associated with patient hemoglobin concentrations, but also with center (range: 3.7%-27.3%) and country (0.4%-25.3%). Even after adjusting for baseline hemoglobin, comorbidities and type of surgery, both center and country were significant sources of variation in transfusion practices. Among transfused participants, 60.4% (n = 3728/6170) had at least 1 hemoglobin concentration ≤80g/L and 86.0% (n = 5305/6170) had at least 1 hemoglobin concentration ≤90g/L, suggesting that relatively restrictive transfusion strategies were used in most. The proportion of patients receiving at least 1 RBC transfusion declined from 20% to 13% over 6 years. However, there was considerable unexplained variation in transfusion practices.

Low-Value Clinical Practices in Pediatric Trauma Care.

Importance: Reducing low-value care has the potential to improve patient experiences and outcomes and decrease the unnecessary use of health care resources. Research suggests that low-value practices (ie, the potential for harm exceeds the potential for benefit) in adult trauma care are frequent and subject to interhospital variation; evidence on low-value practices in pediatric trauma care is lacking. Objective: To estimate the incidence of low-value practices in pediatric trauma care and evaluate interhospital practice variation. Design, Setting, and Participants: A retrospective multicenter cohort study in a Canadian provincial trauma system was conducted. Children younger than 16 years admitted to any of the 59 provincial trauma centers from April 1, 2016, to March 31, 2022, were included. Main Outcomes and Measures: Low-value practices were identified from systematic reviews of clinical practice guidelines on pediatric trauma. The frequencies of low-value practices were evaluated by estimating incidence proportions and cases per 1000 admissions (low if ≤10% and ≤10 cases, moderate if >10% or >10 cases, and high if >10% and >10 cases) were identified. Interhospital variation with intraclass correlation coefficients (ICCs) were assessed (low if <5%, moderate if 5%-20%, and high if >20%). Results: A total of 10 711 children were included (mean [SD] age, 7.4 [4.9] years; 6645 [62%] boys). Nineteen low-value practices on imaging, fluid resuscitation, hospital/intensive care unit admission, specialist consultation, deep vein thrombosis prophylaxis, and surgical management of solid organ injuries were identified. Of these, 14 (74%) could be evaluated using trauma registry data. Five practices had moderate to high frequencies and interhospital variation: head computed tomography in low-risk children (7.1%; 33 per 1000 admissions; ICC, 8.6%), pretransfer computed tomography in children with a clear indication for transfer (67.6%; 4 per 1000 admissions; ICC, 5.7%), neurosurgical consultation in children without clinically important intracranial lesions (11.6%; 13 per 1000 admissions; ICC, 15.8%), hospital admission in isolated mild traumatic brain injury (38.8%; 98 per 1000 admissions; ICC, 12.4%), and hospital admission in isolated minor blunt abdominal trauma (10%; 5 per 1000 admissions; ICC, 31%). Conclusions and Relevance: In this cohort study, low-value practices appeared to be frequent and subject to interhospital variation. These practices may represent priority targets for deimplementation interventions, particularly as they can be measured using routinely collected data.

Clinical Outcomes of Indigenous Versus Non-Indigenous Patients: A Multicenter Retrospective Cohort Study in the Province of Quebec.

INTRODUCTION: Canadian Indigenous populations have a high incidence of poisoning; it has been suggested that care provided to the population living in remote areas is suboptimal. Our study aims to compare the continuum of care of poisoned people in Indigenous communities with those in non-Indigenous communities located in rural regions in the province of Québec. METHODS: We conducted a multicenter retrospective cohort study using data from the Center Antipoison du Québec (CAPQ) over a 2-year period (2016-2017). We evaluated the care trajectory of Indigenous patients suffering of poisoning as compared to non-Indigenous patients living in rural areas. Our primary outcome was the duration of CAPQ involvement in case management. Our secondary outcome was the symptoms severity at the end of case management. RESULTS: Among 491 identified poisoned patients (238 Indigenous/253 non-Indigenous), the duration of CAPQ involvement in case management was 9.4 h [2.9-21.3] for Indigenous patients versus 5.5 h [0.1-14.4] for non-Indigenous patients. No statistically significant difference was found between groups (geometric means ratio (GMR) adjusted = 1.08; [0.84; 1.38]). Results were consistent by age and sex groups. Most patients, in both Indigenous and non-Indigenous, showed mild to moderate symptoms at follow-up (59% vs 54%). One death was registered in each group. The CAPQ received a limited number of calls from the non-conventioned First Nations during the study period. CONCLUSIONS: We did not observe differences on the duration in case management. Perceptions of suboptimal care provided to rural Indigenous population are likely to be related to geographical remoteness rather than ethnicity. Further research is needed to better identify potential factors involved in the continuity of care provided in emergency situations. Another study will be carried out to describe the Indigenous realities and to better understand the results of this study.

Lack of association between four biomarkers and persistent post-concussion symptoms after a mild traumatic brain injury.

Approximately 15 % of individuals who sustained a mild Traumatic Brain Injury (TBI) develop persistent post-concussion symptoms (PPCS). We hypothesized that blood biomarkers drawn in the Emergency Department (ED) could help predict PPCS. The main objective of this project was to measure the association between four biomarkers and PPCS at 90 days post mild TBI. We conducted a prospective cohort study in seven Canadian EDs. Patients aged ≥ 14 years presenting to the ED within 24 h of a mild TBI who were discharged were eligible. Clinical data and blood samples were collected in the ED, and a standardized questionnaire was administered 90 days later to assess the presence of symptoms. The following biomarkers were analyzed: S100B protein, Neuron Specific Enolase (NSE), cleaved-Tau (c-Tau) and Glial Fibrillary Acidic Protein (GFAP). The primary outcome measure was the presence of PPCS at 90 days after trauma. Relative risks and Areas Under the Curve (AUC) were computed. A total of 595 patients were included, and 13.8 % suffered from PPCS at 90 days. The relative risk of PPCS was 0.9 (95 % CI: 0.5-1.8) for S100B ≥ 20 pg/mL, 1.0 (95 % CI: 0.6-1.5) for NSE ≥ 200 pg/mL, 3.4 (95 % CI: 0.5-23.4) for GFAP ≥ 100 pg/mL, and 1.0 (95 % CI: 0.6-1.8) for C-Tau ≥ 1500 pg/mL. AUC were 0.50, 0.50, 0.51 and 0.54, respectively. Among mild TBI patients, S100B protein, NSE, c-Tau or GFAP do not seem to predict PPCS. Future research testing of other biomarkers is needed to determine their usefulness in predicting PPCS.

International comparison of injury care structures, processes, and outcomes between integrated trauma systems in Québec, Canada, and Victoria, Australia.

BACKGROUND: Quality improvement activities in trauma systems are widely based on comparisons between trauma centers within the same system. Comparisons across different trauma systems may reveal further opportunities for quality improvement. OBJECTIVES: This study aimed to compare the integrated trauma systems in Québec, Canada and in Victoria, Australia, regarding their structures, care processes and patient outcomes. METHODOLOGY: The elements recommended by the American College of Surgeons were used to compare trauma systems structures. Comparisons of care processes and patient outcomes were based on data from major trauma admissions extracted from trauma registries (2013 and 2017). Care processes included time to reach a definitive care facility, time spent in the emergency department, and time lapsed before the first head computed tomography (CT) scan. These care processes were compared using a z-test of log-transformed times. Hospital mortality and hospital length of stay (LOS) were compared using indirect standardization based on multiple logistic and linear regression. RESULTS: Major differences in trauma system structure were Advanced Trauma Life Support at the scene of injury (Victoria), the use of validated prehospital triage tools (Québec), and mandatory accreditation of all trauma centers (Québec). Patients in Québec arrived at their definitive care hospital earlier than their counterparts in Victoria (median: 1.93 vs. 2.13 h, p = 0.002), but spent longer in the emergency department (median: 8.23 vs. 5.15 h, p<0.0001) and waited longer before having their first head CT (median: 1.90 vs. 1.52 h, p<0.0001). In-hospital mortality and hospital LOS were higher in Québec than in Victoria (standardized mortality ratio: 1.15, 95% CI: 1.09 - 1.20; standardized LOS ratio: 1.10, 95% CI: 1.09 - 1.11). CONCLUSION: We observed important differences in the structural components and care processes in Québec and Victoria's trauma systems, which might explain some of the observed differences in patient outcomes. This study shows the potential value of international comparisons in trauma care and identifies possible opportunities for quality improvement.

Derivation and validation of actionable quality indicators targeting reductions in complications for injury admissions.

PURPOSE: Approximately, one out of five patients hospitalized following injury will develop at least one hospital complication, more than three times that observed for general admissions. We currently lack actionable Quality Indicators (QI) targeting specific complications in this population. We aimed to derive and validate QI targeting hospital complications for injury admissions and develop algorithms to identify patient charts to review. METHODS: We conducted a retrospective cohort study including patients with major trauma admitted to any level I or II adult trauma center an integrated Canadian trauma system (2014-2019). We used the trauma registry to develop five QI targeting deep vein thrombosis/pulmonary embolism (DVT/PE), decubitus ulcers, delirium, pneumonia and urinary tract infection (UTI). We developed algorithms to identify patient charts to revise on consultation with a group of clinical experts. RESULTS: The study population included 14,592 patients of whom 5.3% developed DVT or PE, 2.7% developed a decubitus ulcer, 8.6% developed delirium, 14.7% developed pneumonia and 7.3% developed UTI. The indicators demonstrated excellent predictive performance (Area Under the Curve 0.81-0.87). We identified 4 hospitals with a higher than average incidence of at least one of the targeted complications. The algorithms identified on average 50 and 20 charts to be reviewed per year for level I and II centers, respectively. CONCLUSION: In line with initiatives to improve the quality of trauma care, we propose QI targeting reductions in hospital complications for injury admissions and algorithms to generate case lists to facilitate the review of patient charts.

Pre- and posttransfer computed tomography imaging in Canadian trauma centers: A multicenter retrospective cohort study.

BACKGROUND: Multiple clinical practice guidelines recommend minimizing radiation in trauma patients but there is a knowledge gap on the importance of this problem for trauma transfers. We aimed to estimate the incidence of pretransfer and repeat posttransfer computed tomography (CT) overall and in patients with an indication for immediate transfer, to assess interhospital practice variation, to identify predictors, and to quantify the influence of pretransfer CT on time to transfer. Methods We conducted a retrospective multicenter cohort study on patients transferred to major trauma centers from 2013 to 2019. Multilevel generalized linear regression was used to generate intraclass correlation coefficients (ICCs) to assess interhospital variation, multilevel logistic regression to generate odds ratios for each predictor, and geometric mean ratios to quantify the influence of CT on time to transfer. Results Of 18,244 patients included, 8501 (47%) had a pretransfer CT and one-quarter (26%) had a repeat posttransfer CT. Interhospital variation was moderate for pretransfer CT (5%-66%, ICC 12.5%) and for repeat posttransfer CT (7%-44%, ICC 14.7%). Pretransfer imaging was more frequent in elders and in males and repeat posttransfer imaging decreased over the study period but was more frequent in patients transferred in from Level III/IV centers than nondesignated hospitals. Time to transfer was doubled in patients who had a pretransfer CT. CONCLUSIONS: Results suggest that pretransfer CT and repeat posttransfer CT are frequent and are subject to significant practice variation. In addition, pretransfer CT is associated with increased times to transfer though additional studies are needed to demonstrate causation. These results highlight potential opportunities to reduce low-value imaging for trauma transfers.

Post-Concussion Symptoms Rule: Derivation and Validation of a Clinical Decision Rule for Early Prediction of Persistent Symptoms after a Mild Traumatic Brain Injury.

Mild traumatic brain injury (mTBI) is a common problem. Depending on diagnostic criteria, 13 to 62% of those patients develop persistent post-concussion symptoms (PPCS). The main objective of this prospective multi-center study is to derive and validate a clinical decision rule (CDR) for the early prediction of PPCS. Patients aged ≥14 years were included if they presented to one of our seven participating emergency departments (EDs) within 24 h of an mTBI. Clinical data were collected in the ED, and symptom evolution was assessed at 7, 30 and 90 days post-injury using the Rivermead Post-Concussion Questionnaire (RPQ). The primary outcome was PPCS at 90 days after mTBI. A predictive model called the Post-Concussion Symptoms Rule (PoCS Rule) was developed using the methodological standards for CDR. Of the 1083 analyzed patients (471 and 612 for the derivation and validation cohorts, respectively), 15.6% had PPCS. The final model included the following factors assessed in the ED: age, sex, history of prior TBI or mental health disorder, headache in ED, cervical sprain and hemorrhage on computed tomography. The 7-day follow-up identified additional risk factors: headaches, sleep disturbance, fatigue, sensitivity to light, and RPQ ≥21. The PoCS Rule had a sensitivity of 91.4% and 89.6%, a specificity of 53.8% and 44.7% and a negative predictive value of 97.2% and 95.8% in the derivation and validation cohorts, respectively. The PoCS Rule will help emergency physicians quickly stratify the risk of PPCS in mTBI patients and better plan post-discharge resources.

Haemoglobin transfusion threshold in traumatic brain injury optimisation (HEMOTION): a multicentre, randomised, clinical trial protocol.

INTRODUCTION: Traumatic brain injury (TBI) is the leading cause of mortality and long-term disability in young adults. Despite the high prevalence of anaemia and red blood cell transfusion in patients with TBI, the optimal haemoglobin (Hb) transfusion threshold is unknown. We undertook a randomised trial to evaluate whether a liberal transfusion strategy improves clinical outcomes compared with a restrictive strategy. METHODS AND ANALYSIS: HEMOglobin Transfusion Threshold in Traumatic Brain Injury OptimizatiON is an international pragmatic randomised open label blinded-endpoint clinical trial. We will include 742 adult patients admitted to an intensive care unit (ICU) with an acute moderate or severe blunt TBI (Glasgow Coma Scale ≤12) and a Hb level ≤100 g/L. Patients are randomly allocated using a 1:1 ratio, stratified by site, to a liberal (triggered by Hb ≤100 g/L) or a restrictive (triggered by Hb ≤70 g/L) transfusion strategy applied from the time of randomisation to the decision to withdraw life-sustaining therapies, ICU discharge or death. Primary and secondary outcomes are assessed centrally by trained research personnel blinded to the intervention. The primary outcome is the Glasgow Outcome Scale extended at 6 months. Secondary outcomes include overall functional independence measure, overall quality of life (EuroQoL 5-Dimension 5-Level; EQ-5D-5L), TBI-specific quality of life (Quality of Life after Brain Injury; QOLIBRI), depression (Patient Health Questionnaire; PHQ-9) and mortality. ETHICS AND DISSEMINATION: This trial is approved by the CHU de Québec-Université Laval research ethics board (MP-20-2018-3706) and ethic boards at all participating sites. Our results will be published and shared with relevant organisations and healthcare professionals. TRIAL REGISTRATION NUMBER: NCT03260478.

Post-concussion symptoms in sports-related mild traumatic brain injury compared to non-sports-related mild traumatic brain injury.

OBJECTIVES: To compare post-concussion symptoms in patients who sustained a sports-related mild traumatic brain injury (TBI) to those with non-sports-related mild TBI at 7 and 90 days post-injury. METHODS: This prospective multicentre cohort study took place in seven Canadian Emergency Departments (ED). Non-hospitalized patients aged ≥ 14 years with a documented mild TBI that occurred ≤ 24 h of ED visit and a Glasgow Coma Scale score ≥ 13 were included. Main outcome measure was the presence of ≥ 3 symptoms on the Rivermead Post-concussion Questionnaire at 90 days post-injury. Secondary outcomes were the prevalence of (1) individual Rivermead Post-concussion Questionnaire symptom, (2) total Rivermead Post-concussion Questionnaire score ≥ 21 and (3) return to normal daily activities. Adjusted risk ratios (RR) were calculated. RESULTS: 1727 patients were included, 363 (21.0%) sustained a sports-related mild TBI. Similar proportions of patients with ≥ 3 symptoms, a Rivermead Post-concussion Questionnaire score ≥ 21 and those who returned to their normal daily activities were observed at 7 and 90 days post-injury. Sports-related mild TBI patients were at higher risk of poor concentration [RR: 1.3 (95% CI 1.05-1.54)] and non-return to sports activities [RR: 2.2 (95% CI 1.69-2.94)] at 7 days post-injury. At 90 days, sports-relate -mild TBI patients reported less fatigue [RR: 0.7 (95% CI 0.51-0.98)] and feeling of dizziness [RR: 0.6 (95% CI 0.35-0.99)]. CONCLUSION: Patients who sustained sports-related mild TBI could be at lower risk of experiencing symptoms such as fatigue and dizziness 90 days post-injury. Clinicians should be mindful that non-sports-related mild TBI patients may experience more post-concussion symptoms and that the level of physical activity may influence the patient's rehabilitation.

RéSUMé: OBJECTIFS: Comparer les symptômes post-commotionnels chez les patients ayant subi un traumatisme cranio-cérébral léger (TCCL) lié au sport à ceux qui ont un TCCL non lié au sport à 7 et 90 jours post-traumatisme. MéTHODES: Cette étude prospective de cohorte multicentrique s'est déroulée dans sept Départements d'urgence (DU) du Canada. Les patients non hospitalisés âgés de ≥ 14 ans ayant subi un TCCL ≤ 24 heures avant leur visite au DU et présentant un score de Glasgow de ≥ 13 ont été inclus. Le critère principal de jugement était la présence d'au moins 3 symptômes au Rivermead Post-concussion Questionnaire 90 jours après le traumatisme. Les critères de jugement secondaires étaient la prévalence de 1) chacun des symptômes du Rivermead Post-concussion Questionnaire 2) score total du Rivermead Post-concussion Questionnaire ≥ 21 et 3) retour aux activités habituelles. Des risques relatifs ajustés (RR) ont été calculés. RéSULTATS: Un total de 1727 patients a été inclu, dont 363 (21,0 %) ont subi un TCCL lié au sport. Des proportions similaires de patients présentant ≥ 3 symptômes, un score ≥ 21 au Rivermead Post-concussion Questionnaire et de participants ayant repris leurs activités habituelles ont été observés à 7 et 90 jours après la blessure. Les patients avec TCCL lié au sport présentaient un risque plus élevé de manque de concentration (RR: 1,3 [IC à 95 % = 1,05-1,54]) et de non-retour aux activités sportives (RR: 2,2 [IC à 95 % = 1,69-2,94]) à 7 jours après la blessure. À 90 jours, les patients avec TCCL lié au sport ont signalé moins de fatigue (RR: 0,7 [IC à 95 % = 0,51-0,98]) et de sensation de vertige (RR: 0,6 [IC à 95 % = 0,35-0,99]). CONCLUSION: Les patients qui ont subi un TCCL lié au sport seraient moins à risque de présenter des symptômes tels que de la fatigue et des étourdissements 90 jours après la blessure. Les cliniciens doivent être conscients que les patients avec TCCL non lié au sport peuvent présenter davantage de symptômes post-commotionnels et que le niveau d'activité physique peut influencer la réadaptation du patient.