Intrauterine Administration of Activated Peripheral Blood Mononuclear Cells in Intrauterine Insemination: A Prospective Double-Blind Randomized Clinical Trial.

OBJECTIVE: To evaluate the effect of intrauterine administration of activated peripheral blood mononuclear cells (PBMC) on intrauterine insemination (IUI) success rates. METHODS: This prospective double-blind randomized parallel clinical trial included 213 patients undergoing IUI at the Fertilys clinic. PBMC were isolated on the day of ovulation (day 0; D0) and stimulated with phytohemagglutinin (PHA) and human chorionic gonadotropin (hCG) for 48 hours (day 2; D2). Patients in the PBMC group (n = 108) underwent in utero administration of 1.106 cells on D2, while patients in the control group (n = 105) were administered sperm-washing medium. Distribution of CD4 T lymphocyte populations (n = 61) was assessed on D0 and D2. Pregnancy and live birth rates were also evaluated. RESULTS: Demographic and clinical characteristics, pregnancy rates, and live birth rates were not significantly different between the PBMC and control groups. Significantly higher levels of T helper (Th) 2, Th22, and T regulatory cells (P < 0.0001) and lower levels of Th17 cells were observed in hCG-activated PBMC at D2 than at D0. CONCLUSION: Intrauterine administration of PBMC was not beneficial in IUI patients. New clinical approaches to better identify patients requiring endometrium immunomodulation needs to be addressed.

Structural validity and internal consistency of an ecological observation-based assessment, the Activities of Daily Living Profile.

INTRODUCTION: Direct observation of everyday task performance is considered the most accurate measure of independence for individuals with executive function impairments. However, few observation-based measures have been shown to have sound psychometric qualities and be clinically applicable. The objective of this study was to investigate the Activities of Daily Living (ADL) Profile's structural validity using exploratory factor analyses and internal consistency in order to identify the minimum set of tasks required to achieve reliable scores in each of three ADL environments (personal, home and community). METHODS: Ninety-one persons with a severe traumatic brain injury aged 16-40 years (convenience sample) were recruited from a university affiliated level 1 trauma hospital. The 17 observation-based tasks of the ADL Profile were administered by one of five occupational therapists, either in the hospital or in the subjects' home and community environments. This measure of independence considers goal formulation, planning, carrying out and verifying goal attainment. RESULTS: Exploratory factor analysis indicated the unidimensionality of the 17 tasks of the ADL Profile. A single factor explained more than 80% of the common variation, which in this case is the concept of independence. Internal consistency of task scores is very high (0.955), suggesting redundancy of the tasks. Approaches used to reduce the number of items, and to optimise the clinical applicability of the tool, showed that a minimum of two tasks per each of three environments (personal, home, community) is required to obtain reliable results that respect the tool's internal structure. Each assessment should contain both simple and familiar and more novel and complex tasks. CONCLUSIONS: Findings show that the ADL Profile is a valid and clinically applicable observation-based measure of independence that considers four important task-related components: goal formulation, planning, carrying out and verifying goal attainment.

Discharge Against Medical Advice in Traumatic Brain Injury: Follow-Up and Readmission Rate.

BACKGROUND: Patients who leave hospital against medical advice (AMA) may be at risk of adverse health outcomes, medical complications, and readmission. In this study, we examined the characteristics of patients who left AMA after traumatic brain injury (TBI), their rates of follow-up visits, and readmission. METHODS: We retrospectively studied 106 consecutive patients who left the tertiary trauma center AMA (1.8% of all admitted patients with a TBI). Preinjury health and social issues, mechanism of injury, computed tomography findings, and injury markers were collected. They were correlated to compliance with follow-up visits and unplanned emergency room (ER) visits and readmission rates. RESULTS: The most prevalent premorbid health or social-related issues were alcohol abuse (33%) and assault as a mechanism of trauma (33%). Only 15 (14.2%) subjects came to follow-up visit for their TBI. Sixteen (15.1%) of the 106 subjects had multiple readmissions and/or ER visits related to substance abuse. Seven (6.6%) had multiple readmissions or ER visits with psychiatric reasons. Those patients with multiple readmissions and ER visits showed in higher proportion preexisting neurological condition (p=0.027), homelessness (p=0.012), previous neurosurgery (p=0.014), preexisting encephalomalacia (p=0.011), and had a higher ISS score (p=0.014) than those who were not readmitted multiple times. CONCLUSIONS: The significantly increased risks of multiple follow-up visits and readmission among TBI patients who leave hospital AMA are related to a premorbid vulnerability and psychosocial issues. Clinicians should target AMA TBI patients with premorbid vulnerability for discharge transition interventions.

Alteration of high-density lipoprotein functionality in Alzheimer's disease patients.

The aims of the present study were to determine whether high-density lipoprotein (HDL) functionality-mediated cholesterol efflux is altered in Alzheimer's disease and to investigate the role and effect of amyloid-beta (Aß) in the regulation of the anti-atherogenic activity of HDL. Eighty-seven elderly subjects were recruited, of whom 27 were healthy, 27 had mild cognitive impairment (MCI), and 33 had mild Alzheimer's disease (mAD). Our results showed that total cholesterol levels are negatively correlated with the Mini-Mental State Examination (MMSE) score (r = -0.2602, p = 0.0182). HDL from the mAD patients was less efficient at mediating cholesterol efflux from J774 macrophages (p < 0.05) than HDL from the healthy subjects and MCI patients. While HDL from the MCI patients was also less efficient at mediating cholesterol efflux than HDL from the healthy subjects, the difference was not significant. Interestingly, the difference between the healthy subjects and the MCI and mAD patients with respect to the capacity of HDL to mediate cholesterol efflux disappeared when ATP-binding cassette transporter A1 (ABCA1)-enriched J774 macrophages were used. HDL fluidity was significantly inversely correlated with the MMSE scores (r = -0.4137, p < 0.009). In vitro measurements of cholesterol efflux using J774 macrophages showed that neither Aß1-40 nor Aß1-42 stimulate cholesterol efflux from unenriched J774 macrophages in basal or ABCA1-enriched J774 macrophages.

Comparative Outcomes of Traumatic Brain Injury from Biking Accidents With or Without Helmet Use.

OBJECTIVE: To determine if health outcomes and demographics differ according to helmet status between persons with cycling-related traumatic brain injuries (TBI). METHODS: This is a retrospective study of 128 patients admitted to the Montreal General Hospital following a TBI that occurred while cycling from 2007-2011. Information was collected from the Quebec trauma registry and the coroner's office in cases of death from cycling accidents. The independent variables collected were socio-demographic, helmet status, clinical and neurological patient information. The dependent variables evaluated were length of stay (LOS), extended Glasgow outcome scale (GOS-E), injury severity scale (ISS), discharge destination and death. RESULTS: 25% of cyclists wore a helmet. The helmet group was older, more likely to be university educated, married and retired. Unemployment, longer intensive care unit (ICU) stay, severe intracranial bleeding and neurosurgical interventions were more common in the no helmet group. There was no significant association between the severity of the TBI, ISS scores, GOS-E or death and helmet wearing. The median age of the subjects who died was higher than those who survived. CONCLUSION: Cyclists without helmets were younger, less educated, single and unemployed. They had more severe TBIs on imaging, longer LOS in ICU and more neurosurgical interventions. Elderly cyclists admitted to the hospital appear to be at higher risk of dying in the event of a TBI.

Epidural Hematoma Treated Conservatively: When to Expect the Worst.

BACKGROUND: The Brain Trauma Foundation's 2006 surgical guidelines have objectively defined the epidural hematoma (EDH) patients who can be treated conservatively. Since then, the literature has not provided adequate clues to identify patients who are at higher risk for EDH progression (EDHP) and conversion to surgical therapy. The goal of our study was to identify those patients. METHODS: We carried a retrospective review over a 5-year period of all EDH who were initially triaged for conservative management. Demographic data, injury severity and history, neurological status, use of anticoagulants or anti-platelets, radiological parameters, conversion to surgery and its timing, and Glasgow Outcome Scale were analyzed. Bivariate association and further logistic regression were used to point out the significant predictors of EDHP and conversion to surgery. RESULTS: 125 patients (75% of all EDH) were included. The mean age was 39.1 years. The brain injury was mild in 62.4% of our sample and severe in 14.4%. Only 11.2% of the patients required surgery. Statistical comparison showed that younger age (p< 0.0001) and coagulopathy (p=0.009) were the only significant factors for conversion to surgery. There was no difference in outcomes between patients who had EDHP and those who did not. CONCLUSIONS: Most traumatic EDH are not surgical at presentation. The rate of conversion to surgery is low. Significant predictors of EDHP are coagulopathy and younger age. These patients need closer observation because of a higher risk of EDHP. Outcome of surgical conversion was similar to successful conservative management.

Point-of-Care Testing of Troponin Levels Compared With Automated Laboratory Evaluation: A Reliability Study.

Traditionally, troponin levels are measured in the blood using an automated laboratory protocol, but the use of a faster technology, the point-of-care (POC) testing of troponin levels, has shown promise in the effective differential diagnosis of cardiac injury. The purpose of this study was to compare the 2 methods. A total of 1567 patients were seen in the emergency department who were tested with both the POC iSTAT troponin and laboratory troponin from a secondary analysis of retrospective data collected between June 2012 and December 2012. The values for laboratory troponin varied between 0 and 30 with a mean and standard deviation of 0.060 ± 0.842 and the values for POC testing varied between 0 and 17.2 with a mean and standard deviation of 0.042 ± 0.492. The Bland-Altman analysis showed a systematic negative bias for the POC values compared with the laboratory troponin values. Lowering the POC cut-off value for troponin to 0.035 yielded 3 out of 4 better validity coefficients compared with those with the suggested manufacturer's cut-off value of 0.08 when predicting the gold standard. The POC troponin can be used to measure troponin level and similar diagnosis if the cut-off value for the POC troponin is lowered to 0.035 instead of the 0.08 suggested manufacturer's cut-off.

Societal cost of traumatic brain injury: A comparison of cost-of-injuries related to biking with and without helmet use.

OBJECTIVE: The goal of this study is to determine if a difference in societal costs exists from traumatic brain injuries (TBI) in patients who wear helmets compared to non-wearers. METHODS: This is a retrospective cost-of-injury study of 128 patients admitted to the Montreal General Hospital (MGH) following a TBI that occurred while cycling between 2007-2011. Information was collected from Quebec Trauma Registry. The independent variables collected were socio-demographic, helmet status, clinical and neurological patient information. The dependent variables evaluated societal costs. RESULTS: The median costs of hospitalization were significantly higher (p = 0.037) in the no helmet group ($7246.67 vs. $4328.17). No differences in costs were found for inpatient rehabilitation (p = 0.525), outpatient rehabilitation (p = 0.192), loss of productivity (p = 0.108) or death (p = 1.000). Overall, the differences in total societal costs between the helmet and no helmet group were not significantly different (p = 0.065). However, the median total costs for patients with isolated TBI in the non-helmet group ($22, 232.82) was significantly higher (p = 0.045) compared to the helmet group ($13, 920.15). CONCLUSION: Cyclists sustaining TBIs who did not wear helmets in this study were found to cost society nearly double that of helmeted cyclists.

Traumatic brain injury in the elderly: A level 1 trauma centre study.

OBJECTIVE: To explore the characteristics and outcome of patients with TBI over 65 years old admitted to an acute care Level 1 Trauma centre in Montreal, Canada. METHODS: Data were retrospectively collected on patients (n = 1812) who were admitted post-TBI to the McGill University Health Centre-Montreal General Hospital from 2000-2011. The cohort was composed of four groups over 65 years old (65-75; 76-85; 86-95; and 96 and more). Outcome measures used were the extended Glasgow Outcome Scale (GOSE) as well as discharge destination. RESULTS: As the patients got older, the odds of having a poor outcome increased (OR = 2.344 for those 75-85 years old, 4.313 for those 86-95 years of age and 3.465 for those aged 96 years of age or older). Also, the proportion of patients going home or going home with out-patient rehabilitation decreased as age increased (p = 0.001 and p < 0.001, respectively). In contrast, the proportion of patients being discharged to long-term care facilities increased significantly as age increased (p < 0.001). CONCLUSION: This descriptive study provides a better understanding of characteristics and outcome of different age groups of patients with TBI all over 65 years old in Montreal, Canada.

Reliability of the Cooking Task in adults with acquired brain injury.

Acquired brain injury (ABI) often leads to deficits in executive functioning (EF) responsible for severe and long-standing disabilities in daily life activities. The Cooking Task is an ecological and valid test of EF involving multi-tasking in a real environment. Given its complex scoring system, it is important to establish the tool's reliability. The objective of the study was to examine the reliability of the Cooking Task (internal consistency, inter-rater and test-retest reliability). A total of 160 patients with ABI (113 men, mean age 37 years, SD = 14.3) were tested using the Cooking Task. For test-retest reliability, patients were assessed by the same rater on two occasions (mean interval 11 days) while two raters independently and simultaneously observed and scored patients' performances to estimate inter-rater reliability. Internal consistency was high for the global scale (Cronbach α = .74). Inter-rater reliability (n = 66) for total errors was also high (ICC = .93), however the test-retest reliability (n = 11) was poor (ICC = .36). In general the Cooking Task appears to be a reliable tool. The low test-retest results were expected given the importance of EF in the performance of novel tasks.

Trends in Hospitalization Associated with TBI in an Urban Level 1 Trauma Centre.

OBJECTIVE: Traumatic brain injury (TBI) is the single largest cause of death and disability following injury worldwide. The aim of this study was to determine the demographic, clinical, medical and accident related trends for patients with TBI hospitalized in an urban level 1 Trauma Centre. METHODS: Data were retrospectively collected on individuals (n = 5,642) who were admitted to the Traumatic Brain Injury Program of the McGill University Health Centre - Montreal General Hospital from 2000 to 2011. RESULTS: Regression analysis showed a significant upward trend in the yearly number of cases as well as an upward trending by year in the proportion of TBI cases aged 70-years-old or more. The Injury Severity Scale scores were positively associated with year indicating a slight increase in injury severity over the years and there was an increase in patient psychological, social and medical premorbid complexity. In addition, the Extended Glasgow Outcome Scale score tended to become more severe over the years. There was a slight decrease in the proportion of discharges home and in the proportion of deaths. CONCLUSIONS: These results will help to understand the impact of TBI in an urban Canadian level 1 Trauma Centre. This information should be used to develop public prevention strategies and to educate the community about the risk of TBI especially the risk of falls in the ageing population. These findings can also provide information to help health policy makers plan for future resources.

Characteristics of patients with acute traumatic brain injury discharged against medical advice in a level 1 urban trauma centre.

PRIMARY OBJECTIVE: To predict which characteristics are associated with patients at risk of discharge against medical advice (AMA). RESEARCH DESIGN: Data were retrospectively collected on individuals (n = 5642) admitted to the Traumatic Brain Injury Program of the MUHC-MGH. METHODS AND PROCEDURES: Outcome measures used were length of stay (LOS), the Extended Glasgow Outcome Scale (GOSE) as well as the Functional Independence Measure (FIM®). MAIN OUTCOMES: The overall rate of patients leaving AMA was 1.9% (n = 108). Age was negatively associated with AMA discharge (95% CI OR = [0.966;0.991]). Patients with a history of substance abuse were ∼2-times more likely to leave AMA than those not using substances before injury (95% CI OR = [1.172;3.314]) and the homeless were ∼3-times more likely to leave AMA compared to those who were not homeless (95% CI OR = [1.260;7.138]). Length of stay (LOS) was shorter for patients leaving AMA (p < 0.001) and they showed better outcome (GOSE: p < 0.001; FIM: p = 0.032). CONCLUSIONS: Knowing the profile of patients with TBI leaving AMA hospitalized in an urban Level 1 Trauma centre will help in the development of effective strategies based on patient needs, values and pre-injury psychosocial situation to encourage them to complete their treatment course in hospital.

Early conversational discourse abilities following traumatic brain injury: an acute predictive study.

PRIMARY OBJECTIVE: To date, little information is available regarding communication and conversational discourse proficiency post-traumatic brain injury (TBI) in the acute care phase. The main goal of this study was to examine how conversational discourse impairment following TBI predicts early outcome. Factors which influence conversational discourse performance were also explored. METHODS: The conversational discourse checklist of the Protocole Montréal d'évaluation de la communication (D-MEC) was administered in an acute tertiary care trauma centre to 195 adults within 3 weeks post-TBI. Outcome was measured with the Disability Rating Scale (DRS), the extended Glasgow Outcome Scale (GOS-E) and included discharge destinations from acute care. MAIN OUTCOMES AND RESULTS: Linear regression results showed that the D-MEC total score, age and initial GCS score accounted for 50% of the variation of the DRS scores. The DRS score was lower, signifying better outcome, when the total D-MEC score was higher, the subject was younger and when the initial GCS score was higher. Moreover, D-MEC performance significantly predicted the moderate and severe disability categories of the GOS-E and the probability of requiring rehabilitation (p < 0.05). CONCLUSION: These results provide additional information to guide healthcare professionals in predicting overall outcome acutely post-TBI.

Acute global outcome in patients with mild uncomplicated and complicated traumatic brain injury.

PRIMARY OBJECTIVE: This study assesses the influence of socio-demographic, psychosocial, clinical and radiological variables on the outcome of patients with mild traumatic brain injury (MTBI) in an acute care inpatient setting. RESEARCH DESIGN: Retrospective cohort study. METHODS AND PROCEDURE: A total of 2127 inpatients with MTBI were included. Outcomes measured were Extended Glasgow Outcome Scale (GOS-E), the FIM® instrument, length of stay (LOS) and discharge destination. MAIN OUTCOMES AND RESULTS: Fifty-four per cent of patients with MTBI with a median GOS-E of 2 were discharged home with no need for further follow-up. Age, LOS, lower Glasgow score (GCS) at admission, insurance coverage and positive CT scans were associated with rehabilitation referrals on discharge. Age, LOS, alcohol and drug abuse, motor vehicle collision and lower GCS at admission were associated with greater physical disabilities and functional impairment at discharge. FIM® cognitive functional scores were higher in women, younger patients and patients without psychiatric disorders. Brain lesions were correlated with longer LOS. CT scan findings in patients with MTBI may help clinicians predict the final outcome and resources required for patient care during their hospitalization and on discharge. CONCLUSION: This study can help healthcare professionals in treating and planning future care of patients with MTBI.

The mini-mental state examination and the Montreal Cognitive Assessment after traumatic brain injury: an early predictive study.

PRIMARY OBJECTIVE: To compare results on the Montreal Cognitive Assessment (MoCA) to those on the Mini-Mental State Examination (MMSE) in patients with traumatic brain injury (TBI) and to predict the outcome at discharge from the acute care setting. RESEARCH DESIGN: A retrospective study. METHODS AND PROCEDURES: The MoCA and the MMSE were administered to 214 patients with TBI during their acute care hospitalization in a Level I trauma centre. Outcome was measured with the Disability Rating Scale (DRS). MAIN OUTCOMES AND RESULTS: A linear regression determined that the MoCA, the MMSE, TBI severity, education level and presence of diffuse injuries predicted 57% of the total variability of the DRS scores. The model without the MMSE had a R2 of 53.7% and the model without the MoCA had a R2 of 55.0%. The models without the MMSE or the MoCA had a R2 of 24.9%. CONCLUSIONS: These results indicated that the MoCA and the MMSE function as similar predictors of the DRS at discharge.

Assessment of uterine artery and aortic isthmus Doppler recordings as predictors of necrotizing enterocolitis.

OBJECTIVE: The purpose of this study was to evaluate whether changes of uterine arteries and aortic isthmus Doppler blood flow recordings could enhance the prediction of necrotizing enterocolitis. STUDY DESIGN: Doppler characteristics of the uterine artery, umbilical and middle cerebral arteries, ductus venosus, and aortic isthmus were reviewed in 123 growth-restricted fetuses who were then divided into 2 groups: with and without necrotizing enterocolitis. RESULTS: Twelve of 123 newborn infants (9%) expressed necrotizing enterocolitis. This group showed significant association between necrotizing enterocolitis and bilateral notching on the uterine artery (83.3% vs 29.7%; P < .001), uterine artery mean resistance index (83.3% vs 36.9%; P < .002), aortic isthmus diastolic blood flow velocity integrals (Z score: -7.32 vs -3.99; P = .028), and absent or negative "a" wave on the ductus venosus (17% vs 1.8%; P = .021). With the use of logistic regression, uterine bilateral notching could predict necrotizing enterocolitis with a sensitivity of 83.3% and a specificity of 70.3%. CONCLUSION: More than any other variable, uterine bilateral notching should be recognized as a strong risk factor for necrotizing enterocolitis.

Criterion validity of a functional cognitive task in patients with severe traumatic brain injury.

PRIMARY OBJECTIVE: To verify criterion validity of measures from a functional cognitive task (FCT) carried out with patients with severe traumatic brain injury (sTBI) at 2-5 years post-injury. METHODS AND PROCEDURES: Forty-six patients with sTBI took part in a long-term outcome study where the FCT and the Neurobehavioural Rating Scale-Revised (NBRS-R) were administered and the FIM™ instrument was rated. The FCT is a telephone information gathering task for evaluating functional cognitive skills. RESULTS: Ten of 16 measures of the FCT were significantly correlated with similar or related concepts from the NBRS-R. The FIM™ cognitive score and the individual items of this score were significantly correlated with 13 of the FCT measures and with the percentage of amount of information gathered. Internal consistency was good for 13 of 16 measures. Overall, patients generally had mild difficulty on the FCT concepts. CONCLUSION: The FCT can be used with patients with sTBI to evaluate certain aspects of functional cognition. It has good criterion validity and internal consistency, but additional research is required to further measure reliability and its applicability to other severity of TBI and to other phases of recovery.

Reassessing the interpretation of oxidation-reduction potential in male infertility.

Male Infertility Oxidative System (MiOXSYS) has been proposed as a rapid and promising technology for the evaluation of sperm oxidative stress. In this case-control study, 134 men with normal sperm parameters (NSP) and 574 men with abnormal sperm parameters (ASP), according to the World Health Organization sperm assessment references values established in 2010, were enrolled. Conventional sperm parameters were evaluated in all patients. Sperm static oxido-reduction potential (sORP) was assessed using the MiOXSYS. Sperm DNA integrity was measured in 604 patients. To ensure that sperm concentration was not a confounding factor in the sORP index ratio, sperm and seminal fluid sORP from 57 randomly selected additional patients were also measured using the MiOXSYS. sORP index (mV/106 sperm/mL) was higher in patients with ASP and seemed to correlate with conventional sperm parameters. Although receiver-operating characteristic analysis revealed that a sORP index cut-off of 0.79 could differentiate normal from ASP with 57.7% sensitivity and 73.1% specificity, these values are much lower than those found in the literature. These values also need to be higher to be applicable in a clinical setting. Furthermore, absolute sORP (mV) was not different in the presence or absence of spermatozoa. sORP index relationships with sperm parameters seem rather be due to sperm concentration, denominator of the sORP index ratio. The establishment of a reliable method using the absolute sORP value, independent of sperm concentration, needs to be addressed. Other oxidative stress biomarkers could be used to validate this method. Lay summary: The World Health Organization (WHO) has recognized that oxidative stress may have a role in male infertility. Oxidative stress happens when there is an imbalance between the production of molecules containing oxygen and the antioxidants, molecules that neutralize the molecules containing oxygen. The molecules containing oxygen can cause damage to sperm DNA. This damage can be measured using a particular index and this study looked at whether the concentration of the sperm sample might have an impact on results and suggests this should be taken into consideration by clinicians and researchers.

Primary or secondary decompressive craniectomy: different indication and outcome.

BACKGROUND: Intracranial hypertension can cause secondary damage after a traumatic brain injury. Aggressive medical management might not be sufficient to alleviate the increasing intracranial pressure (ICP), and decompressive craniectomy (DC) can be considered. Decompressive craniectomy can be divided into categories, according to the timing and rationale for performing the procedure: primary (done at the time of mass lesion evacuation) and secondary craniectomy (done to treat refractory ICP). Most studies analyze primary and secondary DC together. Our hypothesis is that these two groups are distinct and the aim of this retrospective study is to evaluate the differences in order to better predict outcome after DC. METHODS: Seventy patients had DC over a period of four years at our center. They were divided into two groups based on the timing of the DC. Primary DC (44 patients) was done within 24 hours of the injury for mass lesion evacuation. Secondary DC (26 patients) was done after 24 hours and purely for the treatment of refractory ICP. Pre-op characteristics and post-op outcomes were compared between the two groups. RESULTS: There was a significant difference in the mechanism of injury, the pupil abnormalities and Marshall grade between primary and secondary DC. There was also a significant difference in outcome with primary DC showing 45.5% good outcome and 40.9% mortality and secondary DC showing 73.1% good outcome and 15.4% mortality. CONCLUSIONS: Primary and secondary DC have different indications and patients characteristics. Outcome prediction following DC should be adjusted according to the surgical indication.

A critical look at phenytoin use for early post-traumatic seizure prophylaxis.

BACKGROUND: The American Academy of Neurology recommended using phenytoin or carbamazepine to prevent early post-traumatic seizures (PTS) in severe traumatic brain injuries (TBI). In this study, we examined the effects of using phenytoin prophylaxis on mild, moderate, and severe TBIs. There have been no studies looking at compliance rate and side effects of systematic use of phenytoin at a large population scale. The goal of this study is to determine 1) the proportion of TBI patients receiving phenytoin prophylaxis; 2) which parameters decided when to decide administer phenytoin; 3) prophylaxis efficacy and complication rate. METHODS: We retrospectively studied all patients admitted with a TBI over a two year-period and collected the following information: age, GCS score, CT-scan Marshall grade, incidence of early PTS, incidence of phenytoin use and time delay, side effects, and incidence of over-dosage or under-dosage. RESULTS: 1008 patients were included. 5.4 % had early PTS, 2.3 % while on prophylaxis and 3.1% while not on prophylaxis, 1.9% before reaching the hospital and 1.2% prior to phenytoin administration while in hospital. Delay of administration was 5 hours. 64.8% received prophylaxis and physicians used positive CT scan as the primary decision-making parameter (p<.001). Compliance with guidelines was 99.7%. Adverse reactions occurred in 0.5%. Levels were drawn in 42.2% (52% therapeutic, 41% low, 7% high). CONCLUSIONS: Phenytoin is used according to guidelines, with CT scan being the main decision factor for its use. The frequency of early PTS rate is low and side effects are rare. However, earlier administration of phenytoin and adequate levels could further prevent early PTS.