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Divergent Six Month Functional Recovery Trajectories and Predictors after Traumatic Brain Injury: Novel Insights from the Citicoline Brain Injury Treatment Trial Study.

ABSTRACT: Cross-sectional approaches to outcome assessment may not adequately capture heterogeneity in recovery after traumatic brain injury (TBI). Using latent class mixed models (LCMM), a data-driven analytic that identifies groups of patients with similar trajectories, we identified distinct 6 month functional recovery trajectories in a large cohort (n?=?1046) of adults 18-70 years of age with complicated mild to severe TBI who participated in the Citicoline Brain Injury Treatment Trial (COBRIT). We used multinomial logistic fixed effect models and backward elimination, forward selection, and forward stepwise selection with several stopping rules to explore baseline predictors of functional recovery trajectory. Based on statistical and clinical considerations, the seven-class model was deemed superior. Visualization of these seven functional recovery trajectories revealed that each trajectory class started at one of three recovery levels at 1 month, which, for ease of reference we labeled groups A-C: Group A, good recovery (two classes; A1 and A2); Group B, moderate disability (two classes; B1 and B2); and Group C, severe disability (three classes; C1, C2, and C3). By 6 months, these three groups experienced dramatically divergent trajectories. Group A experienced stable good recovery (A1, n?=?115) or dramatic decline (A2, n?=?4); Group B experienced rapid complete recovery (B1, n?=?71) or gradual recovery (B2, n?=?742); Group C experienced dramatic rapid recovery (C1, n?=?12), no recovery (C2, n?=?91), or death (C3, n?=?11). Trajectory class membership was not predicted by citicoline treatment (p?=?0.57). The models identified demographic, pre-injury, and injury-related predictors of functional recovery trajectory, including: age, race, education, pre-injury employment, pre-injury diabetes, pre-injury psychiatric disorder, site, Glasgow Coma Scale (GCS) score, post-traumatic amnesia, TBI mechanism, major extracranial injury, hemoglobin, and acute computed tomographic (CT) findings. GCS was the most consistently selected predictor across all models. All models also selected at least one demographic or pre-injury medical predictor. LCMM successfully identified dramatically divergent, clinically meaningful 6 month recovery trajectories with utility to inform clinical trial design.

SUBMITTER: Gardner RC

PROVIDER: S-EPMC6709728 | biostudies-literature | 2019 Sep

REPOSITORIES: biostudies-literature

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Divergent Six Month Functional Recovery Trajectories and Predictors after Traumatic Brain Injury: Novel Insights from the Citicoline Brain Injury Treatment Trial Study.

Gardner Raquel C RC Cheng Jing J Ferguson Adam R AR Boylan Ross R Boscardin John J Zafonte Ross D RD Manley Geoffrey T GT

Journal of neurotrauma 20190524 17

Cross-sectional approaches to outcome assessment may not adequately capture heterogeneity in recovery after traumatic brain injury (TBI). Using latent class mixed models (LCMM), a data-driven analytic that identifies groups of patients with similar trajectories, we identified distinct 6 month functional recovery trajectories in a large cohort (<i>n</i> = 1046) of adults 18-70 years of age with complicated mild to severe TBI who participated in the Citicoline Brain Injury Treatment Trial (COBRIT) ...[more]

PMID: 30909795

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Project description:Return to work (RTW) is an important milestone of mild traumatic brain injury (mTBI) recovery. The objective of this study was to evaluate whether baseline clinical variables, three-month RTW, and three-month postconcussional symptoms (PCS) were associated with six-month RTW after mTBI. Adult subjects from the prospective multicenter Transforming Research and Clinical Knowledge in Traumatic Brain Injury Pilot study with mTBI (Glasgow Coma Scale 13-15) who were employed at baseline, with completed three-and six-month RTW status, and three-month Acute Concussion Evaluation (ACE), were extracted. Univariate and multivariable analyses were performed for six-month RTW, with focus on baseline employment, three-month RTW, and three-month ACE domains (physical, cognitive, sleep, and/or emotional postconcussional symptoms (PCS)). Odds ratios (OR) and 95% confidence intervals [CI] were reported. Significance was assessed at p < 0.05. In 152 patients aged 40.7 ± 15.0years, 72% were employed full-time at baseline. Three- and six-month RTW were 77.6% and 78.9%, respectively. At three months, 59.2%, 47.4%, 46.1% and 31.6% scored positive for ACE physical, cognitive, sleep, and emotional PCS domains, respectively. Three-month RTW predicted six-month RTW (OR = 19.80, 95% CI [7.61-51.52]). On univariate analysis, scoring positive in any three-month ACE domain predicted inability for six-month RTW (OR = 0.10-0.11). On multivariable analysis, emotional symptoms predicted inability to six-month RTW (OR = 0.19 [0.04-0.85]). Subjects who scored positive in all four ACE domains were more likely to be unable to RTW at six months (4 domains: 58.3%, vs. 0-to-3 domains: 9.5%; multivariable OR = 0.09 [0.02-0.33]). Three-month post-injury is an important time point at which RTW status and PCS should be assessed, as both are prognostic markers for six-month RTW. Clinicians should be particularly vigilant of patients who present with emotional symptoms, and patients with symptoms across multiple PCS categories, as these patients are at further risk of inability to RTW and may benefit from targeted evaluation and support.

Project description:INTRODUCTION: The aim of this study was to evaluate the usefulness of the APACHE II (Acute Physiology and Chronic Health Evaluation II), SAPS II (Simplified Acute Physiology Score II) and SOFA (Sequential Organ Failure Assessment) scores compared to simpler models based on age and Glasgow Coma Scale (GCS) in predicting long-term outcome of patients with moderate-to-severe traumatic brain injury (TBI) treated in the intensive care unit (ICU). METHODS: A national ICU database was screened for eligible TBI patients (age over 15 years, GCS 3-13) admitted in 2003-2012. Logistic regression was used for customization of APACHE II, SAPS II and SOFA score-based models for six-month mortality prediction. These models were compared to an adjusted SOFA-based model (including age) and a reference model (age and GCS). Internal validation was performed by a randomized split-sample technique. Prognostic performance was determined by assessing discrimination, calibration and precision. RESULTS: In total, 1,625 patients were included. The overall six-month mortality was 33%. The APACHE II and SAPS II-based models showed good discrimination (area under the curve (AUC) 0.79, 95% confidence interval (CI) 0.75 to 0.82; and 0.80, 95% CI 0.77 to 0.83, respectively), calibration (P?>?0.05) and precision (Brier score 0.166 to 0.167). The SOFA-based model showed poor discrimination (AUC 0.68, 95% CI 0.64 to 0.72) and precision (Brier score 0.201) but good calibration (P?>?0.05). The AUC of the SOFA-based model was significantly improved after the insertion of age and GCS (?AUC +0.11, P?<?0.001). The performance of the reference model was comparable to the APACHE II and SAPS II in terms of discrimination (AUC 0.77; compared to APACHE II, ?AUC -0.02, P?=?0.425; compared to SAPS II, ?AUC -0.03, P?=?0.218), calibration (P?>?0.05) and precision (Brier score 0.181). CONCLUSIONS: A simple prognostic model, based only on age and GCS, displayed a fairly good prognostic performance in predicting six-month mortality of ICU-treated patients with TBI. The use of the more complex scoring systems APACHE II, SAPS II and SOFA added little to the prognostic performance.

Project description:ImportanceOne traumatic brain injury (TBI) increases the risk of subsequent TBIs. Research on longitudinal outcomes of civilian repetitive TBIs is limited.ObjectiveTo investigate associations between sustaining 1 or more TBIs (ie, postindex TBIs) after study enrollment (ie, index TBIs) and multidimensional outcomes at 1 year and 3 to 7 years.Design, setting, and participantsThis cohort study included participants presenting to emergency departments enrolled within 24 hours of TBI in the prospective, 18-center Transforming Research and Clinical Knowledge in Traumatic Brain Injury (TRACK-TBI) study (enrollment years, February 2014 to July 2020). Participants who completed outcome assessments at 1 year and 3 to 7 years were included. Data were analyzed from September 2022 to August 2023.ExposuresPostindex TBI(s).Main outcomes and measuresDemographic and clinical factors, prior TBI (ie, preindex TBI), and functional (Glasgow Outcome Scale-Extended [GOSE]), postconcussive (Rivermead Post-Concussion Symptoms Questionnaire [RPQ]), psychological distress (Brief Symptom Inventory-18 [BSI-18]), depressive (Patient Health Questionnaire-9 [PHQ-9]), posttraumatic stress disorder (PTSD; PTSD Checklist for DSM-5 [PCL-5]), and health-related quality-of-life (Quality of Life After Brain Injury-Overall Scale [QOLIBRI-OS]) outcomes were assessed. Adjusted mean differences (aMDs) and adjusted relative risks are reported with 95% CIs.ResultsOf 2417 TRACK-TBI participants, 1572 completed the outcomes assessment at 1 year (1049 [66.7%] male; mean [SD] age, 41.6 [17.5] years) and 1084 completed the outcomes assessment at 3 to 7 years (714 [65.9%] male; mean [SD] age, 40.6 [17.0] years). At 1 year, a total of 60 participants (4%) were Asian, 255 (16%) were Black, 1213 (77%) were White, 39 (2%) were another race, and 5 (0.3%) had unknown race. At 3 to 7 years, 39 (4%) were Asian, 149 (14%) were Black, 868 (80%) were White, 26 (2%) had another race, and 2 (0.2%) had unknown race. A total of 50 (3.2%) and 132 (12.2%) reported 1 or more postindex TBIs at 1 year and 3 to 7 years, respectively. Risk factors for postindex TBI were psychiatric history, preindex TBI, and extracranial injury severity. At 1 year, compared with those without postindex TBI, participants with postindex TBI had worse functional recovery (GOSE score of 8: adjusted relative risk, 0.57; 95% CI, 0.34-0.96) and health-related quality of life (QOLIBRI-OS: aMD, -15.9; 95% CI, -22.6 to -9.1), and greater postconcussive symptoms (RPQ: aMD, 8.1; 95% CI, 4.2-11.9), psychological distress symptoms (BSI-18: aMD, 5.3; 95% CI, 2.1-8.6), depression symptoms (PHQ-9: aMD, 3.0; 95% CI, 1.5-4.4), and PTSD symptoms (PCL-5: aMD, 7.8; 95% CI, 3.2-12.4). At 3 to 7 years, these associations remained statistically significant. Multiple (2 or more) postindex TBIs were associated with poorer outcomes across all domains.Conclusions and relevanceIn this cohort study of patients with acute TBI, postindex TBI was associated with worse symptomatology across outcome domains at 1 year and 3 to 7 years postinjury, and there was a dose-dependent response with multiple postindex TBIs. These results underscore the critical need to provide TBI prevention, education, counseling, and follow-up care to at-risk patients.

Project description:ImportanceExecutive functions are critical for school and social success. Although these functions are adversely affected by pediatric traumatic brain injury (TBI), recovery patterns are not well established.ObjectiveTo examine 3-year trajectories of selected children's executive functions after TBI.Design, setting, and participantsThis prospective cohort study was conducted from January 22, 2013, to September 30, 2015, with 3-year follow-up at the level I pediatric trauma centers Primary Children's Hospital in Salt Lake City, Utah and Children's Memorial Hermann Hospital in Houston, Texas. Study participants included children aged 2 to 15 years with TBI or orthopedic injury (OI) who were treated at the participating hospitals. Children were consecutively recruited and stratified by injury severity and age group. A total of 625 children consented and completed a baseline survey; 559 (89%) children completed at least 1 follow-up and composed the analysis cohort. It was hypothesized that recovery would differ by injury severity, age at injury, and sex. Data analyses were performed from June to October 2019.Main outcomes and measuresGrowth curve models examined the pattern of change in the Emotional Control, Inhibit, Working Memory, and Plan-Organize subscales of the Behavior Rating Inventory of Executive Function (BRIEF) or BRIEF-Preschool. For all BRIEF subscales, higher scores indicate worse symptoms, and a score of 65 or greater represents clinical impairment.ResultsA total of 559 children (mean [SD] age, 8.6 [4.4] years; 356 boys [64%], 328 non-Hispanic White children [59%]) were included in the study: 155 (28%) children had mild TBI, 162 (29%) had complicated mild or moderate TBI, 90 (16%) had severe TBI, and 152 (27%) had OI. Growth curve trajectories varied by BRIEF subscale and injury severity. Overall, children with TBI did not return to their preinjury baseline, with a stepwise worsening of each outcome at 36 months by TBI severity compared with OI. Among children with severe TBI, trajectories accelerated fastest, indicating increased problems, from injury to 12 months for the Emotional Control (9.0 points; 95% CI, 6.0-11.9 points), Inhibit (3.6 points; 95% CI, 1.6-5.6 points), and Working Memory (7.0 points; 95% CI, 4.1-9.9 points) subscales. Their trajectories plateaued, with a secondary acceleration before 36 months for the Emotional Control and Working Memory subscales. Children with mild TBI had worse 36-month scores on all subscales except Inhibit compared with OI. Recovery patterns were similar for boys and girls.Conclusions and relevanceIn this longitudinal cohort study of children with TBI, trajectory analysis revealed that some children worsen after a recovery plateau, suggesting a need for longitudinal reassessment beyond 1 year postinjury.

Project description:ImportanceInsomnia is common after traumatic brain injury (TBI) and contributes to morbidity and long-term sequelae.ObjectiveTo identify unique trajectories of insomnia in the 12 months after TBI.Design, setting, and participantsIn this prospective cohort study, latent class mixed models (LCMMs) were used to model insomnia trajectories over time and to classify participants into distinct profile groups. Data from the Transforming Research and Clinical Knowledge in Traumatic Brain Injury (TRACK-TBI) study, a longitudinal, multisite, observational study, were uploaded to the Federal Interagency Traumatic Brain Injury Repository (FITBIR) database. Participants were enrolled at 1 of 18 participating level I trauma centers and enrolled within 24 hours of TBI injury. Additional data were obtained directly from the TRACK-TBI investigators that will be uploaded to FITBIR in the future. Data were collected from February 26, 2014, to August 8, 2018, and analyzed from July 1, 2020, to November 15, 2021.ExposuresTraumatic brain injury.Main outcomes and measuresInsomnia Severity Index assessed serially at 2 weeks and 3, 6, and 12 months thereafter.ResultsThe final sample included 2022 participants (1377 [68.1%] men; mean [SD] age, 40.1 [17.2] years) from the FITBIR database and the TRACK-TBI study. The data were best fit by a 5-class LCMM. Of these participants, 1245 (61.6%) reported persistent mild insomnia symptoms (class 1); 627 (31.0%) initially reported mild insomnia symptoms that resolved over time (class 2); 91 (4.5%) reported persistent severe insomnia symptoms (class 3); 44 (2.2%) initially reported severe insomnia symptoms that resolved by 12 months (class 4); and 15 (0.7%) initially reported no insomnia symptoms but had severe symptoms by 12 months (class 5). In a multinomial logistic regression model, several factors significantly associated with insomnia trajectory class membership were identified, including female sex (odds ratio [OR], 1.65 [95% CI, 1.02-2.66]), Black race (OR, 2.36 [95% CI, 1.39-4.01]), history of psychiatric illness (OR, 2.21 [95% CI, 1.35-3.60]), and findings consistent with intracranial injury on computed tomography (OR, 0.36 [95% CI, 0.20-0.65]) when comparing class 3 with class 1.Conclusions and relevanceThese results suggest important heterogeneity in the course of insomnia after TBI in adults. More work is needed to identify outcomes associated with these insomnia trajectory class subgroups and to identify optimal subgroup-specific treatment approaches.

Dataset Information

Divergent Six Month Functional Recovery Trajectories and Predictors after Traumatic Brain Injury: Novel Insights from the Citicoline Brain Injury Treatment Trial Study.

Publications

Divergent Six Month Functional Recovery Trajectories and Predictors after Traumatic Brain Injury: Novel Insights from the Citicoline Brain Injury Treatment Trial Study.

Similar Datasets

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