TBI surveillance using the common data elements for traumatic brain injury: a population study

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Title:
TBI surveillance using the common data elements for traumatic brain injury: a population study
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English
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Stead, Latha Ganti
Bodhit, Aakash N.
Patel, Pratik Shashikant
Daneshvar, Yasamin
Peters, Keith R.
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Springer Open Journal (International Journal of Emergency Medicine)

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Abstract:
Background: To characterize the patterns of presentation of adults with head injury to the Emergency Department. Methods: This is a cohort study that sought to collect injury and outcome variables with the goal of characterizing the very early natural history of traumatic brain injury in adults. This IRB-approved project was conducted in collaboration with our Institution’s Center for Translational Science Institute. Data were entered in REDCap, a secure database. Statistical analyses were performed using JMP 10.0 pro for Windows. Results: The cohort consisted of 2,394 adults, with 40% being women and 79% Caucasian. The most common mechanism was fall (47%) followed by motor vehicle collision (MVC) (36%). Patients sustaining an MVC were significantly younger than those whose head injury was secondary to a fall (P < 0.0001). Ninety-one percent had CT imaging; hemorrhage was significantly more likely with worse severity as measured by the Glasgow Coma Score (chi-square, P < 0.0001). Forty-four percent were admitted to the hospital, with half requiring ICU admission. In-hospital death was observed in 5.4%, while neurosurgical intervention was required in 8%. For all outcomes, worse TBI severity per GCS was significantly associated with worse outcomes (logistic regression, P < 0.0001, adjusted for age). Conclusion: These cohort data highlight the burden of TBI in the Emergency Department and provide important demographic trends for further research.
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Publication of this article was funded in part by the University of Florida Open-Access publishing Fund. In addition, requestors receiving funding through the UFOAP project are expected to submit a post-review, final draft of the article to UF's institutional repository, IR@UF, (www.uflib.ufl.edu/UFir) at the time of funding. The institutional Repository at the University of Florida community, with research, news, outreach, and educational materials.
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Stead et al. International Journal of Emergency Medicine 2013, 6:5 http://www.intjem.com/content/6/1/5; Pages 1-7
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doi:10.1186/1865-1380-6-5 Cite this article as: Stead et al.: TBI surveillance using the common data elements for traumatic brain injury: a population study. International Journal of Emergency Medicine 2013 6:5.

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ORIGINALRESEARCHOpenAccessTBIsurveillanceusingthecommondataelements fortraumaticbraininjury:apopulationstudyLathaGantiStead1,2,6*,AakashNBodhit1,2,PratikShashikantPatel1,2,YasaminDaneshvar1,2,KeithRPeters1,6,7, AnnaMazzuoccolo1,2,SudeepKuchibhotla1,ChristaPulvino1,KelseyHatchitt1,LawrenceLottenberg1,3, Marie-CarmelleElie-Turenne1,2,RobynMHoelle1,2,AbhijnaVedula1,2,AndreaGabrielli4,BayardDMiller5, JohnHSlish1,2,MichaelFalgiani1,2,TriciaFalgiani1,2,JAdrianTyndall1,2andEmergencyMedicineTraumaticBrain InjuryResearchNetworkInvestigatorsAbstractBackground: TocharacterizethepatternsofpresentationofadultswithheadinjurytotheEmergencyDepartment. Methods: Thisisacohortstudythatsoughttocollectinjuryandoutcomevariableswiththegoalofcharacterizing theveryearlynaturalhistoryoftraumaticbraininjuryinadults.ThisIRB-approvedprojectwasconductedin collaborationwithourInstitution ’ sCenterforTranslationalScienceInstitute.DatawereenteredinREDCap,asecure database.StatisticalanalyseswereperformedusingJMP10.0proforWindows. Results: Thecohortconsistedof2,394adults,with40%beingwomenand79%Caucasian.Themostcommon mechanismwasfall(47%)followedbymotorvehiclecollision(MVC)(36%).PatientssustaininganMVCwere significantlyyoungerthanthosewhoseheadinjurywassecondarytoafall( P <0.0001).Ninety-onepercenthadCT imaging;hemorrhagewassignificantlymorelikelywithworseseverityasmeasuredbytheGlasgowComaScore (chi-square, P <0.0001).Forty-fourpercentwereadmittedtothehospital,withhalfrequiringICUadmission. In-hospitaldeathwasobservedin5.4%,whileneurosurgicalinterventionwasrequiredin8%.Foralloutcomes, worseTBIseverityperGCSwassignificantlyassociatedwithworseoutcomes(logisticregression, P <0.0001, adjustedforage). Conclusion: ThesecohortdatahighlighttheburdenofTBIintheEmergencyDepartmentandprovideimportant demographictrendsforfurtherresearch.BackgroundEachyear,onaverage,traumaticbraininjuries(TBIs)are associatedwithanestimated1.35millionemergencydepartmentvisits,275,000hospitalizations,and52,000 deathsintheUS[1].Thisdoesnotaccountforthose whosustainaheadinjuryandreceivenocare.TBIisa contributingfactortoathird(30.5%)ofallinjury-related deathsintheUS[1,2].RoughlythreequartersofTBIs thatoccureachyearareconcussionsorotherformsof mildTBI[3].TBIisasignificantburdentoourhealthcaresystem.Directmedicalcostsandindirectcostssuch aslostproductivityofTBItotaledanestimated$76.5 billionintheUSin2000[4]. Traumaticbraininjuryisanimportantpublichealth problemintheUS.Itisfrequentlyreferredtoasthe “ silentepidemic ” becausethecomplicationsfromTBI, suchaschangesaffectingthinking,sensation,language,or emotions,maynotbereadilyapparent.Inaddition,awarenessaboutTBIamongthegeneralpublicislimited[1]. TheCDCstates: “ population-baseddataonTBIare criticaltounderstandingitsimpactontheAmerican people.KnowingwhoisaffectedbyTBIsandhowthey occurcanhelpshapepreventionstrategies,prioritiesfor research,andalsosupporttheneedforservicesamong individualslivingwithTBI ” [3].Thisstudywasundertakenspecificallytoaddressthisneedonalocallevel.By understandingourpopulation ’ spatternsofinjuryand *Correspondence: lstead@ufl.edu1CenterforBrainInjuryResearchandEducation,UniversityofFloridaCollege ofMedicine,Gainesville,FL,USA2DepartmentsofEmergencyMedicine,UniversityofFloridaCollegeof Medicine,Gainesville,FL,USA Fulllistofauthorinformationisavailableattheendofthearticle 2013Steadetal.;licenseeSpringer.ThisisanOpenAccessarticledistributedunderthetermsoftheCreativeCommons AttributionLicense(http://creativecommons.org/licenses/by/2.0),whichpermitsunrestricteduse,distribution,andreproduction inanymedium,providedtheoriginalworkisproperlycited.Stead etal.InternationalJournalofEmergencyMedicine 2013, 6 :5 http://www.intjem.com/content/6/1/5

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outcomes,wewouldbeabletodesignanoptimalsystem notonlytoprovideacutecare,butalsotodesign programsthataddressresearchandeducationneeds. Theobjectiveofthisstudywastocharacterizethepopulationofpatientswhosustainheadinjuriesandpresent toouremergencydepartment.Thereasonwastounderstandourlocaldemographicsinanefforttodesign processesandinterventionsthatwouldmitigatethe morbidityandmortalityassociatedwiththisinjury pattern. Inadditiontothepaucityofacuteepidemiological dataonTBI,anotherproblemisthevariabilityinterms ofinformationcollected,makingmeta-analysesor comparisonsacrossstudieschallenging.Toaddressthis, theAmericanCongressofRehabilitationMedicine developedaworkinggrouptodelineatecommondata elementsfordemographicsandclinicalassessmentin traumaticbraininjury[5].Thecurrentstudybasedits datacollectionvariablesontheserecommendations.MethodsThiswasaretrospectivechartreviewthatspanneda30monthperiodfrom1January2008to31August2010. MethodologyandotherstudydetailsarereportedinaccordancewithSTROBEguidelines[6]. ThestudywasconductedintheEmergencyDepartment(ED)ofalevel-onetraumacenterinthe southeasternUS.OurEDseesover79,000visitsper year,andishometobothemergencymedicineandgeneralsurgeryresidencytrainingprograms.Thisstudy wasapprovedbyourinstitution ’ sIRBasanexpedited studywithanHIPAAwaiver. Datawereabstractedfromtheelectronicmedicalrecordusingan apriori designeddataabstractionform. Personsenteringthedatawereblindedtothestudyhypothesesandoutcomes.Datawereenteredintoour ClinicalandTranslationalScienceInstitute ’ sREDCap database.REDCap(ResearchElectronicDataCapture)is asecure,Web-basedapplicationdesignedtosupport traditionalcasereportformdatacapture.StatisticalanalyseswereperformedusingJMPPro10.0forWindows. Normallydistributedvariablesaresummarizedusing meansandstandarddeviations,whileskewedvariables arereportedusingmediansandinterquartileranges (IQR).Missingdatawererecordedasunknown. Subjectswereconsideredeligibleiftheywereage18 orolderandsustainedaheadinjury,asdeterminedby havingacorrespondingICD-9codeamongoneoftheir toptenemergencydepartmentorinpatientdischarge diagnoses.Thecodesusedwere800.0-804.9,850.0854.1,959.01,and995.55(Table1),basedontheCenters forDiseaseControlguidelines[7,8].Thecodeswere selectedinordertocaptureallpossibleheadinjuries.If onreviewarecordwasdetermined not tohavesustained aheadinjury,thenasecondmemberoftheresearch teamreviewedtherecord.Iftherewasagreementby bothresearchersthatthesubjectshouldnotbeincluded, theywereexcludedafterdocumentingthereason. Wheretherewasdisagreement,theprimaryauthor resolvedtheissueviaconsensus. SeverityofheadinjurywasclassifiedusingtheGlasgowComaScale[9],withGCS13 – 15consideredas mild,GCS9 – 12asmoderate,andascorelessthan9 classifiedassevere.Post-injurysymptomatologycollected includedtheoccurrenceoflossofconsciousness(LOC), thedurationofLOC,analterationinconsciousness(AOC), posttraumaticamnesia(PTA ),seizure,andvomiting.An AOCwasconsideredtobepresentifthepatientreported anyofthefollowing:feelingdazedorconfused,havingdifficultythinking,oriftheneurologicexamrevealeda decreasedmentalstatus. Datawerealsocollectedformechanismofinjury,includingafall,trafficaccident,recreationalactivity, sports,andassault.Recreationalactivitiesincludedinjuriesrelatedtobicycles,motorcycles,all-terrainvehicles (ATVs),othervehicles(e.g.,scooters),watercraft,or other(horsebackriding).Informationaboutseatbeltuse inpeopleinvolvedintrafficaccidentsandhelmetusein peoplewithrecreationalvehicleinjurieswasalsocollected. Table1ICD-9codeCorrespondingTBIdiagnosis 800.00to804.9Fractureofskull 850Concussion 851Cerebrallacerationandcontusion 852Subarachnoid,subdural,andextradural hemorrhageafterinjury 853Otherunspecifiedintracranial hemorrhageafterinjury 854Intracranialinjuryofotherand unspecifiednature 959.01Otherunspecifiedinjurytohead Table2Racialandgendercompositionofheadinjury (basedonthe2010census)inadultsubjectsCityof Gainesville Alachua county TBI inED Totalpopulation107,742203,0512,394 Caucasian(Non-HispanicWhite)60.93%66.46%79% BlackorAfrican-American19.44%17.73%14.8% HispanicorLatino10.08%8.24%4.3% Asian7.14%5.52%1.04% OtherNativeAmericanorNativeAlaskan, PacificIslander,twoormoreraces, orsomeotherrace 2.41%2.05%1% Female51.46%52.1%40% Stead etal.InternationalJournalofEmergencyMedicine 2013, 6 :5Page2of7 http://www.intjem.com/content/6/1/5

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ResultsDemographicsThecohortconsistedof2,394subjects.Themedianage was39years,IQR24 – 59.Sixty-onepercentofthecohortwassingle,27%married,7%divorced,and5%did notreportamaritalstatus.Overall,34%ofthecohort wasemployed,and14%peoplewereretired,7.8%were students,and17.8%wereunemployed(employmentstatusfortheremaining28%wasnotreported).Males accountedfor60%ofthetotalpopulation.Theracial compositioninthecontextofthecityandcountypopulationissummarizedinTable2.Thegender,age,and racebreakdownbyTBIseverityisdepictedinFigure1.InjurycharacteristicsThemajority(88%)oftheinjuriesoccurredlessthan12 hpriortopresentation.Another5%presentedwithin24 h.Seventy-fivepercentofthecohortwastransportedby EMSfortheirheadinjury(65.7%ground,9.5%air).The remaining25%presentedtotheEDbycar,anothervehicle,orwalked-in.Themajority(85.1%)hadmildTBI (GCS13 – 15);3.1%weremoderate(GCS9 – 12),and 11.7%weresevere(GCS8orbelow). Lossofconsciousness(LOC)wasdefinitivelyreported by51.3%,whileinanadditional14.1%ofsubjects,itwas unknownwhethertheylostconsciousnessornot. Amongthosewithlossofconsciousness,thedurationof LOCwasknownfor59%(46.1%hadLOCfor0 – 30min, and12.9%reportedLOCofmorethan30min).Altered mentalstatuswasexperiencedby28.9%ofsubjects, while25.6%experiencedpost-traumaticamnesiafor eventsbeforeand/oraftertheinjury.Vomitingand seizurewerelesscommonsymptomsafteraTBI.Inour population,6.5%hadatleastoneepisodeofvomiting afterinjury;3.5%sufferedfromseizureafterhead trauma. MILD (GCS 13-15) n=2038 Race white: 1584black: 320Hispanic: 89 menn= 1169 median age: 37 (IQR 23-54) women n= 869 median age: 42 (IQR 24-65) MODERATE (GCS 9-12) n= 75 Race white: 62black: 10Hispanic: 2 men n= 53 median age: 46 (IQR 27-72) women n= 22 median age: 46 (IQR 19-77) SEVERE (GCS 3-8) n= 280 Race: white: 244 black: 23Hispanic: 1 men n= 213 median age: 37 (IQR 25-53) women n= 67 median age: 46 (IQR 34-61) Figure1 Demographiccharacteristicsofcohort. Figure2 Typesofrecreationalvehiclesinvolvedinheadinjury. Recreationalvehicleswereinvolvedin19%ofheadinjurycases. Stead etal.InternationalJournalofEmergencyMedicine 2013, 6 :5Page3of7 http://www.intjem.com/content/6/1/5

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MechanismofinjuryThemostcommonmechanismforheadinjuryforour populationwasafall(46.8%).Thisincludedfallsfrom thegroundlevelorfromanyheight,includingtreesand roofs,collapseduetosyncope,andalsofallsassociated withassaultorfallbyanyotherreason. Thesecondmostcommonmechanismwasmotorvehiclecollision(MVC),at35.5%.Mostoftenthesubject wasinthedriver ’ sseat(61.2%),followedbyfrontpassengerseat(13%).OutofthoseinvolvedinanMVC,just 46%reportedwearingtheseatbelt.TheMVCmechanismwassignificantlymorecommoninseverecompared tomildTBI(52%vs.34%, P <0.0001). Thenextmostcommonmechanisminvolvedrecreationalvehicles,at19%.Thetypesofrecreational vehiclesaresummarizedinFigure2.Ofthoseridinga bicycle,motorcycle,orATV,only25.5%werewearinga helmet.Ofnote,thestateofFloridadoesnothaveahelmetlawforbicycleorATVridersforpersonsoverthe ageof16years[10].ImagingAcomputedtomography(CT)scanwasperformedin 2201patients,or91.9%ofthecohort.TheCTwasabnormalin1,047patients(47.6%).Excludingextracalvarialsofttissueswelling,theCTscanwasabnormal in28.4%ofthecohort.Theabnormalitiesaredetailed inTable3,andTable4stratifiesthemaccordingto TBIseverity.OutcomesAbout56.1%ofsubjectsweredischargeddirectlyfrom theED.Ofthosewhowereadmitted,overhalf(51%) endedupwithanICU(intensivecareunit)stay,and thesewerepredominantlythosewithmoderateorsevere injury.Themedianhospitallengthofstaywas2days (IQR1 – 7).ThemedianICUlengthofstaywas2days (IQR1 – 10).Atotalof5.4%expiredinthehospital. Neurosurgicalinterventionincludingventriculostomy, craniotomy,andcraniectomywasperformedin8%. Table5showsthebreakdownbyseverity;forall measures,greaterTBIseveritywassignificantlyassociated withworseoutcomes(regressionanalysis, P <0.0001, adjustedforage).Table6showsdischargedispositions stratifiedbyseverity.Onewouldassumethatnoneof themildTBIpatientswouldbeadmittedtotheICU, Table3ThepercentagesofheadCTabnormalitiesAbnormalCTfinding N %oftotalabnormalCTs ( n =1,047) %oftotalCTs ( n =2,201) %oftotalpopulation ( n =2,394) Extracalvarialsofttissueswelling36835.1%16.7%15.3% Fractureofskull25224.1%11.4%10.5% Fractureofmaxillofacialbones(exceptnose)24323.2%11.0%10.2% Fractureofnasalbones938.9%4.2%3.9% Calvarialfracturethroughcarotidcanal101%0.5%0.4% Calvarialfracturethroughforamenmagnum80.8%0.4%0.3% Subfalcineherniation938.9%4.2%3.9% Upwardtranstentorialherniation80.8%0.4%0.3% Downwardtranstentorialherniation767.3%3.5%3.2% Uncalherniation272.6%1.2%1.1% Tonsillarherniation151.4%0.7%0.6% Epiduralhematoma777.4%3.5%3.2% Subduralhematoma33732.2%15.3%14.1% Subarachnoidhemorrhage31930.5%14.5%13.3% Intraventricularhemorrhage656.2%3.0%2.7% Parenchymalorhemorrhagiccontusion36534.9%16.6%15.2% Diffuseaxonalinjury(unilateral/bilateral)504.8%2.3%2.1% ANYbleed70167%31.8%29.8% ANYfracture42540.6%19.3%17.8%AllabnormalitiesweresignificantlymorecommonwithworseTBIseverity ( P < 0 0001 ANOVA ). Table4Percentagesbasedonwholecohort, n =2,394AnyCTabnormality aslistedintable 3 BleedFracture Mild( n =2,038)739(36%)437(21%)262(13%) Moderate( n =75)53(71%)41(55%)22(29%) Severe( n =280)255(91%)223(80%)141(50%) Stead etal.InternationalJournalofEmergencyMedicine 2013, 6 :5Page4of7 http://www.intjem.com/content/6/1/5

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whileallofthemoderateandsevereTBIpatientswould beadmittedtotheICU.Ourdatashowsomedeviation fromthis,sothespecificreasonswereexplored.The 11.7%ofpatientswithmildTBIwhowereadmittedto theICUallhadeitheraskullfractureorintracranial hemorrhageandwereadmittedforeitherobservationor surgicalintervention.Asmallpercentagealsohadmultitrauma.PatientswithmoderateorsevereTBIwhowere notadmittedtotheICUincludedthosewhowere intoxicatedatthetimeofinitialevaluationbutsubsequentlysoberedupandwereabletobedischargedand thosewhoexpiredinthetraumabayoftheEDitself. Almost5%returnedtotheEDwithin72h(Table7), mostcommonlyforsymptomsofpost-concussivesyndrome(30%),withthepredominantcomplaintbeing headache.Thenextmostcommonreasonfor72-hED returnwasbecausethepatientwasspecificallycalled backforamissedreadonradiologicimaging(13%).A returnEDvisitwassignificantlymorecommoninpatients withmildTBI( P =0.0218,chi-square),likelybecause higherseveritypatientsareadmittedtothehospital.Six percentwerere-admittedtothehospitalwithin30days. Thereadmissionwasusuallyunrelatedtotheantecedent TBI,althoughofthereasonsspecified,achronicor worseningsubduralhematomawastheculpritin5%.DiscussionWhythecurrentstudyisimportantOurfindingscharacterizeinjuryseverity,etiology,symptomology,andoutcomeinpatientswithacuteTBI presentingtoaTraumaLevelIteachinginstitution. Internationalthinktanksidentifiedareasoffocusfor TBIresearch[11,12].Aconsistentunderlyingthemeis theneedtodefineepidemiologyandbasichospital outcomesforlocalpopulations.Thecurrentcohort providesanepidemiologicaccountofTBIpatientsthat willaddtounderstandingthemagnitudeofTBI,drive researchpriorities,andidentifyclinicalareasofneed. Ourdescriptivestudyisuniqueinseveralwaysand addstotheliteratureanoveldescriptionofTBIpatients. Thecurrentstudyrepresentsoneofthelargestcohorts ofmildTBIpatientsinthecivilianpopulation.MildTBI (mTBI)accountsfor80 – 85%ofallTBIsandassuch representsalargeproportionofdisabilityfromTBI[13]. Thisimprovedunderstandinghasledtomorewidespreadrecognition[14].Cliniciansandlegislatorshave recognizedtheconsequencesofmildTBIcanbequite significant.ReviewofotherTBIcohortstudiesTherehavebeenafewothercohortsdescribingTBI,but nonehavedescribedtheacutesymptomatologywiththe levelofdetailthatthecurrentstudydoesorinapopulationthathasgeneralizability.Thus,asurveyofsoldiers deployedinIraq[15]doesreportsymptomology,butthe cohortisnotvariedenoughinmechanism,gender,and agetorepresentthegeneralpopulation,anditdescribes thesymptomsexperiencedbythesoldiersreportedata datemuchlaterthantheinjury,whichinherentlycarries recallbias.AhistoricalstudyfromtheMayoClinic reportsonincidencemorbidityandmortalityoutcomes afterTBIforOlmstedcountyfortheyears1935 – 1974, butcouldnotcommentonacuteemergencydepartment variablesbecauseofthedesignandtimeperiod[16]. Similarly,aNewZealandstudyreportsontheincidence andoutcomes,butdidnotassessacutesymptomatology orclinicalvariables[17].TwopapersreportonemergencydepartmentvisitsforTBIfrom1992 – 94[18]and 1995 – 16[19];however,thesestudiesarenotonlynow 15 – 20yearsold,butalsorelyondatacollectedfromthe NationalHospitalAmbulatoryMedicalCareSurvey[20], inwhichhospitalstaffinselectedUShospitalsare instructedtocompletepatientrecordformsforasystematicrandomsampleofpatientvisitsduringarandomlyassigned4-weekreportingperiod.Thissurveyhas inherentlimitations,includingamodestresponserate, optionalparticipationwithoutincentives,andinabilityto Table5HospitaladmissionratesforTBIbasedonseverityEDTBIseverity(GCS)Admitted( n ,%)ICUstay(n,%)Intra-hospitaldeath(n,%)Neurosurgicalintervention Mild(2,038)719(35.3%)239(11.7%)16(0.8%)78(3.8%) Moderate(75)60(80%)48(64%)9(12%)19(25.3%) Severe(280)270(96.4%)248(88.6%)105(37.5%)96(34.3%) Table6DischargedispositionaccordingtoTBIseverityEDTBIseverity(GCS)HomeSkillednursing facility RehabilitationfacilityPsychiatricfacilityLeftagainst medicaladvice Deathinhospital Mild(2,038)1,819(89.3%)117(5.7%)37(1.8%)11(0.6%)37(1.8%)16(0.8%) Moderate(75)41(54.7%)11(14.7%)11(14.7%)1(1.3%)2(2.6%)9(12%) Severe(280)71(25.4%)40(14.3%)59(21.1%)3(1.1%)2(0.7%)105(37.5%) Stead etal.InternationalJournalofEmergencyMedicine 2013, 6 :5Page5of7 http://www.intjem.com/content/6/1/5

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capturemanypatientleveldataincludingacutesymptomatology.Morerecentcohortshavebeendescribedas well,butthesehavebeenlimitedtomoderateandsevere TBI[21,22]orpatientsadmittedtoanICU[23],both distinctfromthecohortdescribedinthecurrentstudy.Comparingoutcomesbetweenthecurrentstudyandthe otherpublishedstudiesAmongthemoderateandsevereTBIs,comparisonscan bemadetootherstudiesevenwhenemergencydepartmentacutesymptomatologywasnotspecificallystudied, asthesearealessheterogeneousgroupthanmildTBI patients.Forexample,Andriessenetal.[21]prospectivelyenrolled508moderateandseverepatientsacross fivelevelItraumacentersinTheNetherlands.Their ratesofabnormalCTswerecomparabletothecurrent cohort(56vs.71%formoderateand81vs.91%forsevere)whenaccountingforextracalvarialsofttissue swelling.Thesestudiesalsomirrorneurosurgicalintervention(26%vs.25%formoderateand29%vs.34%for severe). Astudyexamining476moderateand1,701severeTBI patientsacrossEuropeandNorthAmerica[20]reported MVCasthemechanismataratesimilartothatinthe currentreport(57vs.52%oftheTBIsintheirseverecohortwereduetoanMVCmechanism). Giventhelackofotherlargecohortstudiesthatfocus onacutesymptomatologyinmildTBI,comparisonsof ourstudyfindingswithinthemildTBIcohorttoother suchpopulationsarenotpossible.Wedidnote,forinstance,thatmildTBIhadunexpectedamountsofpathologyonCT(21%hadbleeds,13%hadfractures), neurosurgicalinterventionrates(3.8%),anddeathrates (0.8%).Thishigherthanexpectedacuityinthisgroup mayindicatetheGCSscalewasanunderestimationof illnessorthatthemedicalcommunity ’ sassumptions about “ mild ” TBImaybeunderestimatingthedisease process.LimitationsWhilesomeoftheexplicitstrengthsofourstudyinclude thelargenumberofpatientswithallseveritiesofTBI (especiallymildTBI)presentingtoourEDandtheabilitytocollectclinicalinformationunavailablethrough billingcoding,therearesomeinherentweaknessesin ourmethodsaswell.Thelimitationsofthecurrent studyare:(1)thecohortwasassembledusingbilling codesasastartingpoint;(2)datawereabstractedfrom medicalrecordreviewandthereforecertainpiecesof dataweremissingforsomesubjects;(3)thesedatapertaintoasinglemedicalcenter,althoughthesample appearstoberepresentativeofnationaldemographics.ConclusionThesecohortdatahighlighttheburdenofTBIinthe EmergencyDepartmentandprovideimportantdemographictrendsforfurtherresearch.Thehigherthan expectedpositivityaswellasinterventionratesofthe mildTBIpatientsisaimportantfindingthatwarrants furtherstudy.Competinginterests Theauthorsdeclarethattheyhavenocompetinginterests. Authors ’ contributions LGS,ANB,PSP,andYDconceivedthestudy.ANB,PSP,YD,AM,AV,SK,CP, andKHcollectedthedata.ANBandLGSperformedthestatisticalanalyses andANB,PSP,andYDcrosscheckedthedata.LGSandKRPsupervisedthe conductoftheresearchanddatacollection.LGS,RMH,andANBdraftedthe manuscript,andallauthorscontributedsubstantiallytoitsrevision.All authorsreadandapprovedthefinalmanuscript. Acknowledgements Thisworksupportedbygrantfundingfrom: 1)TheToralFamilyFoundation,Davie,Florida,USA. 2)TheNIH/NCRRClinicalandTranslationalScienceAwardtotheUniversity ofFloridaUL1RR029890. Authordetails1CenterforBrainInjuryResearchandEducation,UniversityofFloridaCollege ofMedicine,Gainesville,FL,USA.2DepartmentsofEmergencyMedicine, UniversityofFloridaCollegeofMedicine,Gainesville,FL,USA.3Departments ofAcuteCareSurgery,UniversityofFloridaCollegeofMedicine,Gainesville, FL,USA.4DepartmentsofAnesthesiology,UniversityofFloridaCollegeof Medicine,Gainesville,FL,USA.5DepartmentsofNeurology,Universityof FloridaCollegeofMedicine,Gainesville,FL,USA.6Departmentsof NeurologicalSurgery,UniversityofFloridaCollegeofMedicine,Gainesville, FL,USA.7DepartmentsofRadiology,UniversityofFloridaCollegeof Medicine,Gainesville,FL,USA. Received:15October2012Accepted:12February2013 Published:27February2013 References1.FaulM,XuL,WaldMM,CoronadoVG: TraumaticbraininjuryintheUnited States:emergencydepartmentvisits,hospitalizations,anddeaths. Atlanta(GA): CentersforDiseaseControlandPrevention,NationalCenterforInjury PreventionandControl;2010. 2.BrunsJ,HauserWA: Theepidemiologyoftraumaticbraininjury:areview. Epilepsia 2003, 44 (10):2 – 10. 3.CentersforDiseaseControlandPrevention(CDC),NationalCenterforInjury PreventionandControl: ReporttoCongressonmildtraumaticbraininjuryin theUnitedStates:stepstopreventaseriouspublichealthproblem. Atlanta (GA):CentersforDiseaseControlandPrevention;2003. 4.FinkelsteinE,CorsoP,MillerT: IncidenceandEconomicBurdenofInjuriesin theUnitedStates. NewYork(NY):OxfordUniversityPress;2006. 5.MaasAI,Harrison-FelixCL,MenonD,AdelsonPD,BalkinT,BullockR,Engel DC,GordonW,LangloisOrmanJ,LewHL,RobertsonC,TemkinN,Valadka A,VerfaellieM,WainwrightM,WrightDW,SchwabK: Commondata elementsfortraumaticbraininjury:recommendationsfromthe InteragencyWorkingGrouponDemographicsandClinicalAssessment. ArchPhysMedRehabil 2010, 91: 1641 – 1649. Table7The72-hreturntotheEDand30-day re-admissionratesbyseverityEDTBIseverity (GCS) ReturntoED within72h( n ,%) Re-admittedtothehospital within30days( n ,%) Mild(2,038)102(5%)105(5.1%) Moderate(75)4(5.3%)6(8%) Severe(280)5(1.8%)24(8.6%) Stead etal.InternationalJournalofEmergencyMedicine 2013, 6 :5Page6of7 http://www.intjem.com/content/6/1/5

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