Department of Neurology, University of Groningen, University Medical Center Groningen, Groningen, Netherlands.
Department of Psychometrics and Statistics, University of Groningen, University Medical Center Groningen, Groningen, Netherlands.
Lancet Neurol. 2017 Jul;16(7):532-540. doi: 10.1016/S1474-4422(17)30117-5. Epub 2017 Jun 13.
Mild traumatic brain injury (mTBI) accounts for most cases of TBI, and many patients show incomplete long-term functional recovery. We aimed to create a prognostic model for functional outcome by combining demographics, injury severity, and psychological factors to identify patients at risk for incomplete recovery at 6 months. In particular, we investigated additional indicators of emotional distress and coping style at 2 weeks above early predictors measured at the emergency department.
The UPFRONT study was an observational cohort study done at the emergency departments of three level-1 trauma centres in the Netherlands, which included patients with mTBI, defined by a Glasgow Coma Scale score of 13-15 and either post-traumatic amnesia lasting less than 24 h or loss of consciousness for less than 30 min. Emergency department predictors were measured either on admission with mTBI-comprising injury severity (GCS score, post-traumatic amnesia, and CT abnormalities), demographics (age, gender, educational level, pre-injury mental health, and previous brain injury), and physical conditions (alcohol use on the day of injury, neck pain, headache, nausea, dizziness)-or at 2 weeks, when we obtained data on mood (Hospital Anxiety and Depression Scale), emotional distress (Impact of Event Scale), coping (Utrecht Coping List), and post-traumatic complaints. The functional outcome was recovery, assessed at 6 months after injury with the Glasgow Outcome Scale Extended (GOSE). We dichotomised recovery into complete (GOSE=8) and incomplete (GOSE≤7) recovery. We used logistic regression analyses to assess the predictive value of patient information collected at the time of admission to an emergency department (eg, demographics, injury severity) alone, and combined with predictors of outcome collected at 2 weeks after injury (eg, emotional distress and coping).
Between Jan 25, 2013, and Jan 6, 2015, data from 910 patients with mTBI were collected 2 weeks after injury; the final date for 6-month follow-up was July 6, 2015. Of these patients, 764 (84%) had post-traumatic complaints and 414 (45%) showed emotional distress. At 6 months after injury, outcome data were available for 671 patients; complete recovery (GOSE=8) was observed in 373 (56%) patients and incomplete recovery (GOSE ≤7) in 298 (44%) patients. Logistic regression analyses identified several predictors for 6-month outcome, including education and age, with a clear surplus value of indicators of emotional distress and coping obtained at 2 weeks (area under the curve [AUC]=0·79, optimism 0·02; Nagelkerke R=0·32, optimism 0·05) than only emergency department predictors at the time of admission (AUC=0·72, optimism 0·03; Nagelkerke R=0·19, optimism 0·05).
Psychological factors (ie, emotional distress and maladaptive coping experienced early after injury) in combination with pre-injury mental health problems, education, and age are important predictors for recovery at 6 months following mTBI. These findings provide targets for early interventions to improve outcome in a subgroup of patients at risk of incomplete recovery from mTBI, and warrant validation.
Dutch Brain Foundation.
轻度创伤性脑损伤（mTBI）占 TBI 的大多数病例，许多患者表现出不完全的长期功能恢复。我们旨在通过结合人口统计学、损伤严重程度和心理因素来创建功能结果的预后模型，以识别 6 个月时未完全恢复的风险患者。特别是，我们研究了在急诊科测量的早期预测指标之外的 2 周内情绪困扰和应对方式的额外指标。
UPFRONT 研究是在荷兰 3 个 1 级创伤中心的急诊部门进行的观察性队列研究，包括 mTBI 患者，定义为格拉斯哥昏迷量表（GCS）评分为 13-15 分，且伴有持续时间小于 24 小时的创伤后遗忘或持续时间小于 30 分钟的意识丧失。急诊科预测指标要么在 mTBI 入院时测量，包括损伤严重程度（GCS 评分、创伤后遗忘和 CT 异常）、人口统计学特征（年龄、性别、教育程度、受伤前心理健康和既往脑损伤）和身体状况（受伤当天饮酒、颈部疼痛、头痛、恶心、头晕），要么在 2 周时测量，此时我们获得了情绪（医院焦虑和抑郁量表）、情绪困扰（事件影响量表）、应对（乌得勒支应对清单）和创伤后投诉的数据。功能结果是在损伤后 6 个月用格拉斯哥结局量表扩展（GOSE）评估的恢复情况。我们将恢复情况分为完全（GOSE=8）和不完全（GOSE≤7）恢复。我们使用逻辑回归分析评估了在急诊部门就诊时收集的患者信息（例如，人口统计学、损伤严重程度）的预测价值，以及在损伤后 2 周收集的预后预测指标（例如，情绪困扰和应对）的预测价值。
2013 年 1 月 25 日至 2015 年 1 月 6 日，共收集了 910 名 mTBI 患者在损伤后 2 周的数据；6 个月随访的最终日期为 2015 年 7 月 6 日。在这些患者中，764 名（84%）有创伤后投诉，414 名（45%）有情绪困扰。在损伤后 6 个月时，671 名患者有功能结果数据；373 名（56%）患者完全恢复（GOSE=8），298 名（44%）患者不完全恢复（GOSE≤7）。逻辑回归分析确定了一些 6 个月结果的预测因素，包括教育和年龄，在急诊科就诊时收集的情绪困扰和应对指标（曲线下面积[AUC]=0.79，乐观 0.02；Nagelkerke R=0.32，乐观 0.05）明显优于仅在就诊时收集的急诊部门预测因素（AUC=0.72，乐观 0.03；Nagelkerke R=0.19，乐观 0.05）。
心理因素（即，受伤后早期经历的情绪困扰和适应不良的应对）与受伤前的心理健康问题、教育程度和年龄相结合，是 mTBI 后 6 个月恢复的重要预测因素。这些发现为改善 mTBI 风险患者不完全恢复的预后提供了目标，并需要验证。
荷兰脑基金会。
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