Keenan Heather T, Clark Amy E, Holubkov Richard, Cox Charles S, Patel Rajan P, Moore Kevin R, Ewing-Cobbs Linda
Department of Pediatrics, University of Utah, Salt Lake City, Utah, USA.
Department of Pediatric Surgery, University of Texas Medical School at Houston, Houston, Texas, USA.
J Neurotrauma. 2020 Jul 1;37(13):1512-1520. doi: 10.1089/neu.2019.6874. Epub 2020 Apr 1.
Heterogeneity of injury severity among children with traumatic brain injury (TBI) classified by the Glasgow Coma Scale (GCS) makes comparisons across research cohorts, enrollment in clinical trials, and clinical predictions of outcomes difficult. The present study uses latent class analysis (LCA) to distinguish severity subgroups from a prospective cohort of 433 children 2.5-15 years of age with TBI who were recruited from two level 1 pediatric trauma centers. Indicator variables available within 48 h post-injury including emergency department (ED) GCS, hospital motor GCS, Abbreviated Injury Score (AIS), Rotterdam Score, hypotension in the ED, and pre-hospital loss of consciousness, intubation, seizures, and sedation were evaluated to define subgroups. To understand whether latent class subgroups were predictive of clinically meaningful outcomes, the Pediatric Injury Functional Outcome Scale (PIFOS) at 6 and 12 months, and the Behavior Rating Inventory of Executive Function at 12 months, were compared across subgroups. Then, outcomes were examined by GCS (primary) and AIS (secondary) classification alone to assess whether LCA provided improved outcome prediction. LCA identified four distinct increasing severity subgroups (1-4). Unlike GCS classification, mean outcome differences on PIFOS at 6 months showed decreasing function across classes. PIFOS differences relative to the lowest latent class (LC1) were: LC2 2.27 (0.83, 3.72), LC3 3.99 (1.88, 6.10), and LC4 11.2 (7.04, 15.4). Differences in 12 month outcomes were seen between the most and least severely injured groups. Differences in outcomes in relation to AIS were restricted to the most and less severely injured at both time points. This study distinguished four latent classes that are clinically meaningful, distinguished a more homogenous severe injury group, and separated children by 6-month functional outcomes better than GCS alone. Systematic reporting of these variables would allow comparisons across research cohorts, potentially improve clinical predictions, and increase sensitivity to treatment effects in clinical trials.
根据格拉斯哥昏迷量表（GCS）分类的创伤性脑损伤（TBI）儿童的损伤严重程度异质性，使得跨研究队列的比较、临床试验的入组以及结果的临床预测变得困难。本研究采用潜在类别分析（LCA），从两个一级儿科创伤中心招募的433名2.5至15岁TBI儿童的前瞻性队列中区分严重程度亚组。评估伤后48小时内可用的指标变量，包括急诊科（ED）GCS、医院运动GCS、简明损伤评分（AIS）、鹿特丹评分、急诊科低血压以及院前意识丧失、插管、癫痫发作和镇静情况，以定义亚组。为了解潜在类别亚组是否能预测具有临床意义的结果，比较了各亚组在6个月和12个月时的儿童损伤功能结局量表（PIFOS）以及12个月时的执行功能行为评定量表。然后，仅通过GCS（主要）和AIS（次要）分类检查结果，以评估LCA是否能提供更好的结果预测。LCA确定了四个不同的严重程度递增亚组（1 - 4）。与GCS分类不同，6个月时PIFOS的平均结果差异显示各亚组功能逐渐下降。相对于最低潜在类别（LC1），PIFOS差异为：LC2 2.27（0.83，3.72），LC3 3.99（1.88，6.10），LC4 11.2（7.04，15.4）。在最严重和最不严重受伤组之间观察到12个月结局的差异。与AIS相关的结局差异在两个时间点都仅限于最严重和较不严重受伤的情况。本研究区分了四个具有临床意义的潜在类别，区分出了一个更同质的重伤组，并且比单独使用GCS能更好地根据6个月功能结局对儿童进行分类。系统报告这些变量将允许跨研究队列进行比较，可能改善临床预测，并提高临床试验中对治疗效果的敏感性。
