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Unique considerations in the assessment and management of traumatic brain injury in older adults.
The age-specific incidence of traumatic brain injury in older adults is rising in high-income countries, mainly due to an increase in the incidence of falls. The severity of traumatic brain injury in older adults can be underestimated because of a delay in the development of mass effect and symptoms of intracranial haemorrhage. Management and rehabilitation in older adults must consider comorbidities and frailty, the treatment of pre-existing disorders, the reduced potential for recovery, the likelihood of cognitive decline, and the avoidance of future falls. Older age is associated with worse outcomes after traumatic brain injury, but premorbid health is an important predictor and good outcomes are achievable. Although prognostication is uncertain, unsubstantiated nihilism (eg, early withdrawal decisions from the assumption that old age necessarily leads to poor outcomes) should be avoided. The absence of management recommendations for older adults highlights the need for stronger evidence to enhance prognostication. In the meantime, decision making should be multidisciplinary, transparent, personalised, and inclusive of patients and relatives.
Common Data Elements for Disorders of Consciousness: Recommendations from the Working Group on Outcomes and Endpoints.
BACKGROUND: Clinical management of persons with disorders of consciousness (DoC) is dedicated largely to optimizing recovery. However, selecting a measure to evaluate the extent of recovery is challenging because few measures are designed to precisely assess the full range of potential outcomes, from prolonged DoC to return of preinjury functioning. Measures that are designed specifically to assess persons with DoC are often performance-based and only validated for in-person use. Moreover, there are no published recommendations addressing which outcome measures should be used to evaluate DoC recovery. The resulting inconsistency in the measures selected by individual investigators to assess outcome prevents comparison of results across DoC studies. The National Institute of Neurological Disorders and Stroke (NINDS) common data elements (CDEs) is an amalgamation of standardized variables and tools that are recommended for use in studies of neurologic diseases and injuries. The Neurocritical Care Society Curing Coma Campaign launched an initiative to develop CDEs specifically for DoC and invited our group to recommend CDE outcomes and endpoints for persons with DoCs. METHODS: The Curing Coma Campaign Outcomes and Endpoints CDE Workgroup, consisting of experts in adult and pediatric neurocritical care, neurology, and neuroscience, used a previously established five-step process to identify and select candidate CDEs: (1) review of existing NINDS CDEs, (2) nomination and systematic vetting of new CDEs, (3) CDE classification, (4) iterative review and approval of panel recommendations, and (5) development of case report forms. RESULTS: Among hundreds of existing NINDS outcome and endpoint CDE measures, we identified 20 for adults and 18 for children that can be used to assess the full range of recovery from coma. We also proposed 14 new outcome and endpoint CDE measures for adults and 5 for children. CONCLUSIONS: The DoC outcome and endpoint CDEs are a starting point in the broader effort to standardize outcome evaluation of persons with DoC. The ultimate goal is to harmonize DoC studies and allow for more precise assessment of outcomes after severe brain injury or illness. An iterative approach is required to modify and adjust these outcome and endpoint CDEs as new evidence emerges.
Common Data Elements for Disorders of Consciousness: Recommendations from the Working Group on Behavioral Phenotyping.
BACKGROUND: The recent publication of practice guidelines for management of patients with disorders of consciousness (DoC) in the United States and Europe was a major step forward in improving the accuracy and consistency of terminology, diagnostic criteria, and prognostication in this population. There remains a pressing need for a more precise brain injury classification system that combines clinical semiology with neuroimaging, electrophysiologic, and other biomarker data. To address this need, the National Institute of Neurological Disorders and Stroke launched the Common Data Elements (CDEs) initiative to facilitate systematic collection of high-quality research data in studies involving patients with neurological disease. The Neurocritical Care Society's Curing Coma Campaign expanded this effort in 2018 to develop CDEs for DoC. Herein, we present CDE recommendations for behavioral phenotyping of patients with DoC. METHODS: The Behavioral Phenotyping Workgroup used a preestablished, five-step process to identify and select candidate CDEs that included review of existing National Institute of Neurological Disorders and Stroke CDEs, nomination and systematic vetting of new CDEs, CDE classification, iterative review, and approval of panel recommendations and development of corresponding case review forms. RESULTS: We identified a slate of existing and newly proposed basic, supplemental, and exploratory CDEs that can be used for behavioral phenotyping of adult and pediatric patients with DoC. CONCLUSIONS: The proposed behavioral phenotyping CDEs will assist with international harmonization of DoC studies and allow for more precise characterization of study cohorts, favorably impacting observational studies and clinical trials aimed at improving outcome in this population.
Comprehensive analysis of stroke epidemiology in Vietnam: Insights from GBD 1990-2019 and RES-Q 2017-2023.
BACKGROUND: Stroke is a significant health burden in Vietnam, with substantial impacts on mortality, morbidity, and healthcare resources. An up-to-date report on stroke epidemiology and associated risk factors in Vietnam was missing. METHOD: We analyzed the data published in the Global Burden of Disease (GBD) 2019, in combination with the first-time analysis of the Registry of Stroke Care Quality Improvement (RES-Q) initiative in Vietnam from 2017 to 2023. FINDINGS: Comparative analysis globally revealed that Vietnam had one of the highest stroke incidence and prevalence rates in Southeast Asia and ranked 4th in stroke mortality among 11 neighbouring countries. In the RES-Q dataset, 95,696 patients (77 %) were ischemic stroke, 23,203 (18 %) were intracerebral haemorrhage, and 2816 (2 %) were subarachnoid haemorrhage. In GBD 2019, stroke was the leading cause of death among cardiovascular diseases in Vietnam, accounting for 135,999 fatalities. The incidence of stroke was 222 (95 % UIs 206-242) per 100,000 population, with a prevalence of 1541 (1430-1679) per 100,000. Results align with the report from the RES-Q dataset in two megacities of Vietnam: Hanoi (incidence rate of 168.9, prevalence rate of 1182.2) and Ho Chi Minh City (incidence rate of 207.1, prevalence rate of 1221.8). Key risk factors for stroke mortality are high systolic blood pressure (79,000 deaths), unhealthy dietary (43,000 deaths), high fasting plasma glucose (35,000 deaths), and air pollution (33,000 deaths). Incidence is lower in rural Vietnam, but availability and quality of care are higher in megacities. INTERPRETATION: The results promote a further understanding of stroke and risk factors for the Vietnamese population and suggest prevention and treatment strategies for the Vietnamese government, including facility and capacity improvement and applications of advanced technologies.
Selecting outcome measures to validate prognostic biomarkers of paediatric mild traumatic brain injury: challenges and priorities.
Outcomes following paediatric mild traumatic brain injury (mTBI) are extremely heterogenous. While emerging biomarkers promise enhanced prognostic accuracy, a critical question remains unanswered-which outcome measures provide the most accurate assessment of injury impact? In this article, we highlight barriers to selecting appropriate outcome measures, including variability in how outcomes are defined and the wide range of assessment tools used. With reference to the most recent literature, we summarise current evidence of adverse outcomes following paediatric mTBI and highlight emerging candidate biomarkers of these outcomes. We emphasise the unique challenges associated with interpreting outcome measures in younger patients, from the impact of developmental stage and assessment timing to the influence of injury-independent factors. We assert the need to consider these obstacles when designing and interpreting mTBI biomarker studies. To realise the potential of prognostic biomarkers, future research should prioritise establishing consensus definitions, compiling a set of accessible and comprehensive outcome measures, and capturing injury-independent factors through longitudinal study designs.
Personalizing transcranial electrical stimulation.
Transcranial electrical stimulation (tES) encompasses non-invasive neuromodulation techniques, such as transcranial direct and alternating current stimulation, which modulate the central nervous system to probe causal links between the brain and behavior and treat disorders. Unfortunately, fixed stimulation paradigms induce variable effects due to intra- and interindividual factors. Consequently, personalized approaches to tES are increasingly used. In this review, we highlight this emerging domain of human brain stimulation, examining strategies for the personalization of stimulation parameters and their underlying rationales. Multiparameter personalization and the identification of markers indicating tES efficacy represent promising directions. Personalization is not a panacea for all the challenges of tES, but marks an essential step toward reducing the variability of this technique.
Unpacking the relationship between exercise and amyotrophic lateral sclerosis
This scientific commentary refers to ‘Extreme exercise in males is linked to mTOR signalling and onset of amyotrophic lateral sclerosis’ by O’Brien et al. (https://doi.org/10.1093/brain/awaf235).
MRS-BIDS, an extension to the Brain Imaging Data Structure for magnetic resonance spectroscopy.
The Brain Imaging Data Structure (BIDS) is an increasingly adopted standard for organizing scientific data and metadata. It facilitates easier and more straightforward data sharing and reuse. BIDS currently encompasses several biomedical imaging and non-imaging techniques, and as more research groups begin to use it, additional experimental techniques are being incorporated into the standard, allowing diverse experimental methods to be stored within the same cohesive structure. Here, we present an extension for magnetic resonance spectroscopy (MRS) data, termed MRS-BIDS.
Real-World Multinational Survey of Chronic Inflammatory Demyelinating Polyneuropathy: Disease Characteristics and Therapeutic Landscape.
Background and aimsChronic inflammatory demyelinating polyneuropathy (CIDP) is an immune-mediated syndrome characterized by progressive muscle weakness and sensory impairment. Clinical similarities with other neuropathies can cause misdiagnoses and delayed diagnoses. Additionally, a large proportion of patients appropriately treated according to current guidelines still show residual disability. This real-world study aimed to characterize a global cohort of patients with CIDP.MethodsData were drawn from the Adelphi CIDP Disease Specific Programme, a cross-sectional survey with retrospective data collection, conducted in China, France, Germany, Italy, Japan, Spain, the United Kingdom, and the United States between September 2022 and April 2023. Neurologists and neuromuscular specialists reported on patient demographic and clinical characteristics at the time of the survey. Patients self-reported treatment satisfaction, disease control, and health-related outcome measures.ResultsOverall, 164 physicians provided data for 1056 patients, with 428 (40.5%) providing self-reported data. Patients were diagnosed with typical CIDP (69.2%) and variant CIDP (30.8%). Overall, initial misdiagnosis occurred in 37.2% of patients, with a median (interquartile range) diagnostic delay of 6.0 (3.0-12.0) months. Maintenance therapy was prescribed for 81.6% of patients, with corticosteroid use ranging from 25.7% in the United States to 80.0% in China. Some patients were dissatisfied by treatment outcomes (11.0%) and symptom control (12.2%). Overall, mean (SD) patient-reported scores were 62.1 (20.4) for I-RODS, 35.0 (11.1) for FACIT fatigue, and 0.662 (0.253) for EQ-5D-5L.InterpretationDiagnostic delay and misdiagnoses were common occurrences across typical CIDP and variant CIDP. Despite the use of guideline treatments, there were unmet needs and a continued disease burden for patients.