2014-07-27 23:39 Source: dingxiang garden Author: caifengzjsx
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– | + Li Xuejun, Department of Neurosurgery, Xiangya Hospital, Central South University
Currently, there is no strict uniform definition for concussion in either clinical or basic research fields. In response, a research group led by Dr. Nancy Carney of the University of Oregon and Dr. Jamshid Ghajar of the New York Traumatic Brain Injury Foundation convened a group of experts in the field to define and implement a research strategy to develop a new clinical guideline for concussion, which will be based on evidence-based medicine and will be used to explain the exact definition of concussion and propose appropriate diagnostic criteria and prognostic indicators. The first part of the research project is to develop a new clinical guideline for concussion.
The first part of the research project is to identify the most common signs, symptoms and neurological deficits (SSDs) of concussion and their interrelationships by searching databases, screening the required literature, and analyzing and integrating data to provide evidence for a definitive definition of concussion. The results of this first part of the study, i.e., brain The results of this first part of the study, the concussion-related clinical features, will be published in the September issue of Neurosurgery this year.
The main findings of this study.
First, the most important finding, and the main purpose of this study, is the concussion-related clinical features, which include.
1) disorientation or impaired consciousness in the immediate post-injury period.
2) balance deficits occurring within 1 day after injury
3) unresponsiveness present within 2 days of injury.
4) Impairment of learning ability and memory within 2 days of injury.
In addition, some other findings were included: for example, for most post-injury patients, cognitive deficits will be recovered within 1 week; reaction time, memory, attention, executive ability, and productivity will be impaired to varying degrees within 1 week post-injury; from the immediate post-injury period to 5 days post-injury, patients with a history of prior trauma will have more severe deficits in cognitive function than patients with their first injury; in addition In addition, there were significant correlations between injury severity and cognitive function within 7 days after injury, subjective symptoms and neurological/cognitive function within 48 hours after injury, and Glasgow score (13-14) and plasma levels of ubiquitin C-terminal hydrolase and glial fibrillary acidic protein.
The following is the process of analyzing and organizing the information needs for this study.
Prior to conducting the database search, the research team transformed and split the initial question (purpose) into clinical questions that could be answered, namely.
1. what are the most common signs, symptoms, and neurological impairments (SSDs) within 3 months after potential concussive events (PCEs)?
For each PCE, do SSDs within 3 months vary according to demographic characteristics, the patient’s pre-injury general condition, mechanism of injury, case diagnostic criteria, or other factors that are not dependent on the PCEs?
3. Is there some association between different SSDs? Or, is there some association between the same SSDs in the same patient at different time points?
4. Are there any associations between imaging or biomarkers that appear after PCEs and SSDs?
Accordingly, a total of 5437 abstracts were retrieved, of which 1362 could be downloaded in full text, and 26 met the inclusion criteria. Among these 26 papers, a total of 8 papers (containing 11 independent samples) provided relevant data at certain time points that could be used to answer the above question and draw their respective corresponding conclusions.
Results of the analysis for question 1.
1) Signs: In this section, a total of 14 literatures met the inclusion requirements. Of these, 13 papers were studied with athletes; six groups of samples were taken from adults, five groups were from adolescents, another three groups included both adults and adolescents, and one group also included both adults and children. Thus, a total of 1007 participants were enrolled. Results: incidence of loss of consciousness: 1%-14.3%; incidence of post-injury amnesia: 2%-29.7%; incidence of retrograde amnesia: 7.4%-53.3%; incidence of disorientation: 18%-44.7%.
(2) Symptoms: including 7 categories of symptoms: headache, dizziness, blurred vision, nausea, diplopia, noise-sensitive spots, and light-sensitive spots; measurement time: 2 hours post-injury; 28 adult athlete patients, and 28 controls. Results: see Table 1.
Table 1 Comparison of the incidence of various types of symptoms in individuals with PCEs cases and controls
PCEs case group
(n=28) %
Control group
(n=28) %
Absolute prevalence
%
Headache
93
18
75
Dizziness
64
4
60
Blurred vision
75
0
75
Nausea
61
7
54
Diplopia
11
0
11
Noise hypersensitivity
4
0
4
Light oversensitivity
4
0
4
(3) Neurological deficits: 4 papers were included; the only measurable index was balance; 266 patients were enrolled, all adult athletes. A total of 11 tests were performed from the immediate post-injury period to the seventh post-injury day, including 20 functional tests covering compound sensory functions, proprioceptive functions, vision, vestibular functions, and balance functions. RESULTS: Among the 20 tests used to measure balance sensation, statistically significant differences were found between the PCEs and control groups in 12 tests within 1 week after injury; the rate of decline in balance function in the PCEs group ranged from 23.8% to 36.5% within 24 hours after injury; by the second day after injury, the rate ranged from 19.2% to 24%.
(4) Cognitive function: A total of 9 papers were enrolled, 604 in the PCEs group and 720 in the control group. Measurements ranged from the immediate post-injury period to the seventh post-injury day. There were 100 functional test items in a total of 27 categories of cognitive tests. Results: reaction time: the incidence of decreased reaction at 24 hours post-injury ranged from 41.7% to 71.4%; attention/productivity: the incidence of decreased this function ranged from 0%-30.4% to 50%-52.2% from the immediate post-injury to 24 hours post-injury, and there was no evidence that the decrease in this function lasted more than 24 hours; memory: the incidence of decreased this function ranged from 0%-20.2% from the immediate post-injury to Memory: the incidence of decline in this function ranged from 0%-20.8% to 39.1%-41.7% from the immediate post-injury period to 24 hours post-injury; Executive ability: the incidence of decline in this function ranged from 0%-34.8% to 52.2% from the immediate post-injury period to 24 hours post-injury, and there was no evidence that the decline in this function lasted for more than 24 hours; in addition, decline in motor/sensory function and overall cognitive function were not available.
In addition, the team analyzed the results of cognitive function tests at different time points: Table 2 shows the total number of relevant tests performed at each time point and a summary of the percentage of tests that differed between the PCEs and control groups; Figure 1 clearly shows that the rate of decline in cognitive function decreased from 58% on the first post-injury day to 8% on the seventh post-injury day. Finally, the data from the analysis of each test item from the immediate post-injury period to the seventh post-injury day were summarized and analyzed, with the percentage of response times that differed between the two groups accounting for 83%. (See Table 3 and Figure 2)
Table 2 Summary of cognitive trials at different time points
Number of cognitive trials, n
Positive rate of trials with differences between the PCEs group and the control group, %
Number of literature, n
Immediate post-injury
5
100
1
First day
26
58
3
36 hours
1
100
1
Day 2
15
40
3
Day 3
13
31
2
Day 4
1
100
1
Day 5
13
8
2
Day 7
25
8
5
Figure 1 Trial positivity rates showing differences between the PCEs group and the control group at different time points
Table 3 Summary of trials across cognitive domains
Number of cognitive trials, n
Positive rate of trials that differed between the PCEs and control groups, %
Number of literature, n
Reaction time
6
83
3
Attention/efficiency
15
29
4
Memory
53
43
8
Executive ability
16
6
3
Motor/sensory
8
12.5
5
Fig. 2 Test positive rates showing differences between the PCEs group and the control group in the cognitive domain. RT: reaction time; Att/PS/WM: attention/productivity/working memory; Fx: function
Results of the analysis for question 2.
A total of 4 papers met the inclusion criteria for this section and all were relevant to athletes; 2 of the studies were in adults and the other 2 included adults and adolescents; 2 studies also included athletes with a prior history of concussion; one study also assessed gender differences and the other assessed differences between Caucasians and Blacks.
Results: 1) History of traumatic brain injury: 2 of 9 total neuropsychiatric tests showed that athletes with a history of prior traumatic brain injury had lower baseline scores than athletes without a history of traumatic brain injury; athletes with a history of prior traumatic brain injury were 7-8 times more likely than athletes without a history of traumatic brain injury to be at risk for a 14-point drop in the ImPACT Memory Index within 5 days of injury; 2) Mental retardation. One study suggested that intellectual disability had no effect on pre-injury neuropsychiatric test results in male athletes; 3) Gender: the results of one study suggested that for one of the ImPACT tests, visual memory, the female group had significantly lower scores than the male group at 1-3 days post-injury; 4) Race: the results of one study suggested that at day 7 post-injury, for one of the four ImPACT tests the risk of a significant decrease in one of the scores was 2.4 times higher for black athletes than for whites.
Results of the analysis addressing question 3.
A total of four papers met the inclusion criteria for this section, three of which were related to athletes and the corresponding studies were conducted in adults, adolescents, and adults and adolescents; the other was conducted in adult and pediatric patients in a hospital setting; three assessed the relationship between signs and cognitive test scores and the other analyzed the relationship between symptoms and cognitive function.
Results: 1) Physical signs and cognitive function: the results of one study suggested that on the seventh day after injury, athletes with post-injury amnesia or disorientation lasting more than 5 minutes had a more pronounced decrease in memory capacity than patients with impairment lasting less than 5 minutes; another study found that, relative to patients with only transient amnesia or transient loss of consciousness after injury, and patients who did not experience either of these categories of symptoms Another study found that patients with both transient amnesia and transient loss of consciousness had a more pronounced decline in functional capacity in the immediate post-injury period than those without transient amnesia or transient loss of consciousness; finally, another study showed that in hospitalized patients, those with transient amnesia had a significantly lower functional test score in the 24 hours after injury than those without the symptom.
2) Symptoms and cognitive function: one study demonstrated the relationship between patients’ subjective symptoms and objective cognitive and balance function test indices within 48 hours after injury, including: internal unpleasantness and reaction time (p=.03); sensory inability to attend to them and verbal memory (p=.01); recall difficulties and verbal memory (p<.001), and with reaction time (p=.03); balance impairment with compound sensation (p<.001), with proprioception (p=.03), with vision (p=.04), and with vestibular function (p<.001); dizziness with compound sensation ((p<.001), with vestibular function (p=.01). < p="">
Results of the analysis for question 4.
In this section, a total of 7 papers met the inclusion requirements. Of these, a total of 4 studies examined the interrelationship between CT and SSDs; the other 3 reported on the relationship between biomarkers and SSDs. In addition, all studies were inpatients: four included adult patients, two included adult and pediatric patients, and one included pediatric patients only.
Results: 1) CT: In all studies enrolled, CT examinations were performed within 24 hours of injury. Out of a total of 4803 patients, 360 had positive CT findings (7.5%); 2) biomarkers: the study found that within 4 hours after injury, the Glasgow score (13-14 vs. 15) was associated with plasma ubiquitin C-terminal hydrolase (ubiquitin C-terminal hydrolase) and glial fibrillary acidic protein ( glial fibrillary acidic protein) in plasma, respectively.
Finally, the researchers proposed the following research plan: some of the studies were not included in this systematic analysis because the results did not provide evidence that could be used directly to develop definitions or clinical diagnostic criteria, so the team will further analyze and explore the data from these studies and include them in a later systematic review; they will also include some of the larger studies that are currently underway in the future. They will also incorporate data from some of the larger studies currently underway (e.g., the RaDaR project funded by the U.S. Army Command) to further analyze and validate the concussion-related clinical features derived from this study in conjunction with retrospective and prospective studies, and ultimately develop new, standardized, and unified clinical guidelines for concussion diagnosis and treatment.