Predicting Outcomes in Children with Mild Traumatic Brain Injury

描述（由申请人提供）：卫生保健提供者面临的一个关键决策是如何在急性环境中预测轻度创伤性脑损伤（TBI）后哪些儿童会出现持续的震荡后症状（PCS）和功能障碍。轻度创伤性脑损伤每年发生在150万15岁以下的青少年中，可导致与显著功能损伤相关的持续症状。对轻度TBI儿童的诊断评估推荐多种方法：表现体征/症状评估、急性精神状态检查和平衡测试、神经心理测试和神经影像学。然而，之前没有研究系统地比较这些方法的预后意义。拟议项目的总体目标是检查临床环境中常用的诊断方法在预测持续性PCS和功能障碍方面的效用。参与者将包括在两家大型儿童医院的急诊科（ED）招募的8- 15岁的轻度TBI儿童（n = 200）或轻度骨科损伤儿童（n = 100）。在招募时，将使用标准化方法评估脑震荡的急性体征和症状，以及精神状态和平衡。所有儿童将在受伤后7天内完成计算机神经心理测试和磁共振成像（MRI）。在受伤后的前6个月内，PCS将每周使用电子设备进行远程评估。功能损伤将在损伤后3个月和6个月进行评估。其他潜在的混淆（例如，儿童的病前功能、努力、疼痛、症状夸大）也将被评估。这项研究具有创新性，因为之前没有研究比较这些常用方法在评估儿童轻度创伤性脑损伤方面的预测效用。其他创新包括收集家用电子设备上个人电脑的评分，以获取参与者的实时数据；使用运动脑震荡研究中常用的一种简单测量方法评估平衡，但尚未在轻度TBI儿童的广泛样本中进行研究；使用新开发的计算机化神经心理学测试来评估认知能力；并采用能够检测细微异常（即SWI， DTI）的较新的MRI序列。我们的具体目标是：(1)研究轻度脑外伤后PCS和功能损伤的预测；(2)确定四种评估方法中每一种的增量预测效用。统计分析将评估四组变量对预测PCS和功能障碍的独立和综合贡献：(a)出现体征/症状；(b)急性精神状态和平衡测试；(c)神经心理测试；(d)神经成像。预测将使用混合模型以及传统的临床效用指标进行评估。对这些诊断方法的全面研究及其在预测结果方面的增量效用将对临床实践产生重大影响，特别是在急性护理环境中，通过帮助改善预后确定、开发决策工具和集中治疗工作。

DESCRIPTION (provided by applicant): A critical decision confronting health care providers is how to predict in the acute setting which children will suffer persistent postconcussive symptoms (PCS) and functional impairments after mild traumatic brain injury (TBI). Mild TBI occur in >450,000 youth under 15 years of age annually and can result in persistent symptoms associated with significant functional impairments. Various methods are recommended for the diagnostic evaluation of children with mild TBI: assessment of presenting signs/symptoms, acute mental status examination and balance testing, neuropsychological testing, and neuroimaging. However, no previous study has systematically compared the prognostic significance of these methods. The overall goal of the proposed project is to examine the utility of diagnostic methods commonly used in clinical settings in the prediction of persistent PCS and functional impairments. Participants will include 8- to 15-year-old children with mild TBI (n = 200) or mild orthopedic injuries (n = 100), recruited in the Emergency Departments (ED) at two large children's hospitals. Acute signs and symptoms of concussion, as well as mental status and balance, will be assessed using standardized methods at the time of recruitment. All children will complete computerized neuropsychological testing and magnetic resonance imaging (MRI) within 7 days of injury. PCS will be assessed remotely on a weekly basis using electronic devices during the first 6 months post injury. Functional impairments will be assessed in person acutely and 3 and 6 months post injury. Other potential confounds (e.g., children's premorbid functioning; effort; pain; symptom exaggeration) also will be assessed. The proposed research is innovative because no previous study has compared the predictive utility of these commonly-used methods for assessing pediatric mild TBI. Additional innovations include collecting ratings of PCS at home on electronic devices to obtain real-time data from participants; assessing balance using a simple measure commonly employed in sports concussion research but not yet studied in a broad sample of children with mild TBI; using a newly-developed, computerized neuropsychological test battery to assess cognitive abilities; and employing newer MRI sequences capable of detecting subtle abnormalities (i.e., SWI, DTI). Our specific aims are (1) to examine the prediction of PCS and functional impairments following mild TBI and (2) to determine the incremental predictive utility of each of four assessment methods. Statistical analyses will assess the independent and combined contributions of four sets of variables to the prediction of PCS and functional impairments: (a) presenting signs/symptoms; (b) acute mental status and balance testing; (c) neuropsychological testing; and (d) neuroimaging. Prediction will be evaluated using mixed models, as well as traditional indices of clinical utility. A comprehensive study of these diagnostic methods and their incremental utility in predicting outcomes will have a major impact on clinical practice, particularly in acute care settings, by helping improve prognostic determinations, develop decision tools, and focus treatment efforts.