Predicting Outcomes in Children with Mild Traumatic Brain Injury

描述(由申请人提供)：医疗保健提供者面临的一个关键决定是如何在急性情况下预测哪些儿童在轻度创伤性脑损伤(TBI)后将遭受持续性脑震荡后症状(PCS)和功能障碍。每年有450,000名15岁以下的青少年发生轻微的脑外伤，并可能导致与严重的功能障碍相关的持续性症状。建议采用多种方法对轻度脑外伤儿童进行诊断评估：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成像。然而，以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在临床环境中常用的诊断方法在预测持续性PCS和功能损害方面的实用性。参与者将包括在两家大型儿童医院的急诊科招募的8至15岁患有轻度脑外伤(n=200)或轻度骨科损伤(n=100)的儿童。在招募时，将使用标准化方法评估脑震荡的急性症状和症状，以及精神状态和平衡。所有儿童将在受伤后7天内完成计算机化的神经心理测试和磁共振成像(MRI)。在受伤后的头6个月内，将使用电子设备每周远程评估PC。功能障碍将在受伤后3个月和6个月进行亲自评估。其他潜在的混淆(例如，儿童病前的功能；努力；疼痛；症状夸大)也将被评估。这项拟议的研究是创新的，因为以前没有研究比较过这些评估儿童轻度脑外伤常用方法的预测效用。其他创新包括在家中通过电子设备收集PCS的评级，以获得参与者的实时数据；使用一种在运动脑震荡研究中常用但尚未在轻度脑损伤儿童中进行研究的简单测量来评估平衡；使用新开发的计算机化神经心理测试单元来评估认知能力；以及使用能够检测微小异常的较新MRI序列(即SWI、DTI)。我们的具体目标是(1)检查轻度脑外伤后PCS和功能损害的预测，以及(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和功能损害的独立和联合作用：(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实用指数进行评估。对这些诊断方法及其在预测结果方面的增量效用进行全面研究，将有助于改善预后判断、开发决策工具和集中治疗努力，从而对临床实践产生重大影响，特别是在急性护理环境中。

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.