Methodological quality of multivariate prognostic models for intracranial haemorrhages in intensive care units: a systematic review.

OBJECTIVES: Patients with severe spontaneous intracranial haemorrhages, managed in intensive care units, face ethical issues regarding the difficulty of anticipating their recovery. Prognostic tools help clinicians in counselling patients and relatives and guide therapeutic decisions. We aimed to methodologically assess prognostic tools for functional outcomes in severe spontaneous intracranial haemorrhages. DATA SOURCES: Following Preferred Reporting Items for Systematic Reviews and Meta-Analyses recommendations, we conducted a systematic review querying Medline, Embase, Web of Science, and the Cochrane in January 2020. STUDY SELECTION: We included development or validation of multivariate prognostic models for severe intracerebral or subarachnoid haemorrhage. DATA EXTRACTION: We evaluated the articles following the CHecklist for critical Appraisal and data extraction for systematic Reviews of prediction Modelling Studies and Transparent Reporting of multivariable prediction model for Individual Prognosis Or Diagnosis statements to assess the tools' methodological reporting. RESULTS: Of the 6149 references retrieved, we identified 85 articles eligible. We discarded 43 articles due to the absence of prognostic performance or predictor selection. Among the 42 articles included, 22 did not validate models, 6 developed and validated models and 14 only externally validated models. When adding 11 articles comparing developed models to existing ones, 25 articles externally validated models. We identified methodological pitfalls, notably the lack of adequate validations or insufficient performance levels. We finally retained three scores predicting mortality and unfavourable outcomes: the IntraCerebral Haemorrhages (ICH) score and the max-ICH score for intracerebral haemorrhages, the SubArachnoid Haemorrhage International Trialists score for subarachnoid haemorrhages. CONCLUSIONS: Although prognostic studies on intracranial haemorrhages abound in the literature, they lack methodological robustness or show incomplete reporting. Rather than developing new scores, future authors should focus on externally validating and updating existing scores with large and recent cohorts.

Impact of routine S100B protein assay on CT scan use in children with mild traumatic brain injury.

OBJECTIVES: To evaluate the impact of implementing a modified Pediatric Emergency Care Applied Research Network (PECARN) rule including the S100B protein assay for managing mild traumatic brain injury (mTBI) in children. METHODS: A before-and-after study was conducted in a paediatric emergency department of a French University Hospital from 2013 to 2015. We retrospectively included all consecutive children aged 4 months to 15 years who presented mTBI and were at intermediate risk for clinically important traumatic brain injury (ciTBI). We compared the proportions of CT scans performed and of in-hospital observations before (2013-2014) and after (2014-2015) implementation of a modified PECARN rule including the S100B protein assay. RESULTS: We included 1,062 children with mTBI (median age 4.5 years, sex ratio [F/M] 0.73) who were at intermediate risk for ciTBI: 494 (46.5%) during 2013-2014 and 568 (53.5%) during 2014-2015. During 2014-2015, S100B protein was measured in 451 (79.4%) children within 6 h after mTBI. The proportion of CT scans and in-hospital observations significantly decreased between the two periods, from 14.4 to 9.5% (p=0.02) and 73.9-40.5% (p<0.01), respectively. The number of CT scans performed to identify a single ciTBI was reduced by two-thirds, from 18 to 6 CT scans, between 2013-2014 and 2014-2015. All children with ciTBI were identified by the rules. CONCLUSIONS: The implementation of a modified PECARN rule including the S100B protein assay significantly decreased the proportion of CT scans and in-hospital observations for children with mTBI who were at intermediate risk for ciTBI.

The Biomarker S100B and Mild Traumatic Brain Injury: A Meta-analysis.

CONTEXT: The usefulness of S100B has been noted as a biomarker in the management of mild traumatic brain injury (mTBI) in adults. However, S100B efficacy as a biomarker in children has previously been relatively unclear. OBJECTIVE: A meta-analysis is conducted to assess the prognostic value of S100B in predicting intracerebral lesions in children after mTBI. DATA SOURCES: Medline, Embase, the Cochrane Central Register of Controlled Trials (CENTRAL), Web of Science, Scopus, and Google Scholar. STUDY SELECTION: Studies including children suffering mTBI who underwent S100B measurement and computed tomography (CT) scans were included. DATA EXTRACTION: Of 1030 articles screened, 8 studies met the inclusion criteria. RESULTS: The overall pooled sensitivity and specificity were 100% (95% confidence interval [CI]: 98%-100%) and 34% (95% CI: 30%-38%), respectively. A second analysis was based on the collection of 373 individual data points from 4 studies. Sensitivity and specificity results, obtained from reference ranges in children with a sampling time <3 hours posttrauma, were 97% (95% CI: 84.2%-99.9%) and 37.5% (95% CI: 28.8%-46.8%), respectively. Only 1 child had a low S100B level and a positive CT scan result without clinically important traumatic brain injury. LIMITATIONS: Only patients undergoing both a CT scan and S100B testing were selected for evaluation. CONCLUSIONS: S100B serum analysis as a part of the clinical routine could significantly reduce the number of CT scans performed on children with mTBI. Sampling should take place within 3 hours of trauma. Cutoff levels should be based on pediatric reference ranges.

Reference ranges for serum S100B neuroprotein specific to infants under four months of age.

BACKGROUND: Minor head traumatisms are a common reason for consultation in paediatric emergency departments. The diagnosis of traumatic brain injuries involves performing a cranial computed tomography (CCT), associated with a risk of cancer due to the radiation. The serum S100B is an effective biomarker used to reduce reliance on CCT. While reference ranges have been determined, the limited number of cases regarding infants less than 4months of age has not allowed this biomarker to be used with this age group. Our study aimed to determine reference ranges for serum S100B based on a larger number of infants from birth to 4months of age. METHODS: Three centres included infants coming to the hospital for whom blood samples were taken. These samples were analysed to determine the upper reference values based on the 95th percentile. RESULTS: 135 samples were analysed. The upper reference value was 0.51µg/L for children aged 0 to 4months. There was no effect of the gender. CONCLUSIONS: This study provides serum S100B reference ranges based on the largest group of neurologically healthy 0 to 4-month-old infants analysed to date. Reliable reference values of S100B for children are now determined. It is the first step towards validation of thresholds for studies integrating S100B into a clinical decision rule for MHT in children.

[Minor traumatology in children]. / Petite traumatology chez l'enfant.

Small injuries in children are a very common reason of consultation in emergency departments or in primary care. Most of them could be managed in ambulatory care, with the precondition of knowing the diagnostic red flags, which require a specialised advice or hospital surveillance. Minor head traumas are managed according to a clinical decision rule, that identify children with a very low risk of intracranial injury, who do not need head CT scan nor hospital surveillance. Small bounds can be managed in ambulatory care if they are not located in risk areas and if the child is compliant. Bites are at risk of septic complication, or organic complication due to their potential depth, requiring a hospital care most of the time. Burns are still very common, causing significant morbidity in terms of aesthetic and functional disabilities. First aid or care is essential, as well as evaluating the severity of the burn to identify children who need to be referred to a specialist. Managing childhood fractures, considered most of the time as benign, requires knowing particular features depending on the age of the child, in order to appropriately diagnose, treat and follow the fracture.

Serum S100ß Neuroprotein Reduces Use of Cranial Computed Tomography in Children After Minor Head Trauma.

Minor head trauma is a common reason for consultation in pediatric emergency departments. In 2009, the Pediatric Emergency Care Applied Research Network (PECARN) published a clinical decision rule for its management. It aimed to help clinicians identify children with a very low risk of developing intracranial lesions, so that unnecessary cranial computed tomography (CCT) scan radiation could be avoided, as such exposure is associated with a rising risk of cancer in this young population. In the meantime, the serum S100ß neuroprotein showed encouraging results, with a 30% potential decrease in CCTs for the management of minor head traumas in adults and children. The aim of this study was to determine if the serum S100ß neuroprotein, associated with the PECARN clinical decision rule, could safely reduce the use of CCTs. We included children who were examined at the pediatric emergency department for minor head trauma, who underwent a CCT, whose blood samples were analyzed to determine the level of the serum S100ß protein. They were managed according to the PECARN clinical decision rule. We afterward assessed the potential decrease in the number of CCTs, according to a modified PECARN clinicobiological decision rule, had we taken into account the result of the blood tests. One hundred nine children were included, and nine of them had clinically important traumatic brain injury. Four of them had a negative S100ß value but were classified as high risk of developing intracranial lesion according to the PECARN clinical decision rule. Had we taken into account the modified PECARN clinicobiological decision rule, none of them would have been missed. However, there were 32 true negatives of the rule, allowing a potential decrease in CCTs rated at 29% (95% confidence interval, 21-38). Integrating the serum S100ß neuroprotein assessment in the PECARN clinical decision rule could avoid deleterious exposure to CCT radiation, with the condition of using a clinicobiological rule to avoid missing clinically important traumatic brain injuries. Those results have yet to be confirmed relying on a large multicentric study.