Should we have a guard against therapeutic nihilism for patients with severe traumatic brain injury?

Hirschi, Ryan; Rommel, Casey; Hawryluk, Gregory

doi:10.4103/1673-5374.219037

Cited by 21 publications

(14 citation statements)

References 10 publications

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“…Problematic qualities for clinicians included being poorly informed, misinformed, or perpetuating stigmatising attitudes and therapeutic nihilism (an inappropriately pessimistic view regarding the potential benefits of treatment) [ 72 ] about CEN. Some sources identified underlying problems as lack of training in working with people with CEN, poor empathy, and understanding, or a perception of people with CEN as “difficult”.…”

Section: Resultsmentioning

confidence: 99%

Service user experiences of community services for complex emotional needs: A qualitative thematic synthesis

et al. 2021

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Background There is a recognised need to develop clear service models and pathways to provide high quality care in the community for people with complex emotional needs, who may have been given a “personality disorder” diagnosis. Services should be informed by the views of people with these experiences. Aims To identify and synthesise qualitative studies on service user experiences of community mental health care for Complex Emotional Needs. Methods We searched six bibliographic databases for papers published since 2003. We included peer reviewed studies reporting data on service user experiences and views about good care from community-based mental health services for adults with CEN, including generic mental health services and specialist “personality disorder” services. Studies using any qualitative method were included and thematic synthesis used to identify over-arching themes. Results Forty-seven papers were included. Main themes were: 1) The need for a long-term perspective on treatment journeys; 2) The need for individualised and holistic care; 3) Large variations in accessibility and quality of mental health services; 4) The centrality of therapeutic relationships; 5) Impacts of ‘personality disorder’ diagnosis. Themes tended to recur across studies from different countries and years. Discussion Recurrent major themes included wanting support that is individualised and holistic, provides continuity over long journeys towards recovery, and that is delivered by empathetic and well-informed clinicians who are hopeful but realistic about the prospects of treatment. Care that met these simple and clearly stated priorities tended to be restricted to often limited periods of treatment by specialist “personality disorder” services: generic and primary care services were often reported as far from adequate. There is an urgent need to co-design and test strategies for improving long-term support and treatment care for people with “personality disorders” throughout the mental health care system.

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Section: Resultsmentioning

confidence: 99%

Service user experiences of community services for complex emotional needs: A qualitative thematic synthesis

et al. 2021

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“…Letsinger et al 9 conducted a survey of neurotrauma practitioners and reported that, among surgeons aware of the IMPACT calculator, 53.3% use it to inform clinical decision making at least part of the time. Hirschi et al 14 reported integrating the IMPACT TBI prognostic calculator into their clinical practice's electronic health record to support clinical decision support (at the request of staff clinicians). This strays from the intended use of prognostic models such as CRASH and IMPACT, which were developed to inform the design, randomization, and analysis of future randomized controlled trials in TBI.…”

Section: %mentioning

confidence: 99%

Prognostic Models for Traumatic Brain Injury Have Good Discrimination but Poor Overall Model Performance for Predicting Mortality and Unfavorable Outcomes

et al. 2022

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BACKGROUND:The most extensively validated prognostic models for traumatic brain injury (TBI) are the Corticoid Randomization after Significant Head Injury (CRASH) and International Mission on Prognosis and Analysis of Clinical Trials (IMPACT). Model characteristics outside of area under the curve (AUC) are rarely reported. OBJECTIVE: To report the discriminative validity and overall model performance of the CRASH and IMPACT models for prognosticating death at 14 days (CRASH) and 6 months (IMPACT) and unfavorable outcomes at 6 months after TBI. METHODS: This retrospective cohort study included prospectively collected patients with severe TBI treated at a single level I trauma center (n = 467). CRASH and IMPACT percent risk values for the given outcome were computed. Unfavorable outcome was defined as a Glasgow Outcome Scale-Extended score of 1 to 4 at 6 months. Binary logistic regressions and receiver operating characteristic analyses were used to differentiate patients from the CRASH and IMPACT prognostic models. RESULTS: All models had low R 2 values (0.17-0.23) with AUC values from 0.77 to 0.81 and overall accuracies ranging from 72.4% to 78.3%. Sensitivity (35.3-50.0) and positive predictive values (66.7-69.2) were poor in the CRASH models, while specificity (52.3-53.1) and negative predictive values (58.1-63.6) were poor in IMPACT models. All models had unacceptable false positive rates (20.8%-33.3%). CONCLUSION: Our results were consistent with previous literature regarding discriminative validity (AUC = 0.77-0.81). However, accuracy and false positive rates of both the CRASH and IMPACT models were poor.

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“…Despite poor predictive ability, many neurotrauma clinicians do use the IMPACT or CRASH calculator to inform clinical decision making, including withdrawal-of-care decisions. 20 , 22 …”

Section: Discussionmentioning

confidence: 99%

Performance of CRASH and IMPACT Prognostic Models for Traumatic Brain Injury at 12 and 24 Months Post-Injury

Eagle

Nwachuku

Elmer

et al. 2023

Neurotrauma Reports

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The Corticoid Randomization after Significant Head Injury (CRASH) and International Mission for Prognosis and Analysis of Clinical Trials (IMPACT) prognostic models are the most reported prognostic models for traumatic brain injury (TBI) in the scientific literature. However, these models were developed and validated to predict 6-month unfavorable outcome and mortality, and growing evidence supports continuous improvements in functional outcome after severe TBI up to 2 years post-injury. The purpose of this study was to evaluate CRASH and IMPACT model performance beyond 6 months post-injury to include 12 and 24 months post-injury. Discriminative validity remained consistent over time and comparable to earlier recovery time points (area under the curve = 0.77–0.83). Both models had poor fit for unfavorable outcomes, explaining less than one quarter of the variation in outcomes for severe TBI patients. The CRASH model had significant values for the Hosmer-Lemeshow test at 12 and 24 months, indicating poor model fit past the previous validation point. There is concern in the scientific literature that TBI prognostic models are being used by neurotrauma clinicians to support clinical decision making despite the goal of the models' development being to support research study design. The results of this study indicate that the CRASH and IMPACT models should not be used in routine clinical practice because of poor model fit that worsens over time and the large, unexplained variance in outcomes.

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Should we have a guard against therapeutic nihilism for patients with severe traumatic brain injury?

Cited by 21 publications

References 10 publications

Service user experiences of community services for complex emotional needs: A qualitative thematic synthesis

Service user experiences of community services for complex emotional needs: A qualitative thematic synthesis

Prognostic Models for Traumatic Brain Injury Have Good Discrimination but Poor Overall Model Performance for Predicting Mortality and Unfavorable Outcomes

Performance of CRASH and IMPACT Prognostic Models for Traumatic Brain Injury at 12 and 24 Months Post-Injury

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