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Background Fluid therapy-the administration of fluids to maintain adequate organ tissue perfusion and oxygenation-is essential in patients admitted to the intensive care unit (ICU) with traumatic brain injury. We aimed to quantify the variability in fluid management policies in patients with traumatic brain injury and to study the effect of this variability on patients' outcomes.Methods We did a prospective, multicentre, comparative effectiveness study of two observational cohorts: CENTER-TBI in Europe and OzENTER-TBI in Australia. Patients from 55 hospitals in 18 countries, aged 16 years or older with traumatic brain injury requiring a head CT, and admitted to the ICU were included in this analysis. We extracted data on demographics, injury, and clinical and treatment characteristics, and calculated the mean daily fluid balance (difference between fluid input and loss) and mean daily fluid input during ICU stay per patient. We analysed the association of fluid balance and input with ICU mortality and functional outcome at 6 months, measured by the Glasgow Outcome Scale Extended (GOSE). Patient-level analyses relied on adjustment for key characteristics per patient, whereas centre-level analyses used the centre as the instrumental variable.Findings 2125 patients enrolled in CENTER-TBI and OzENTER-TBI between Dec 19, 2014, and Dec 17, 2017, were eligible for inclusion in this analysis. The median age was 50 years (IQR 31 to 66) and 1566 (74%) of patients were male. The median of the mean daily fluid input ranged from 1middot48 L (IQR 1middot12 to 2middot09) to 4middot23 L (3middot78 to 4middot94) across centres. The median of the mean daily fluid balance ranged from -0middot85 L (IQR -1middot51 to -0middot49) to 1middot13 L (0middot99 to 1middot37) across centres. In patient-level analyses, a mean positive daily fluid balance was associated with higher ICU mortality (odds ratio [OR] 1middot10 [95% CI 1middot07 to 1middot12] per 0middot1 L increase) a

In medical research, missing data is common. In acute diseases, such as traumatic brain injury (TBI), even well-conducted prospective studies may suffer from missing data in baseline characteristics and outcomes. Statistical models may simply drop patients with any missing values, potentially leaving a selected subset of the original cohort. Imputation is widely accepted by methodologists as an appropriate way to deal with missing data. We aim to provide practical guidance on handling missing data for prediction modeling. We hereto propose a five-step approach, centered around single and multiple imputation: 1) explore the missing data patterns; 2) choose a method of imputation; 3) perform imputation; 4) assess diagnostics of the imputation; and 5) analyze the imputed data sets. We illustrate these five steps with the estimation and validation of the IMPACT (International Mission on Prognosis and Analysis of Clinical Trials in Traumatic Brain Injury) prognostic model in 1375 patients from the CENTER-TBI database, included in 53 centers across 17 countries, with moderate or severe TBI in the prospective European CENTER-TBI study. Future prediction modeling studies in acute diseases may benefit from following the suggested five steps for optimal statistical analysis and interpretation, after maximal effort has been made to minimize missing data.

CONTEXT: Fatigue is prevalent among hemodialysis (HD) patients and associated with depressive mood. To advance our understanding of its etiology and develop appropriate treatments, reliable measurement instruments are needed. However, conventional fatigue and mood questionnaires are prone to bias due to their retrospective nature and may misrepresent or overestimate actual symptom experience (i.e., the so-called 'memory-experience' gap). Experience sampling Methodology (ESM) overcomes this limitation through repeated real-time assessments in patients' natural environment, thereby providing reliable and ecologically valid data.OBJECTIVES: We investigated to what extent retrospective symptom reporting accurately represents real-time experiences of fatigue and mood in HD patients using an ESM mobile Health application (PsyMateTM).METHODS: Forty HD patients used the PsyMateTM for one week to assess real-time fatigue and mood. Additionally, they retrospectively evaluated their symptom experience completing end-of-day and end-of-week questionnaires; and the conventional Fatigue Severity Scale (FSS) and Hospital Anxiety and Depression Scale (HADS).RESULTS: Results of real-time observations (N=1777) showed that fatigue and mood varied between and within individuals. Retrospective end-of-week fatigue evaluation was significantly higher than the average real-time fatigue score, t(38)=3.54, p=0.001, d=0.57. FSS and HADS correlated moderately to strong with the average ESM score for fatigue and mood: r=0.66 and r=0.77, respectively.CONCLUSION: Retrospective fatigue assessment may lead to overestimation of real-time symptom experience. ESM provides detailed insight and personalized information about symptom experiences which may be crucial for the design of more targeted and personalized interventions for fatigue and mood problems in HD patients.

OBJECTIVE: To investigate the effectiveness and feasibility of a Socratic feedback programme to improve awareness of deficits in patients with acquired brain injury (ABI).SETTING: Rehabilitation centre.PARTICIPANTS: Four patients with ABI with awareness problems.DESIGN: A series of single-case experimental design studies with random intervention starting points (A-B + maintenance design).MAIN MEASURES: Rate of trainer-feedback and self-control behaviour on everyday tasks, patient competency rating scale (PCRS), self-regulating skills interview (SRSI), hospital anxiety and depression scale.RESULTS: All patients needed less trainer feedback, the change was significant in 3 out of 4. One patient increased in overt self-corrective behaviour. SRSI performance increased in all patients (medium to strong effect size), and PCRS performance increased in two patients (medium and strong effect size). Mood and anxiety levels were elevated in one patient at the beginning of the training and decreased to normal levels at the end of the training. The feasibility of the programme was scored 9 out of 10.CONCLUSIONS: The Socratic feedback method is a promising intervention for improving awareness of deficits in patients with ABI. Controlled studies with larger populations are needed to draw more solid conclusions about the effect of this method.

OBJECTIVE: This study aimed to identify predictors of long-term consequences for activities and participation in children and adolescents with mild traumatic brain injury (mTBI).METHODS: A multicentre prospective longitudinal cohort study was conducted. The primary outcome measure was activities and participation measured with the Child and Adolescent Scale of Participation - CASP and completed by children (N = 156) and caregivers (N = 231) six months post-mTBI. The CASP items were categorized into home, community, school, and environment. Predictors were categorized according to the International Classification of Functioning, Disability and Health for Children and Youth. Predictors included pre-injury personal- and environmental factors, injury-related factors, symptoms, and resumption of activities in the first two weeks after mTBI. Univariate and multivariate logistic regression analyses were used to determine the predictive value of these factors.RESULTS: Results show that predictors differ across settings and perspectives (child or caregiver). Decreased activities and participation in children with mTBI can be predicted by adverse pre-injury behavioral functioning of the child (p < .000 - p = .038), adverse pre-injury family functioning (p = .001), lower parental SES (p = .038), more stress symptoms post-injury (p = .017 - p = .032), more post-concussive symptoms (p = .016 - p = .028) and less resumption of activities (p = .006 - p = .045).DISCUSSION: Pre-injury factors, more symptoms post-injury and less resumption of activities should be considered when children are screened for unfavorable outcomes. Additional factors may add to the prediction, but injury-related factors do not. It is recommended that future research explores psychosocial factors, such as coping styles, emotion-regulation, personality traits, social support, and other comorbid problems of both children and caregivers.

Objective: To investigate whether the ‘Brains Ahead! Intervention for children and adolescents with mild traumatic brain injury’ was implemented as intended. In addition, involvement in and satisfaction with the intervention among patients, caregivers and professionals delivering the intervention were studied. Design: Mixed methods, prospective study. Participants: Children with mild traumatic brain injury and their caregivers, allocated to the intervention group of the randomized controlled trial in the ‘Brains Ahead!’ study, and the two professionals providing the intervention. Intervention: The intervention consists of a standardized and individualized psychoeducational session with written take-home information, and follow-up telephone call(s). Main measures: Registration forms, evaluation questionnaires for patients and caregivers and semi-structured interviews for professionals. Data analysis: Qualitative data were categorized based on content. Quantitative data were reported as descriptive statistics. Results: Fifty-five patients and caregivers out of 60 study-participants attended both sessions. All elements of the intervention were delivered to 53 study-participants. Evaluation questionnaires were completed by 21 of the 31 patients aged 12 years and older, and by 41 caregivers. Overall, the sessions were considered useful by 19 patients, 40 caregivers and both professionals. Reassurance, creating a better understanding and recognition of symptoms were rated as important aspects. On a scale from 1 to 10, the intervention was rated by children, caregivers and professionals with 7.6 (SD 1.2), 8.1 (SD .9) and 8.0 (SD .0), respectively. Conclusion: The ‘Brains Ahead!’ intervention was largely implemented as intended and the process evaluation revealed that it is considered feasible according to patients, caregivers and professionals.