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Dr. Kevin Sheth: On shepherding outcomes data on traumatic brain injury

Wesolowski, Kierstin

doi: 10.1097/01.NT.0000387642.19629.1e

While tremendous progress has been made in the resuscitation and stabilization of patients with traumatic brain injury (TBI) over the past twenty years, there is still a great deal of equipoise when it comes to the day to day decision making in TBI,” said Kevin N. Sheth, assistant professor of neurology and neurosurgery, surgery, anesthesiology, and emergency medicine at the University of Maryland Medical Center. Dr. Sheth hopes to make an impact in that area — and his research and clinical focus have already gained traction in the field.

Dr. Sheth received the AAN Foundation Clinical Training Fellowship in April at the AAN annual meeting for his research on physiological predictors of outcome in TBI. In June, he became the first neurologist to serve at the University of Maryland Medical Center's R. Adams Cowley Shock Trauma Center. His appointment reflects a unique collaboration among the trauma, neurology, neurosurgery, and surgery departments, which will now feature the integration of clinical care and research for patients with CNS trauma.

Dr. Sheth earned his medical degree in 2003 from the University of Pennsylvania School of Medicine, and was the chief resident in neurology at Brigham and Women's Hospital/Massachusetts General Hospital from 2006 to 2007. He also received the AAN Resident Scholarship in 2007 and Medical Student Prize in 2003. In June, he joined the Neurology Today editorial advisory board.

In an interview with Neurology Today, Dr. Sheth discusses his novel research on predictors of outcome in TBI and how he hopes his research will impact patients and future research.

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The registry has two parts: The R. Adams Cowley Shock Trauma registry collects demographic and admission data for every patient that comes through Shock Trauma, which has been in place for at least for many years. The other part of the registry, which was developed within the past one to two years, has the ability to download and process continuous vital sign data for patients that come through Shock Trauma, including a patient's blood pressure, intracranial pressure, and body temperature to name a few variables.



Data from the trauma registry and the physiological data from the vital sign database have already been collected from a cohort of patients, which will be used for analysis that will begin soon. There's definitely going to be additional data collection, but over what time frame and how many patients will be included has yet to be defined.

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Previously, many of the known predictors of outcome for TBI have been non-modifiable risk factors, such as Glasgow Coma Scale scores or age. We hope to use our research registry and the high volume of patients to identify aspects related to clinical decision making, physiology, and neuroimaging that may be associated with poor outcome, and specifically, to look for potential therapeutic targets.

We'll evaluate the robust physiological data we have collected and will look for novel associations with outcome. For example, past studies have shown that one episode of hypotension is associated with poor outcome. Our data collection system allows us to look at blood pressure and other vital signs — intracranial pressure and cerebral perfusion pressure — over a broad time window to see if the total amount and duration of hypotension, or any abnormal vital sign, is more strongly associated with poor outcome rather than evaluating just one point in time.

We're also in the process of working with our radiology group to acquire diffusion tensor imaging and other MRI-based imaging to identify structural correlates that are associated with poor outcome. We plan to collect and analyze this data over the next one to two years before we begin our analysis. We will also evaluate our data to identify those measures that may be used for potential clinical trial endpoints.

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Currently, we're looking at the relationship between the quantification of intracranial pressure and outcomes. The next step in this research — which may be accomplished during my fellowship — will be to evaluate which medical therapy does a better a job of lowering a patient's intracranial pressure using these novel methods of quantifying elevated intracranial pressure.

We will also use imaging to see and evaluate differences in some patients who may have more brain swelling than others and perhaps use it as a basis to test therapies that minimize brain edema. Ultimately, this research is patient orientated, and we hope to use insights from the research to form the basis for clinical trials in the acute care of patients with traumatic and non-traumatic cerebral edema.

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I became interested in neuro-critical care partly because of the unique opportunity to become intimately involved with patients and their families; scientifically I found studying the physiology of acute brain injury to be rewarding. In some ways the logical approach to patients and their problems seemed to be a natural extension of the kind of thinking we're taught as neurologists, to examine a patient's problems as if assembling a puzzle — localize the lesion and form a differential diagnosis. In neuro-critical care, you're really putting two puzzles together: the clinical information melds with the physiologic and systems-based information to create a solution. Of all the diseases in the neuro-ICU, TBI is really the one where these principals are at the forefront of clinical care and decision-making, and I realized how much we still don't know about the daily decisions we make. In addition, TBI is the leading cause of death and disability for young adults, so it is a very serious problem.

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As a first year neurology resident, while rotating through the neuro-ICU, we were helping to take care of a man my age who had been in a motor vehicle collision and suffered multiple intracranial and systemic injuries; he had diffuse subarachnoid hemorrhage and bifrontal contusions, in addition to an extensive laparotomy and removal of his spleen.

For the next two weeks, I learned from my fellows and attendings about how sick patients like him need excellent critical care, and how for almost every organ system we touched, there was some unique way in which it interfaced with the brain. Also, communicating the complexity of his care, admittedly not knowing how things were going to turn out, was one of the most important things our team did. After a decompressive craniectomy, he left for a long course of rehabilitation, and a year later he walked into the ICU to visit with the ICU team.

In taking care of this one patient, I was able to be challenged by his degree of illness and stimulated by the complex physiology we faced every day. And in parallel, I tried to be a doctor for him and his family at a time of high emotional intensity. He was one of a handful of patients early on that strongly reinforced my desire to become a neuro-intensivist.

©2010 American Academy of Neurology