David K Menon
In the past decade, evidence-based medicine has guided treatment of traumatic brain injury (TBI), with an increased number of systematic reviews leading to standardised treatment guidelines. Although some success has been achieved with this approach, it ignored substantial injury-specific and patient-specific variability. Clinical trials during this time had similar limitations because they unsuccessfully targeted discrete disease mechanisms in the hope of finding a magic bullet that would universally benefit all patients with TBI, and ignored underlying interindividual pathophysiological heterogeneity. In the past year there has been a shift in thinking, and recognition of the need for better, more uniform characterisation to guide management. Such characterisation, together with new developments, provides opportunities for personalised approaches to clinical management.
In a humorous persiflage of systematic reviews, Kamp and colleagues analysed the epidemiology and risk factors of TBI in Asterix, an illustrated series of comic books documenting the adventures of the characters as they defend their village against Roman occupation. Limitations acknowledged by the authors include the retrospective design, variability in documentation, and incomplete outcome assessment at variable times, all of which are issues relevant to many more serious studies. A recent international and interagency initiative has recognised the importance of standardisation of data collection and coding, and has developed common data elements for clinical variables, neuroimaging, biomarkers, and outcome data in clinical studies.1 The full scope of the clinical data recommendations,2 with examples of how to build a case report form, was published this year and is now being developed into open-access web-based formats. These approaches will help with comparisons between meta-analyses based on individual patient data.
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