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LETTER TO EDITOR
Year : 2022  |  Volume : 49  |  Issue : 2  |  Page : 217-218

Overdiagnosis and underdiagnosis in traumatic brain injury: A reality in the management of neurotrauma


1 Department of Research, Independent University, Dhaka, Bangladesh
2 Department of Critical Care Medicine, Physician Regional Medical Center, Naples, FL, USA
3 Department of Neurosurgery, Holy Family Red Crescent, Medical College, Dhaka, Bangladesh
4 Neurocritical Care, Colombian Clinical Research Group in Neurocritical Care, Cartagena, Colombia

Date of Submission08-Mar-2022
Date of Acceptance19-Apr-2022
Date of Web Publication23-Aug-2022

Correspondence Address:
Luis Rafael Moscote-Salazar
Neurocritical Care, Colombian Clinical Research Group in Neurocritical Care, Bogota
Colombia
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jss.jss_45_22

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How to cite this article:
Rahman S, Janjua T, Rahman M, Picon-Jaimes YA, Lozada-Martinez ID, Moscote-Salazar LR. Overdiagnosis and underdiagnosis in traumatic brain injury: A reality in the management of neurotrauma. J Sci Soc 2022;49:217-8

How to cite this URL:
Rahman S, Janjua T, Rahman M, Picon-Jaimes YA, Lozada-Martinez ID, Moscote-Salazar LR. Overdiagnosis and underdiagnosis in traumatic brain injury: A reality in the management of neurotrauma. J Sci Soc [serial online] 2022 [cited 2022 Oct 3];49:217-8. Available from: https://www.jscisociety.com/text.asp?2022/49/2/217/354274



The care of patients with traumatic brain injury (TBI) in all its presentations requires a thorough clinical examination and complementary tests to define subsequent management. Unfortunately, during the evaluation, we can fall into unnecessary measures that force us to reflect on whether our clinical practice is the most appropriate. Two important concepts that we want to point out are over- and underdiagnosis in patients with TBI.


  Overdiagnosis Top


The prevalence of overtesting, overdiagnosing, and overtreating in modern medicine has been brought to light over the last decade.[1] Overdiagnosis has implications for health systems, sometimes turning a stable patient into a sick one.[2] This directly affects patients and health-care systems. For patients, when diagnosed with a condition that does not impact the outcome, that can lead to unnecessary anxiety for the family. To health-care systems, turning a minor head injury into a traumatic injury for the sake of billing, very frequent in privatized health systems that depend on production, will entail uneven and inadequate TBI statistics. TBI patients will get many imaging studies, including computed tomography scans. These can be harmful in younger patients with future risk for radiation-induced brain injury.[2] The availability of portable imaging systems is without major risk as the radiation dose is much higher as compared to ultrafast stationary imaging systems.[2] The utility of neuromonitoring is important, but a good clinical neurologic examination cannot be replaced with unnecessarily prolonged monitoring with equipment such as video electroencephalography.[2] Overdiagnosis of combat-related mild TBI (mTBI) might stigmatize and lower expectations, lowering self-confidence, and resulting in poorer outcomes.[3] As a result of the pursuit of inefficient or inappropriate treatment, there is a risk of adverse effects and a great deal of frustration.[3] Overtesting with sophisticated imaging raises the potential of injury from the inherent danger of the test. Another problem is overtreatment, which is related to the basic issue of overdiagnosis, which is that no one recognizes the overdiagnosed person at the point of care.[1],[4]

Underdiagnosis

Multiple treatment modalities are used to stabilize, improve, and reduce the morbidity in TBI. These modalities are not without risk and require frequent monitoring. Initiation of hypertonic saline, sedation, pain control, anxiolytics, etc., needs to be used in the correct perspective. These can be used when a diagnosis of TBI is made. There are other reasons to be less alert with minor head injury with clearly no TBI. Patients can be intoxicated with alcohol, drugs, uremia, liver failure, and hypercarbia. Older patients presenting with falls and “TBI” with confusion are probably septic from urinary tract infection or pneumonia, as confusion is very common in the elderly with acute pulmonary infection.

Initiatives such as “too much medicine” led by the British Medical Journal and “Choosing Wisely” have been created to create awareness for the rational use of resources. The purpose of these efforts is that the indication of diagnostic procedure is evidence based.

Health professionals should be encouraged to know the economic implications of requesting studies automatically. There should be a more prudent use of resources. Although defensive medicine is one of the explanations, with the support of evidence-based clinical judgment, it is reasonable to hold investigations and procedures.

mTBI is much harder to characterize and is likely underdiagnosed. Estimates of the prevalence range from 100 to 600/100,000 individuals each year.[5] Overdiagnosis of sports-related mTBI might limit athletic participation needlessly, causing professional players' careers to be jeopardized.[3] Before diffusion imaging for mTBI can be widely adopted, the underdiagnosis–overdiagnosis trade-off must be addressed. Because it can deceive doctors into assuming that brain injury does not exist in the absence of abnormal diffusion measures, unrestricted reliance on diffusion imaging for mTBI diagnosis could lead to underdiagnosis. Other imaging methods have overshot the underdiagnosis chasm, resulting in a bloated condition of overdiagnosis, and the neuroimaging community must learn from these missteps. The lack of an interdisciplinary consensus on what constitutes an mTBI adds to the problem of mTBI's potential underdiagnosis.[6] Traumatic axonal damage has been shown to be is a good predictor of poor long-term survival.[5],[7] However, due to a lack of techniques with adequate detection thresholds, it is commonly underdiagnosed, particularly in mTBI.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Carpenter CR, Raja AS, Brown MD. Overtesting and the downstream consequences of overtreatment: Implications of “preventing overdiagnosis” for emergency medicine. Acad Emerg Med 2015;22:1484-92.  Back to cited text no. 1
    
2.
Singh H, Dickinson JA, Thériault G, Grad R, Groulx S, Wilson BJ, et al. Overdiagnosis: Causes and consequences in primary health care. Can Fam Physician 2018;64:654-9.  Back to cited text no. 2
    
3.
Ware JB, Jha S. Balancing underdiagnosis and overdiagnosis: The case of mild traumatic brain injury. Acad Radiol 2015;22:1038-9.  Back to cited text no. 3
    
4.
Welch HG. Overdiagnosed: Making People Sick inthe Pursuit of Health. Boston, MA: Beacon Press; 2011.  Back to cited text no. 4
    
5.
Park E, Bell JD, Baker AJ. Traumatic brain injury: Can the consequences be stopped? CMAJ 2008;178:1163-70.  Back to cited text no. 5
    
6.
Prince C, Bruhns ME. Evaluation and treatment of mild traumatic brain injury: The role of neuropsychology. Brain Sci 2017;7:105.  Back to cited text no. 6
    
7.
King JT Jr., Carlier PM, Marion DW. Early Glasgow Outcome Scale scores predict long-term functional outcome in patients with severe traumatic brain injury. J Neurotrauma 2005;22:947-54.  Back to cited text no. 7
    




 

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