A comprehensive picture of 4-year outcome of severe brain injuries. Results from the PariS-TBI study

A Detailed Overview of Long-Term Outcomes in Severe Traumatic Brain Injury Eight Years Post-injury

Background and aims: Severe traumatic brain injury is a leading cause of acquired persistent disabilities, and represents an important health and economic burden. However, the determinants of long-term outcome have rarely been systematically studied in a prospective longitudinal study of a homogeneous group of patients suffering exclusively from severe TBI

Methods: Prospective observational study of an inception cohort of adult patients with severe traumatic brain injury in the Parisian area (PariS-TBI). Outcome was assessed with face-to-face interview 8 years after Traumatic Brain Injury, focusing on impairments, activity limitations, and participation restriction.

Results: Five hundred and four patients were included between 2005 and 2007. At 8-year follow-up, 261 patients were deceased, 128 were lost to follow-up, 22 refused to participate, and 86 were finally evaluated. Age, gender, initial injury severity did not significantly differ between evaluated patients and lost to follow-up, but the latter were more frequently students or unemployed. Mean age was 41.9 (SD 13.6), 79% were male, median initial Glasgow Coma Scale Score was 6. The most frequent somatic complaints concerned balance (47.5%), motricity (31%), and headaches (36%), but these were less frequent than cognitive complaints (Memory 71%, Slowness 68%, Concentration 67%). According to the Hospital Anxiety and Depression Scale (HADS), 25 % had a score >8 for anxiety and 23.7% for depression. According to the Extended Glasgow Outcome Scale, 19.8% remained severely disabled, 46.5% moderately disabled, 33.7% had a good recovery. Older age, longer education duration, lower functional status upon intensive care discharge, and more severe 8-year dysexecutive problems were significantly associated with a lower Extended Glasgow Outcome Scale score in multivariable analysis. At 8 years, 48.7% of patients were employed in a productive job. Of those, 38% declared a salary loss since traumatic brain injury. Unemployment was significantly associated with lower 1-year GOSE score and more severe 8-year dysexecutive problems.

Conclusions: These results from an inception cohort study highlight the fact that long-term outcome after severe TBI is determined by a complex combination of injury-related, demographic and neuropsychological factors. Long after the injury, persisting impairments still interfere with social integration, and participation.

Loss of friendship following traumatic brain injury: A model grounded in the experience of adults with severe injury

Relationships make important contributions to wellbeing and maintenance of self-worth. For those who sustain traumatic brain injury (TBI), life is frequently characterized by declining interpersonal relationships. The aim of this study was to understand the post-injury experience of friendship from the perspective of adults with severe TBI. Participants were 23 adults who had sustained severe TBI on average 10 years earlier; the majority was between 25 and 45 years old. The experience of friendship was explored using a convergent mixed methods design (quantitative self-report measures and in-depth interviews). Qualitative analysis of interview transcripts employed open and focussed coding to reveal themes and categories. Participants nominated on average 3.35 (SD 2.19) friends. When paid carers and family members were excluded, the mean dropped to 1.52 (SD 1.38). Exploratory correlations between number of friends and quality of life, depression and strong-tie support revealed significant associations of moderate to large effects. The post-injury experience of friendship was broadly conceptualized as "going downhill" with four overlapping phases: losing contact, being misunderstood, wanting to share and hanging on. Participants' stories illustrated how rehabilitation can focus on friendship by supporting established relationships and facilitating access to activities that afford interpersonal encounters and opportunities to share experiences.

Traumatic brain injured patients: primum non nocere

PURPOSE OF REVIEW

Traumatic brain injury (TBI) remains an unfortunately common disease with potentially devastating consequences for patients and their families. However, it is important to remember that it is a spectrum of disease and thus, a one 'treatment fits all' approach is not appropriate to achieve optimal outcomes. This review aims to inform readers about recent updates in prehospital and neurocritical care management of patients with TBI.

RECENT FINDINGS

Prehospital care teams which include a physician may reduce mortality. The commonly held value of SBP more than 90 in TBI is now being challenged. There is increasing evidence that patients do better if managed in specialized neurocritical care or trauma ICU. Repeating computed tomography brain 12 h after initial scan may be of benefit. Elderly patients with TBI appear not to want an operation if it might leave them cognitively impaired.

SUMMARY

Prehospital and neuro ICU management of TBI patients can significantly improve patient outcome. However, it is important to also consider whether these patients would actually want to be treated particularly in the elderly population.

The Things that Help, the Things that Get in the Way: Working Together to Improve Outcome Following Acquired Brain Injury

Working in neurological rehabilitation brings with it numerous opportunities to gain an understanding of the factors that contribute to shaping meaningful living and wellbeing for those tackling the major life changes encountered following acquired brain injury (ABI). These opportunities come in many forms: challenging and brave clients, wise and worrying families, questioning and inspiring colleagues, empowering and limiting work environments and rigid and advancing policy and legislative contexts.

Our personal and collective understanding ofthe things that helpandthe things that get in the wayof effective rehabilitation continuously emerges from the convergence of the experience and knowledge afforded by these opportunities. The aim of this paper is to considerthe things that helpandthe things that get in the wayas they have been identified by people with ABI, their families and those who work with them and have been further evidenced through research targeted towards improving short, medium and long-term outcomes for those living with the consequences of ABI. Thesethingsas discussed in this paper capture the essential role of the self, the importance of rights and access to rehabilitation, the impact of the family and the contribution of social connection.

Pain with traumatic brain injury and psychological disorders

Traumatic brain injury (TBI) is the cause for long-term disability in more than 3 million patients in the US alone, with chronic pain being the most frequently reported complain. To date, predisposing mechanisms for chronic pain in TBI patients are largely unknown. Psychological disorders, including post-traumatic stress disorder, depression and anxiety following TBI are commonly reported comorbidities to post-traumatic pain. Long term consequences can be debilitating and affect quality of life even when the injury is mild. In this review, we present the most commonly reported chronic pain conditions across the spectrum of severity of TBI, mainly focusing on mild TBI. We discuss chronic post- traumatic headaches, widespread pain as well as post-traumatic central pain. We discuss pain in the context of injury severity and military versus civilian populations. We are only starting to understand the biological mechanisms behind post-traumatic pain and associated psychological distress following TBI, with genetic, biochemical and imaging studies pointing to the dopaminergic, neurotrophic factors and the role of Apolipoprotein. Physiological and neurological mechanisms are proposed to partially explain this interaction between post-traumatic pain and psychological distress. Nevertheless, the evidence for the role of structural brain damage remains incomplete and to a large extent debatable, as it is still difficult to establish clear causality between brain trauma and chronic pain. Finally, general aspects of management of chronic pain post-TBI are addressed.

Friendship Quality, Friendship Quantity, and Social Participation in Adults with Traumatic Brain Injury

Adults with traumatic brain injury (TBI) often report reduced social participation and loss of friends, but little is known about quality of friendship after TBI. Our objective was to characterize social participation, friendship quantity, and friendship quality of adults with TBI and a comparison group of uninjured adults. Participants included 18 adults with moderate to severe TBI and 16 of their informant friends; and 18 uninjured adults and 11 of their informant friends. The main measures used were the Participation Assessment with Recombined Tools-Objective, the Social Network Questionnaire, and the McGill Friendship Questionnaire. Participants with TBI reported significantly less social participation and had fewer total friends, although this difference was not statistically significant. Adults with TBI differed from their friends on one measure of friendship quality, but reports for friendship quality were high in both groups. Adults with TBI reported overall high levels of friendship quality despite having lower levels of social participation compared with uninjured adults. Future research should investigate how the balance of quantity and quality of friendships relates to satisfaction with social participation and overall quality of life.

Systematic Review of Caregiver and Dyad Interventions After Adult Traumatic Brain Injury

OBJECTIVE

To describe and synthesize the literature on adult traumatic brain injury (TBI) family caregiver and dyad intervention. TBI is a common injury that has a significant long-term impact, and is sometimes even characterized as a chronic condition. Informal (ie, unpaid) family caregivers of adults with TBI experience high rates of burnout, depression, fatigue, anxiety, lower subjective well-being, and poorer levels of physical health compared to noncaregivers. This study addresses the critical gap in the understanding of interventions designed to address the impact of TBI on adult patients and their family caregivers.

DATA SOURCES

PubMed and MEDLINE.

STUDY SELECTION

Studies selected for review had to be written in English and be quasi-experimental or experimental in design, report on TBI caregivers, survivors with heavy involvement of caregivers, or caregiver dyads, involve moderate and severe TBI, and describe an intervention implemented during some portion of the TBI care continuum.

DATA EXTRACTION

The search identified 2171 articles, of which 14 met our criteria for inclusion. Of the identified studies, 10 were randomized clinical trials and 4 were nonrandomized quasi-experimental studies. A secondary search to describe studies that included individuals with other forms of acquired brain injury in addition to TBI resulted in 852 additional titles, of which 5 met our inclusion criteria.

DATA SYNTHESIS

Interventions that targeted the caregiver primarily were more likely to provide benefit than those that targeted caregiver/survivor dyad or the survivor only. Many of the studies were limited by poor fidelity, low sample sizes, and high risk for bias based on randomization techniques.

CONCLUSIONS

Future studies of TBI caregivers should enroll a more generalizable number of participants and ensure adequate fidelity to properly compare interventions.

The Development of Two New Computer Adaptive Tests To Evaluate Feelings of Loss in Caregivers of Individuals With Traumatic Brain Injury: TBI-CareQOL Feelings of Loss-Self and Feelings of Loss-Person With Traumatic Brain Injury

OBJECTIVE

To develop new patient-reported outcome (PRO) measures to better understand feelings of loss in caregivers of individuals with traumatic brain injury (TBI).

DESIGN

Cross-sectional survey study.

SETTING

Three TBI Model Systems rehabilitation hospitals, an academic medical center, and a military medical treatment facility.

PARTICIPANTS

Caregivers (N=560) of civilians with TBI (n=344) or service members/veterans (SMVs) with TBI (n=216).

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Traumatic Brain Injury Caregiver Quality of Life (TBI-CareQOL) Feelings of Loss-Self and TBI-CareQOL Feelings of Loss-Person with Traumatic Brain Injury item banks.

RESULTS

While the initial exploratory and confirmatory factor analyses of the feelings of loss item pool (98 items) potentially supported a unidimensional set of items, further analysis indicated 2 different factors: Feelings of Loss-Self (43 items) and Feelings of Loss-Person with TBI (20 items). For Feelings of Loss-Self, an additional 13 items were deleted due to item-response theory-based item misfit; the remaining 30 items had good overall model fit (comparative fit index [CFI]=0.96, Tucker-Lewis index [TLI]=.96, root mean squared error of approximation [RMSEA]=.10). For Feelings of Loss-Other, 1 additional item was deleted due to an associated high correlated error modification index value; the final 19 items evidenced good overall model fit (CFI=0.97, TLI=.97, RMSEA=.095). The final item banks were developed to be administered as either a Computer Adaptive Test (CAT) or a short-form (SF). Clinical experts approved the content of the 6-item SFs of the 2 measures (3-week test-retest was r=.87 for Feelings of Loss-Self and r=.85 for Feelings of Loss-Person with TBI).

CONCLUSIONS

The findings from this study resulted in the development of 2 new PROs to assess feelings of loss in caregivers of individuals with TBI; TBI-CareQOL Feelings of Loss-Self and TBI-CareQOL Feelings of Loss-Person with TBI. Good psychometric properties were established and an SF was developed for ease of use in clinical situations. Additional research is needed to determine concurrent and predictive validity of these measures in the psychological treatment of those caring for persons with TBI.

Disability and quality of life 20 years after traumatic brain injury

OBJECTIVES

The study describes functional outcomes and health-related quality of life (HRQL) in patients with traumatic brain injury (TBI) 20 years postinjury.

MATERIALS AND METHODS

Forty-four survivors who acquired moderate and severe TBI during 1995-1996 were followed 10 and 20 years postinjury. Outcomes were Glasgow Outcome Scale Extended (GOSE), Community Integration Questionnaire (CIQ), and SF-36 questionnaire (SF-36). Multiple regressions were performed to examine the relationship between follow-up measurements, controlling for baseline demographics and injury severity.

RESULTS

There were no significant differences in baseline age and civil status between moderate and severe TBI, but patients with severe injury had significantly lower employment rates (p = 0.05). Mean age at 20-years follow-up was 50.8 (SD 11.4) years, and 73% were males. Most patients showed good recovery (52%) or moderate disability (43%). Disability levels remained stable between and within severity groups from 10 to 20 years. Community integration including social integration improved from 10 to 20 years (p = 0.01 and p = 0.005, respectively). HRQL remained stable, except for subscales Bodily Pain and Role Emotional (p = 0.02 and p = 0.06). Depression at 10 years and females were associated with poorer mental health, while productive activity at 10 years indicated better physical and mental health at 20 years postinjury, respectively.

CONCLUSIONS

Functional limitations persist even decades after moderate and severe TBI, with poorer prognosis for females and persons who were depressed at the 10-year follow-up. Development and evaluation of targeted long-term follow-up programs and access to rehabilitation services for these groups should be highlighted. Improved community integration despite stable functional limitations draws attention to long-term adaptation to adversity and illness.

Late Functional Changes Post-Severe Traumatic Brain Injury Are Related to Community Reentry Support: Results From the PariS-TBI Cohort

OBJECTIVES

To explore late functional changes after a traumatic brain injury and their relation to patients' characteristics and reentry support.

DESIGN

Prospective follow-up of an inception cohort of adults with severe traumatic brain injury recruited in 2005-2007 in the Parisian area, France. One and 4-year assessments were performed by trained neuropsychologists. One-to-4-year change in the Glasgow Outcome Scale-Extended defined 3 groups: "improvement," "stability," and "worsening." Relationships between these groups and patients' characteristics were analyzed.

RESULTS

Among 504 recruited patients and 245 four-year survivors, 93 participated in both evaluations. Overall Glasgow Outcome Scale-Extended improved by 0.4. Forty percent of the sample improved, 44% were stable, and 16% worsened. Being in a more unfavorable group was related to preinjury alcohol abuse and to higher anxiety and depression at 4 years. Attendance to a specialized community reentry unit was related to higher chances of being in the "improvement" group in univariate analyses and after adjustment for age, time to follow command, preinjury alcohol and occupation, and mood disorders (adjusted odds ratio [OR] = 4.6 [1.1-20]).

CONCLUSION

Late functional changes were related to psychosocial variables and to reentry support. The effect of reentry support on late recovery needs to be confirmed by further investigations.

Cognitive impairment after traumatic brain injury is associated with reduced long-term depression of excitatory postsynaptic potential in the rat hippocampal dentate gyrus

Traumatic brain injury can cause loss of neuronal tissue, remote symptomatic epilepsy, and cognitive deficits. However, the mechanisms underlying the effects of traumatic brain injury are not yet clear. Hippocampal excitability is strongly correlated with cognitive dysfunction and remote symptomatic epilepsy. In this study, we examined the relationship between traumatic brain injury-induced neuronal loss and subsequent hippocampal regional excitability. We used hydraulic percussion to generate a rat model of traumatic brain injury. At 7 days after injury, the mean modified neurological severity score was 9.5, suggesting that the neurological function of the rats was remarkably impaired. Electrophysiology and immunocytochemical staining revealed increases in the slope of excitatory postsynaptic potentials and long-term depression (indicating weakened long-term inhibition), and the numbers of cholecystokinin and parvalbumin immunoreactive cells were clearly reduced in the rat hippocampal dentate gyrus. These results indicate that interneuronal loss and changes in excitability occurred in the hippocampal dentate gyrus. Thus, traumatic brain injury-induced loss of interneurons appears to be associated with reduced long-term depression in the hippocampal dentate gyrus.

Experimental repetitive mild traumatic brain injury induces deficits in trabecular bone microarchitecture and strength in mice

To evaluate the long-term consequence of repetitive mild traumatic brain injury (mTBI) on bone, mTBI was induced in 10-week-old female C57BL/6J mice using a weight drop model, once per day for 4 consecutive days at different drop heights (0.5, 1 and 1.5 m) and the skeletal phenotype was evaluated at different time points after the impact. In vivo micro-CT (μ-CT) analysis of the tibial metaphysis at 2, 8 and 12 weeks after the impact revealed a 5%-32% reduction in trabecular bone mass. Histomorphometric analyses showed a reduced bone formation rate in the secondary spongiosa of 1.5 m impacted mice at 12 weeks post impact. Apparent modulus (bone strength), was reduced by 30% (P<0.05) at the proximal tibial metaphysis in the 1.5 m drop height group at 2 and 8 weeks post impact. Ex vivo μ-CT analysis of the fifth lumbar vertebra revealed a significant reduction in trabecular bone mass at 12 weeks of age in all three drop height groups. Serum levels of osteocalcin were decreased by 22%, 15%, and 19% in the 0.5, 1.0 and 1.5 m drop height groups, respectively, at 2 weeks post impact. Serum IGF-I levels were reduced by 18%-32% in mTBI mice compared to contro1 mice at 2 weeks post impact. Serum osteocalcin and IGF-I levels correlated with trabecular BV/TV (r² =0.14 and 0.16, P<0.05). In conclusion, repetitive mTBI exerts significant negative effects on the trabecular bone microarchitecture and bone mechanical properties by influencing osteoblast function via reduced endocrine IGF-I actions.

Cognitive Event-Related Potentials during the Sub-Acute Phase of Severe Traumatic Brain Injury and Their Relationship to Outcome

Predicting outcome in the early phase after severe traumatic brain injury (sTBI) is a major clinical challenge, particularly identifying patients with potential for good cognitive outcome. The current single-center prospective study aimed to explore presence and normalization of electroencephalography (EEG)-based event-related potentials (ERPs) in the early phase followings TBI, and their relationship to functional and cognitive outcome 6 months post-injury. Fourteen adult patients (eight males) with sTBI were recruited from the neurointensive care unit (mean age = 38.2 years [standard deviation (SD) = 14.7]; mean lowest Glasgow Coma Scale (GCS) score within first 24 h = 5.4, SD = 1.87). EEG recordings were conducted biweekly at three time-points applying an ERP paradigm encompassing a passive condition involving hearing their own name randomly interspersed between an unfamiliar name (UN), and an active condition with instruction to count their own name. Functional and cognitive outcome 6 months post-injury was measured with Glasgow Outcome Scale-Extended (GOSE) and neuropsychological tests of attention and memory. Ten patients demonstrated a significantly enhanced cognitive P3 in the active counting task compared with passive listening across recordings, and six presented with normalization of P3 in the counting task. Moreover, P3 amplitude to the counting task at the third time-point was positively correlated with both functional outcome (GOSE) and cognition (verbal learning, attentional set-shifting, and switching) 6 months post-injury. ERP can index cognitive capacities in the early phase following sTBI, and the cognitive P3 component in an active design is associated with functional and cognitive outcome, demonstrating that the cognitive P3 may yield valuable information of residual cognition and provide supplementary prognostic information.

Self-awareness four years after severe traumatic brain injury: discordance between the patient’s and relative’s complaints. Results from the PariS-TBI study

Objective:

To evaluate the patient’s awareness of his or her difficulties in the chronic phase of severe traumatic brain injury (TBI) and to determine the factors related to poor awareness.

Design/Setting/Subjects:

This study was part of a larger prospective inception cohort study of patients with severe TBI in the Parisian region (PariS-TBI study).

Intervention/Main measures:

Evaluation was carried out at four years and included the Brain Injury Complaint Questionnaire (BICoQ) completed by the patient and his or her relative as well as the evaluation of impairments, disability and quality of life.

Results:

A total of 90 patient-relative pairs were included. Lack of awareness was measured using the unawareness index that corresponded to the number of discordant results between the patient and relative in the direction of under evaluation of difficulties by the patient. The only significant relationship found with lack of awareness was the subjective burden perceived by the relative (Zarit Burden Inventory) ( r = 0.5; P < 0.00001). There was no significant relationship between lack of awareness and injury severity, pre-injury socio-demographic data, cognitive impairments, mood disorders, functional independence (Barthel index), global disability (Glasgow Outcome Scale), return to work at four years or quality of life (Quality Of Life after Brain Injury scale (QOLIBRI)).

Conclusion:

Lack of awareness four years post severe TBI was not related to the severity of the initial trauma, sociodemographic data, the severity of impairments, limitations of activity and participation, or the patient’s quality of life. However, poor awareness did significantly influence the weight of the burden perceived by the relative.

Subjective complaints after acquired brain injury: presentation of the Brain Injury Complaint Questionnaire (BICoQ)

The objective of the present study was to present a new complaint questionnaire designed to assess a wide range of difficulties commonly reported by patients with acquired brain injury. Patients (n =  619) had been referred to a community re-entry service at a chronic stage after brain injury, mainly traumatic brain injury (TBI). The Brain Injury Complaint Questionnaire (BICoQ) includes 25 questions in the following domains: cognition, behavior, fatigue and sleep, mood, and somatic problems. A self and a proxy questionnaire were given. An additional question was given to the relative, about the patient's awareness of his difficulties. The questionnaires had a good internal coherence, as measured with Cronbach's alpha. The most frequent complaints were, in decreasing order, mental slowness, memory troubles, fatigue, concentration difficulties, anxiety, and dual tasking problems. Principal component analysis with varimax rotation yielded six underlying factors explaining 50.5% of total variance: somatic concerns, cognition, and lack of drive, lack of control, psycholinguistic disorders, mood, and mental fatigue/slowness. About 52% of patients reported fewer complaints than their proxy, suggesting lack of awareness. The total complaint scores were not significantly correlated with any injury severity measure, but were significantly correlated with disability and poorer quality of life (Note: only factor 2 [cognition/lack of drive] was significantly related to disability.) The BICoQ is a simple scale that can be used in addition to traditional clinical and cognitive assessment measures, and to assess awareness of everyday life problems.

Psychometric properties of the French version of the Rating Scale of Attentional Behaviour

The Rating Scale of Attentional Behaviour (RSAB) was devised by Ponsford and Kinsella to assess the impact of attentional impairments on everyday behaviour. The scale includes 14 items. The objective of this study was to assess the psychometric properties of a French translation of the RSAB. A sample of 196 healthy participants and 27 patients with chronic acquired brain injury was included. For healthy participants, both self and a relative's ratings were independently recorded. For the patients, a therapist's rating was obtained in addition. The scale showed good internal consistency. A mild significant effect of education duration was found in the healthy control group. Principal component analysis in healthy participants (self-assessment) yielded three underlying factors accounting for 58.2% of the variance. The scale was able to adequately discriminate patients from healthy controls. The area under the ROC curve was 0.76 both for self- and proxy ratings. In the patient group, the item related to fatigue was the one that obtained the highest ranking. RSAB ratings were poorly related to neuropsychological testing, but proxy ratings were significantly correlated with other questionnaires assessing cognitive failures, mood and fatigue.

Nursing Management of Adults with Severe Traumatic Brain Injury: A Narrative Review

Effective nursing management strategies for adults with severe traumatic brain injury (STBI) are still a remarkable issue and a difficult task for neurologists, neurosurgeons, and neuronurses. A list of justified indications and scientific rationale for nursing management of these patients are continuously evolving. The objectives of the study are to analyze the pertinently available research and clinical studies that demonstrate the nursing management strategies for adults with STBI and to synthesize the available evidence based on the review. A comprehensive literature search was made in following databases such as Google Scholar, Cochrane, J-Gate, ProQuest, and ScienceDirect for retrieving the related studies. In the included studies, data were extracted and evaluated according to the objective. Narrative analysis was adopted to write this review. Patients with STBI have poor prognosis and require quality care for maximizing patients' survival. With a thorough knowledge and discernment of care of such patients, nurses can improve these patients' neurological outcomes.

Neuropsychology of traumatic brain injury: An expert overview

Traumatic brain injury (TBI) is a serious healthcare problem, and this report is a selective review of recent findings on the epidemiology, pathophysiology and neuropsychological impairments following TBI. Patients who survive moderate-to-severe TBI frequently suffer from a wide range of cognitive deficits and behavioral changes due to diffuse axonal injury. These deficits include slowed information-processing and impaired long-term memory, attention, working memory, executive function, social cognition and self-awareness. Mental fatigue is frequently also associated and can exacerbate the consequences of neuropsychological deficits. Personality and behavioral changes can include combinations of impulsivity and apathy. Even mild TBI raises specific problems: while most patients recover within a few weeks or months, a minority of patients may suffer from long-lasting symptoms (post-concussion syndrome). The pathophysiology of such persistent problems remains a subject of debate, but seems to be due to both injury-related and non-injury-related factors.

Indicators of Survival and Favorable Functional Outcomes after Decompressive Craniectomy: A Multi-Institutional Retrospective Study

The role of decompressive craniectomy (DC) for severe traumatic brain injury (STBI) remains controversial. The purpose of this study was to identify factors that are indicators of survival and improved functional outcome in patients who undergo DC for STBI. A retrospective review of STBI patients who underwent DC was performed at four trauma centers during a 45-month period. Data collected included age, gender, mechanism of injury, Injury Severity Score (ISS), admission Glasgow Coma Scale (GCS), time from admission to DC, mortality, and extended Glasgow Outcome Score before discharge. Sixty-nine STBI patients were treated with DC during the study period. A higher initial GCS, lower ISS, and longer time to DC were all statistically significant for improved survival after DC. A younger age, higher initial GCS, and lower ISS were all statistically significant for a favorable functional outcome after DC. Patients with a higher initial GCS and lower ISS are more likely to survive DC and have a favorable functional outcome, whereas a longer time to DC was indicative of improved survival after DC.

A narrative literature review of depression following traumatic brain injury: prevalence, impact, and management challenges

Depression is one of the most common conditions to emerge after traumatic brain injury (TBI), and despite its potentially serious consequences it remains undertreated. Treatment for post-traumatic depression (PTD) is complicated due to the multifactorial etiology of PTD, ranging from biological pathways to psychosocial adjustment. Identifying the unique, personalized factors contributing to the development of PTD could improve long-term treatment and management for individuals with TBI. The purpose of this narrative literature review was to summarize the prevalence and impact of PTD among those with moderate to severe TBI and to discuss current challenges in its management. Overall, PTD has an estimated point prevalence of 30%, with 50% of individuals with moderate to severe TBI experiencing an episode of PTD in the first year after injury alone. PTD has significant implications for health, leading to more hospitalizations and greater caregiver burden, for participation, reducing rates of return to work and affecting social relationships, and for quality of life. PTD may develop directly or indirectly as a result of biological changes after injury, most notably post-injury inflammation, or through psychological and psychosocial factors, including pre injury personal characteristics and post-injury adjustment to disability. Current evidence for effective treatments is limited, although the strongest evidence supports antidepressants and cognitive behavioral interventions. More personalized approaches to treatment and further research into unique therapy combinations may improve the management of PTD and improve the health, functioning, and quality of life for individuals with TBI.

Employment outcome four years after a severe traumatic brain injury: results of the Paris severe traumatic brain injury study

OBJECTIVE

To describe employment outcome four years after a severe traumatic brain injury by the assessment of individual patients' preinjury sociodemographic data, injury-related and postinjury factors.

DESIGN

A prospective, multicenter inception cohort of 133 adult patients in the Paris area (France) who had received a severe traumatic brain injury were followed up postinjury at one and four years. Sociodemographic data, factors related to injury severity and one-year functional and cognitive outcomes were prospectively collected.

METHODS

The main outcome measure was employment status. Potential predictors of employment status were assessed by univariate and multivariate analysis.

RESULTS

At the four-year follow-up, 38% of patients were in paid employment. The following factors were independent predictors of unemployment: being unemployed or studying before traumatic brain injury, traumatic brain injury severity (i.e., a lower Glasgow Coma Scale score upon admission and a longer stay in intensive care) and a lower one-year Glasgow Outcome Scale-Extended score.

CONCLUSION

This study confirmed the low rate of long-term employment amongst patients after a severe traumatic brain injury. The results illustrated the multiple determinants of employment outcome and suggested that students who had received a traumatic brain injury were particularly likely to be unemployed, thus we propose that they may require specific support to help them find work. Implications for rehabilitation Traumatic brain injury is a leading cause of persistent disablity and can associate cognitive, emotional, physical and sensory impairments, which often result in quality-of-life reduction and job loss. Predictors of post-traumatic brain injury unemployment and job loss remains unclear in the particular population of severe traumatic brain injury patients. The present study highlights the post-traumatic brain injury student population require a close follow-up and vocational rehabilitation. The study suggests that return to work post-severe traumatic brain injury is frequently unstable and workers often experience difficulties that caregivers have to consider.

Negative impact of litigation procedures on patient outcomes four years after severe traumatic brain injury: results from the PariS-traumatic brain injury study

PURPOSE

To analyze the effect of litigation procedures on long-term outcomes in severe traumatic brain injury.

MATERIALS AND METHODS

Prospective observational follow-up of an inception cohort including 504 adults with severe traumatic brain injury recruited in 2005-2007 in the Parisian area, France, with initial, one- and four-year outcomes measures.

RESULTS

Four years after the traumatic brain injury, 147 patients, out of 257 who survived the acute phase, were assessed. Among these patients, 53 patients declared being litigants and 78 nonlitigants (litigation status was unknown in 16 cases). Sociodemographic characteristics, type of injury and initial severity did not differ significantly between litigants and nonlitigants, except for Injury Severity Score (worse in litigants) and the proportion of road traffic accidents (higher in litigants). One- and four-year outcomes were significantly worse in litigants for autonomy, participation, psychiatric and cognitive function but not quality of life (measured with the Glasgow Outcome Scale-Extended, the working activity status, the Brain Injury Community Rehabilitation Outcome, the Hospital Anxiety and Depression scale, the Neurobehavioral Rating Scale-revised and the Quality of Life after Brain Injury, respectively). Multivariate analyses highlighted litigation procedure as an independent significant predictor of lower autonomy, participation and psychiatric function and tended to predict lower cognitive function, but not lower quality of life, after adjustment for pretrauma characteristics, Injury Severity Score, road traffic accidents and work-related accident status.

CONCLUSIONS

Patients with severe traumatic brain injury have a worse prognosis when involved in a litigation procedure and require special attention in clinical practice. Implications for rehabilitation The influence of litigation procedure on health and social outcomes in severe traumatic brain injury is a major issue that entail numerous levels of complexities. A wide range of interactions and factors related to the prolonged process of litigation against a third party may influence recovery. Results from the PariS-Traumatic Brain Injury study suggest that patients with a severe Traumatic Brain Injury who are involved in a litigation procedure within French jurisdiction compensation scheme have a worse prognosis than patients who do not. Health professionals should be aware of the potential adverse effects of litigation procedures on recovery, and provide appropriate interventions and information to patients and families in such cases.

A prospective outcome study observing patients with severe traumatic brain injury over 10-15 years

BACKGROUND

Severe traumatic brain injury (sTBI) can be divided into primary and secondary injuries. Intensive care protocols focus on preventing secondary injuries. This prospective cohort study was initiated to investigate outcome, including mortality, in patients treated according to the Lund Concept after a sTBI covering 10-15 years post-trauma.

METHODS

Patients were included during 2000-2004 when admitted to the neurointensive care unit, Sahlgrenska University Hospital. Inclusion criteria were: Glasgow coma scale score of ≤8, need for artificial ventilation and intracranial monitoring. Glasgow Outcome Scale (GOS) was used to evaluate outcome both at 1-year and 10-15 years post-trauma.

RESULTS

Ninety-five patients, (27 female and 68 male), were initially included. Both improvement and deterioration were noted between 1- and 10-15 years post-injury. Mortality rate (34/95) was higher in the studied population vs. a matched Swedish population, (Standard mortality rate (SMR) 9.5; P < 0.0001). When dividing the cohort into Good (GOS 4-5) and Poor (GOS 2-3) outcome at 1-year, only patients with Poor outcome had a higher mortality rate than the matched population (SMR 7.3; P < 0.0001). Further, good outcome (high GOS) at 1-year was associated with high GOS 10-15 years post-trauma (P < 0.0001). Finally, a majority of patients demonstrated symptoms of mental fatigue.

CONCLUSION

This indicates that patients with severe traumatic brain injury with Good outcome at 1-year have similar survival probability as a matched Swedish population and that high Glasgow outcome scale at 1-year is related to good long-term outcome. Our results further emphasise the advantage of the Lund concept.