Traumatic brain injury in children in Denmark: a national 15-year study

Data-driven characterization of traumatic brain injury severity from clinical, neuroimaging, and blood-based indicators

The conventional clinical approach to characterizing traumatic brain injuries (TBIs) as mild, moderate, or severe using the Glasgow Coma Scale (GCS) total score has well-known limitations, prompting calls for more sophisticated strategies to characterize TBI. Here, we use item response theory (IRT) to develop a novel method for quantifying TBI severity that incorporates neuroimaging and blood-based biomarkers along with clinical measures. Within the multicenter Transforming Research and Clinical Knowledge in TBI (TRACK-TBI) study sample (N = 2545), we show that a set of 23 clinical, head computed tomography (CT), and blood-based biomarker variables familiar to clinicians and researchers index a common latent continuum of TBI severity. We illustrate how IRT can be used to identify the relative value of these features to estimate an individual's position along the TBI severity continuum. Finally, we show that TBI severity scores generated using this novel IRT-based method incrementally predict functional outcome over classic clinical (mild, moderate, severe) or International Mission for Prognosis and Analysis of Clinical Trials in TBI (IMPACT) classification methods. Our findings directly inform ongoing international efforts to refine and deploy new pragmatic, empirically-supported strategies for characterizing TBI, while illustrating a strategy that may be useful to evolve staging systems for other diseases.

Canadians Reporting Sport-Related Concussions: Increasing and Now Stabilizing

BACKGROUND

Canada is currently engaged in a national harmonization of strategies to prevent and manage sport-related concussions.

OBJECTIVE

To examine the annual incidence rates of reported sport-related concussions or other brain injuries by participants in the Canadian Community Health Survey, a national public health survey which provides nearly 2 decades of serial data using consistent methodology.

DESIGN

Serial cross-sectional survey.

SETTING

Population-based Canadian survey from 2000 to 2018 that collects data on "concussions or other brain injuries."

PARTICIPANTS

Respondents 12 years and older.

INDEPENDENT VARIABLES

Sex and age categorized 12 to 14 years, 15 to 19 years, 20 to 29 years, and 30+ years.

OUTCOME MEASURES

National incidence rates of participants reporting concussions or other brain injuries occurring within the previous year while engaged in "organized sports/leisure sports or physical exercise."

RESULTS

Data were available for 2000/01, 2003, 2005/6, 2009/10, 2013/4, and 2017/8 (N = 757 383). A previously stable annual incidence of reported sport-related concussions or other brain injuries increased nearly 2 and a half-fold from 2005/06 through 2013/14 (P < 0.0001) but seems to have stabilized recently (2013/14 vs 2017/8, P = 0.35). This trend is similar for both men and women but is manifest primarily within youth (12-19 years) as opposed to adults (>19 years). Approximately 1 in 450 Canadians 12 years and older report sport-related concussions or other brain injuries as their most significant injury associated with disability in the previous year (2017-2018: 221 per 100 000 population, 95% confidence interval: 179-264).

CONCLUSIONS

In Canada, the annual incidence rates of reported sport-related concussions or other brain injuries is changing and may reflect improved reporting and recognition.

Epidemiology of Traumatic Brain Injury in Europe: A Living Systematic Review

This systematic review provides a comprehensive, up-to-date summary of traumatic brain injury (TBI) epidemiology in Europe, describing incidence, mortality, age, and sex distribution, plus severity, mechanism of injury, and time trends. PubMed, CINAHL, EMBASE, and Web of Science were searched in January 2015 for observational, descriptive, English language studies reporting incidence, mortality, or case fatality of TBI in Europe. There were no limitations according to date, age, or TBI severity. Methodological quality was assessed using the Methodological Evaluation of Observational Research checklist. Data were presented narratively. Sixty-six studies were included in the review. Country-level data were provided in 22 studies, regional population or treatment center catchment area data were reported by 44 studies. Crude incidence rates varied widely. For all ages and TBI severities, crude incidence rates ranged from 47.3 per 100,000, to 694 per 100,000 population per year (country-level studies) and 83.3 per 100,000, to 849 per 100,000 population per year (regional-level studies). Crude mortality rates ranged from 9 to 28.10 per 100,000 population per year (country-level studies), and 3.3 to 24.4 per 100,000 population per year (regional-level studies.) The most common mechanisms of injury were traffic accidents and falls. Over time, the contribution of traffic accidents to total TBI events may be reducing. Case ascertainment and definitions of TBI are variable. Improved standardization would enable more accurate comparisons.

Estimating the global incidence of traumatic brain injury

OBJECTIVE

Traumatic brain injury (TBI)-the "silent epidemic"-contributes to worldwide death and disability more than any other traumatic insult. Yet, TBI incidence and distribution across regions and socioeconomic divides remain unknown. In an effort to promote advocacy, understanding, and targeted intervention, the authors sought to quantify the case burden of TBI across World Health Organization (WHO) regions and World Bank (WB) income groups.

METHODS

Open-source epidemiological data on road traffic injuries (RTIs) were used to model the incidence of TBI using literature-derived ratios. First, a systematic review on the proportion of RTIs resulting in TBI was conducted, and a meta-analysis of study-derived proportions was performed. Next, a separate systematic review identified primary source studies describing mechanisms of injury contributing to TBI, and an additional meta-analysis yielded a proportion of TBI that is secondary to the mechanism of RTI. Then, the incidence of RTI as published by the Global Burden of Disease Study 2015 was applied to these two ratios to generate the incidence and estimated case volume of TBI for each WHO region and WB income group.

RESULTS

Relevant articles and registries were identified via systematic review; study quality was higher in the high-income countries (HICs) than in the low- and middle-income countries (LMICs). Sixty-nine million (95% CI 64-74 million) individuals worldwide are estimated to sustain a TBI each year. The proportion of TBIs resulting from road traffic collisions was greatest in Africa and Southeast Asia (both 56%) and lowest in North America (25%). The incidence of RTI was similar in Southeast Asia (1.5% of the population per year) and Europe (1.2%). The overall incidence of TBI per 100,000 people was greatest in North America (1299 cases, 95% CI 650-1947) and Europe (1012 cases, 95% CI 911-1113) and least in Africa (801 cases, 95% CI 732-871) and the Eastern Mediterranean (897 cases, 95% CI 771-1023). The LMICs experience nearly 3 times more cases of TBI proportionally than HICs.

CONCLUSIONS

Sixty-nine million (95% CI 64-74 million) individuals are estimated to suffer TBI from all causes each year, with the Southeast Asian and Western Pacific regions experiencing the greatest overall burden of disease. Head injury following road traffic collision is more common in LMICs, and the proportion of TBIs secondary to road traffic collision is likewise greatest in these countries. Meanwhile, the estimated incidence of TBI is highest in regions with higher-quality data, specifically in North America and Europe.

Validation of 'reported concussion' within a national health survey

SETTING

The Canadian Community Health Survey (CCHS) is a national cross-sectional health survey, which has collected information on injuries serious enough to limit normal activity.

OBJECTIVE

To assess the construct and discriminant validity of reporting 'concussion or other brain injury' in the CCHS as the respondents' most serious injury.

METHODS

Construct validity was assessed by describing the injury profile. Discriminant validity was assessed by examining differences between those reporting concussion or other brain injury, and either: respondents not reporting brain injury (population control); or respondents reporting orthopaedic injuries (orthopaedic control).

RESULTS

In total, 1,852 of the 682,455 eligible CCHS respondents (≥12 years) reported a concussion or other brain injury within the prior year, a population annual incidence of 0.29%. Those reporting concussion or other brain injury were younger and male (p < 0.001), with an injury acquired by falling (p < 0.001) or sport or physical exercise (p < 0.001). Most (78.4%) who reported concussions or other brain injuries received medical attention from a health professional within 48 hours of their injury. The reported injury profiles appear to differ from the population controls and those reporting orthopaedic injuries.

CONCLUSIONS

The report of 'concussion or other brain injury' in the CCHS may be a valid source of population-based traumatic brain injury epidemiological data.

The Epidemiology of Traumatic Brain Injury in Children and Youths: A Review of Research Since 1990

This report reviews recent research on the epidemiology of traumatic brain injuries among children and youth aged 0 to 20 years. Studies representing populations in North America, Europe, Australia, and New Zealand yield these median estimates of the annual incidence of childhood brain injuries: 691 per 100 000 population treated in emergency departments, 74 per 100 000 treated in hospital, and 9 per 100 000 resulting in death. Males have a higher risk of injury than females: 1.4 times higher among those aged less than 10 years and 2.2 times among those older than 10 years. The leading cause of injury among children aged less than 5 years is falls, whereas the leading cause of injury among youths aged 15 years and older is motor vehicle crashes. The prevalence of disability among all persons who have sustained traumatic brain injury in childhood is unknown, but among those who were hospitalized could approximate 20%.

Head Injury in Children: Has a Change in Circumstances Caused an Increase in Treatment Numbers?

The number of hospitalizations for head injuries in children is rising. The exact causes remain unclear. We analyzed data of children aged between 0 and 18 years who sustained a head injury between 2010 and 2011. The analysis focused on data related to demographics, trauma mechanism, clinical course, results of imaging scans, concomitant injuries, and outcome. A total of 794 inpatient cases of head injury were treated. The leading mechanism of injury was a fall (at home) primarily at the age of 1 to 4 years (46.5%), with the majority of the children sustaining a mild brain injury (764, 96.2%). Neurosurgery was performed in 21 (2.64%) cases; average hospital stay was 2.9 days (range: 0-68 days). This study is not able to confirm that children are increasingly being brought to the hospital by their parents because of new trauma mechanisms or parents' uncertainty, nor can we confirm that the number of nonaccidental injuries is rising.

Longitudinal Trajectories of Health Related Quality of Life in Danish Family Members of Individuals with Severe Brain Injury

Scant research has examined health-related quality of life (HRQoL) in family members of patients with severe brain injury, even less has been done in Scandinavian countries, and none has examined this construct longitudinally. The current study therefore used multilevel modelling to investigate the trajectories of HRQoL in 94 Danish family members of patients with severe brain injury at five time points, beginning at the patient's stay in a neuro intensive care unit through one year after injury. The family members’ HRQoL scores significantly and strongly increased over time, and Role Limitations – Emotional scores were higher when patients had high Rancho Los Amigos Scale scores at admission to early intensive rehabilitation in hospital. These results suggest that the acute and sub-acute periods after brain injury are an extremely difficult time psychologically for many families, and family-based mental health interventions during the acute and sub-acute phases are critical, especially for families who have a patient with severe deficits.

The changing face of mild head injury: temporal trends and patterns in adolescents and adults from 1997 to 2008

OBJECTIVE

To explore the temporal trend of incidence, causes of injury and main characteristics of adolescent and adult subjects with mild head injury (MHI).

DESIGN

This study had a retrospective design.

SETTING

The study was conducted in a longitudinal database of an Italian Emergency Department (ED).

PARTICIPANTS

The study comprised 19124 consecutive subjects who visited and were managed within 24 h from the event, according to a predefined protocol for MHI from 1997 to 2008.

MAIN OUTCOME MEASURES

Incidence, demography, cause of injury and characteristics of any post-traumatic intracranial lesion within 7 days from MHI.

RESULTS

The number of subjects with MHI decreased from 2019 per year (1997-1999) to 1232 per year (2006-2008; P for linear trend <0.001), without differences in the total number of subjects visited in the ED. The decrease was observed in all age-decades, in particular, in subjects in the age ranges of 20-29 and 30-39 years. Over time, the age of subjects with MHI lost a bimodal distribution, and the mean age increased from 43 (25-69) years (median (interquartile range)) in 1997-1999 to 56 (33-78) years in 2006-2008 (P<0.001). The prevalence of falls increased from 36.5% to 55.0%, whereas crashes fell from 53.2% to 31.9%. The incidence of subdural haematoma (SDH) and epidural haematoma (EDH) did not change over time, whereas traumatic subarachnoid haemorrhage (t-SAH) and intra-cerebral haematoma/brain contusion (ICH) increased (from 0.7% to 1.9% and from 2.5% to 3.2%; P for trend: <0.001 for both.

CONCLUSIONS

The incidence and the clinical characteristics of MHI subjects are rapidly changing in our setting. These data need to be considered in defining the effectiveness of preventive measures and deciding resource allocation.

Subjective well-being and quality of life following traumatic brain injury in adults: A long-term population-based follow-up

PRIMARY OBJECTIVE

To assess subjective well-being and quality-of-life in nationally representative samples of patients at long intervals following traumatic brain injuries.

METHODS AND PROCEDURES

Patients with either cranial fractures or cerebral lesions were identified in a national computer-based register of hospital admissions and random samples were selected among those who had suffered the injury at 5, 10 or 15 years prior to the follow-up. Postal questionnaires were sent to them covering quality of life, e.g. return to employment, family relations and current subjective well-being in terms of symptomatology, e.g. somatic complaints, cognitive dysfunction. A response rate of 76% was obtained, comprising 114 patients with cranial fracture and 126 with cerebral lesions.

MAIN OUTCOMES AND RESULTS

The group with cerebral lesions had markedly poorer quality of life and subjective well-being than the group with cranial fractures and this did not vary across time. In both groups, the most common symptoms concerned cognition. Among the cerebral lesion group, quality of life outcome was fairly well predicted by severity of injury, but subjective well-being was less well predicted.

CONCLUSIONS

The negative consequences of traumatic cerebral lesions are marked and do not vary at long periods following injury.

Head trauma in children, part 1: admission, diagnostics, and findings

The objective of this study is to describe and to determine the preclinical situation and early in-clinical situation, diagnostic findings, and factors influencing the outcome of severe head trauma in children. Records of 48 children (0-16 years) were analyzed during a 3-year interval. Correlations with the outcome (Glasgow Outcome Scale) were determined by focusing on different scales, clinical findings, biochemistry, and clinical course features. The initial shock index had a major relevance (P = .0089). Systolic blood pressure (P = .0002) and bradycardia (P = .035) were important factors. Assessing the severity of trauma according to the Glasgow Coma Score, the most accurate parameter for outcome is based on the detailed quality of ''eye opening'' (P = .0155). Pupillary motoricity at the accident site (P = .002) and emergency room (P = .0004) are strong predictors. Preclinical measurements of stabilization and oxygenation have the same impact as the in-clinical management.

Pediatric brain trauma outcome prediction using paired serum levels of inflammatory mediators and brain-specific proteins

Many potential brain trauma biomarkers have been reported, but no previous study has described outcome prediction using combinations of biomarker levels. We aimed to investigate the outcome predictive values of multiple biomarkers from different mediator families and to determine whether combinations of two serum biomarkers may achieve higher outcome predictive values than individual biomarker levels. A prospective observational study was conducted involving 28 children requiring intensive care management following brain trauma. Day 1 post-injury serum concentrations of eight different biomarkers--S100b protein (S100b), neuron-specific enolase (NSE), interleukin-6 (IL-6), interleukin-8 (IL-8), interleukin-10 (IL-10), soluble intracellular adhesion molecule (SICAM), L-selectin, and endothelin--were quantified using enzyme-linked immunosorbent assay (ELISA). Global outcome was assessed at 6 months post-injury using the Glasgow Outcome Score (GOS). Receiver operator characteristic curve (ROC) analysis and its multivariate extension, Multivariate ROC (MultiROC), were used to assess the outcome predictive values of the individual and the paired biomarkers. None of the eight biomarkers assessed individually achieved an area under the ROC curve (AUC) of more than 0.95 for predicting unfavorable outcome, but five of the 20 biomarker pairs assessed had this high degree of outcome predictability. Two combinations using S100b as the "screening marker" and either L-selectin or IL-6 as the "varying marker" achieved an AUC of 0.98, and their specificity and sensitivity for unfavorable outcome prediction were 96% and 100%, respectively. Prognostic pairs combining serum levels of two biomarkers (inflammatory mediators and brain-specific proteins) offer better outcome predictive values for unfavorable outcome after childhood brain trauma than may be achieved using individual marker levels.

Long-term risk of epilepsy after traumatic brain injury in children and young adults: a population-based cohort study

BACKGROUND

The risk of epilepsy shortly after traumatic brain injury is high, but how long this high risk lasts is unknown. We aimed to assess the risk of epilepsy up to 10 years or longer after traumatic brain injury, taking into account sex, age, severity, and family history.

METHODS

We identified 1 605 216 people born in Denmark (1977-2002) from the Civil Registration System. We obtained information on traumatic brain injury and epilepsy from the National Hospital Register and estimated relative risks (RR) with Poisson analyses.

FINDINGS

Risk of epilepsy was increased after a mild brain injury (RR 2.22, 95% CI 2.07-2.38), severe brain injury (7.40, 6.16-8.89), and skull fracture (2.17, 1.73-2.71). The risk was increased more than 10 years after mild brain injury (1.51, 1.24-1.85), severe brain injury (4.29, 2.04-9.00), and skull fracture (2.06, 1.37-3.11). RR increased with age at mild and severe injury and was especially high among people older than 15 years of age with mild (3.51, 2.90-4.26) and severe (12.24, 8.52-17.57) injury. The risk was slightly higher in women (2.49, 2.25-2.76) than in men (2.01, 1.83-2.22). Patients with a family history of epilepsy had a notably high risk of epilepsy after mild (5.75, 4.56-7.27) and severe brain injury (10.09, 4.20-24.26).

INTERPRETATION

The longlasting high risk of epilepsy after brain injury might provide a window for prevention of post-traumatic epilepsy.

Impact of a program for the prevention of traffic accidents in a Southern Brazilian city: a model for implementation in a developing country

BACKGROUND

Traffic accidents constitute the main cause of death in the first decades of life. Traumatic brain injury is the event most responsible for the severity of these accidents. The SBN started an educational program for the prevention of traffic accidents, adapted from the American model "Think First" to the Brazilian environment, since 1995, with special effort devoted to the prevention of TBI by using seat belts and motorcycle helmets. The objective of the present study was to set up a traffic accident prevention program based on the adapted Think First and to evaluate its impact by comparing epidemiological variables before and after the beginning of the program.

METHODS

The program was executed in Maringá city, from September 2004 to August 2005, with educational actions targeting the entire population, especially teenagers and young adults. The program was implemented by building a network of information facilitators and multipliers inside the organized civil society, with widespread population dissemination. To measure the impact of the program, a specific software was developed for the storage and processing of the epidemiological variables.

RESULTS

The results showed a reduction of trauma severity due to traffic accidents after the execution of the program, mainly TBI.

CONCLUSIONS

The adapted Think First was systematically implemented and its impact measured for the first time in Brazil, revealing the usefulness of the program for reducing trauma and TBI severity in traffic accidents through public education and representing a standardized model of implementation in a developing country.

A Danish National Strategy for Treatment and Rehabilitation After Acquired Brain Injury

This study describes the establishment of a Danish national strategy for treatment and rehabilitation of acquired brain injury, particularly traumatic brain injury, in 1997. The vision was to create a system of tax-financed continuous treatment, restoration of function, and outpatient rehabilitation. Recommendations and their fulfillment are described. Focus is on the establishment and function of early intensive interdisciplinary rehabilitation after severe traumatic brain injury, centralized as 2 units since the year 2000, each with half the country as uptake area, corresponding to populations of around 2.5 million. Advantages gained by this centralization are increased focus on brain injury so that everybody gets specialized rehabilitation, regardless of the prognosis, the introduction of a database for severe brain injuries with unified measures of function and outcome, and the creation of a basis for method development and interdisciplinary research. Results for the first 3 years also indicate that outcome is improved after centralization.

Pediatric minor traumatic brain injury

The literature surrounding minor traumatic brain injury is complex, methodologically challenging, and controversial. Although we lack a consistent standardized definition, the annual rate is likely in excess of 200 per 100,000 children. The proportion of children with minor traumatic brain injury who will require neurosurgery is certainly <1%. Several studies are underway that have the potential to significantly advance our understanding of the specific risk factors for intracranial injury and more specifically neurosurgical injury. The mortality within children is very low, with estimates of 0% to 0.25%. Virtually all studies of the prognosis of minor brain injury in children have reported no long-term behavioral or cognitive sequelae as a specific result of the brain injury. Symptoms fall in 4 domains: somatic, cognitive, sleep/fatigue, and affective. Limited pediatric studies are available to assist clinicians in the prognosis or in optimizing recovery. Until further studies are available, a conservative approach is recommended. Children with suspected concussions should be removed from activity and observed. Children with symptomatic concussions must be limited to no physical activity. Adolescents and families need to self-monitor symptoms and limit environments or circumstances that exacerbate any symptoms. When symptoms resolve, a gradual progressive return to play is currently recommended. The recurrence risk for subsequent concussions is elevated, but there is limited documentation of the effectiveness of preventative efforts. Much remains to be learned.

Bench-to-bedside review: Apoptosis/programmed cell death triggered by traumatic brain injury

Apoptosis, or programmed cell death, is a physiological form of cell death that is important for normal embryologic development and cell turnover in adult organisms. Cumulative evidence suggests that apoptosis can also be triggered in tissues without a high rate of cell turnover, including those within the central nervous system (CNS). In fact, a crucial role for apoptosis in delayed neuronal loss after both acute and chronic CNS injury is emerging. In the current review we summarize the growing evidence that apoptosis occurs after traumatic brain injury (TBI), from experimental models to humans. This includes the identification of apoptosis after TBI, initiators of apoptosis, key modulators of apoptosis such as the Bcl-2 family, key executioners of apoptosis such as the caspase family, final pathways of apoptosis, and potential therapeutic interventions for blocking neuronal apoptosis after TBI.

Cognitive dysfunction in young men following head injury in childhood and adolescence: a population study

OBJECTIVES

To examine the prevalence of cognitive dysfunction among young men who had suffered a head injury during childhood or adolescence, in particular focusing upon the effects of age and the severity of the injury.

METHODS

By cross linkage of Danish national registers for hospital admissions and the draft board, 3091 young men were identified who had been injured before age 18 and tested at age 18 or shortly thereafter: 970 had suffered a single concussion and were in hospital for one day only; 521 had two concussions at separate times and were in hospital for one day only on each occasion; 961 had a cranial fracture; and 639 had a cerebral lesion. For all of these, scores on the draft board's cognitive screening test were obtained, dichotomised as dysfunctional or non-dysfunctional. Prevalences of dysfunctional scores were compared with population base rates (about 20% of all Danish men appearing before the draft board had a score classified as dysfunctional).

RESULTS

For young men who had suffered a single concussion, cranial fracture, or cerebral lesion before 12 years of age, resulting in less than 12 days of hospital admission (n = 376), rates of cognitive dysfunction did not exceed those in the general population (odds ratios < 1.4, NS), but the odds ratios became significant and > 1.4 where the injury occurred after age 11. For those with a cerebral lesion resulting in over 11 days of hospital admission (n = 263), all odds ratios were significant and >or= 2.0, irrespective of age at injury. For cases of two concussions, all odds ratios were > 1.4 but were not significant for all age groupings.

CONCLUSIONS

For milder forms of single head injury before age 12 there is no evidence of enduring cognitive dysfunction. The apparent effect at later ages may reflect predisposing psychosocial factors. For more serious injury, and for cases with two concussions, the effect is marked and not clearly related to age. For the former, this suggests enduring neurological effects of the injury; for the latter, where the effect is unrelated to time between injuries, predisposing factors may again play a role.

Incidence, characteristics, and predictive factors for Dysphagia after pediatric traumatic brain injury

OBJECTIVE

(1) To establish an incidence figure for dysphagia in a population of pediatric traumatic brain injury (TBI) cases; (2) to provide descriptive data on the admitting characteristics, patterns of resolution, and outcomes of children with and without dysphagia after TBI; and (3) to identify any factors present at admission that may predict dysphagia.

PARTICIPANTS

A total of 1,145 children consecutively admitted to an acute care setting for traumatic brain injury between July 1995 and July 2000.

MAIN OUTCOME MEASURE

Medical parameters relating to dysphagia based on medical chart review.

RESULTS

(1) Dysphagia incidence figure of 5.3% across all pediatric head injury admissions. Incidence figures of 68% for severe TBI, 15% for moderate TBI, and only 1% for mild brain injury. (2) Statistically significant differences were found between the dysphagic and nondysphagic subgroups on the variables of length of stay, length of ventilation, Glasgow Coma Scale (GCS), computed tomography classification, duration of speech pathology intervention, supplemental feeding duration, duration until initiation of oral intake (DIOF), duration to total oral intake (DTOF), and period of time from the initiation of intake until achievement of total oral intake (DI-TOF). (3) Significant predictive factors for dysphagia included GCS < 8.5 and a ventilation period in excess of 1.5 days.

CONCLUSION

The provision of incidence data and predictive factors for dysphagia will enable clinicians in acute care settings to allocate resources necessary to deal with the predicted number of dysphagia cases in a pediatric population, and assist in predicting patients who are at risk for dysphagia following TBI. Early detection of patients with swallowing dysfunction will be aided by these data, in turn helping to facilitate effective medical and speech pathology intervention via assisting the reduction of medical complications such as aspiration pneumonia.

Traumatic brain injury in Denmark 1979-1996. A national study of incidence and mortality

In order to describe and analyse the development of the incidence of traumatic brain injury (TBI) in Denmark for different age groups of the two genders from 1979 through 1993 (for fatal injuries through 1996), a computerised search corresponding to diagnoses ICD 8th ed., 800, 801, 803, 850-854 from 1979 through 1993 was carried through in the national hospital register. Each person was counted only once, according to the most serious injury during the study period. For fatal cases, the search was extended till 1996. From 1979-1981 to 1991-1993, the total age-adjusted incidence of persons hospitalised under diagnoses ICD 800, 801, 803, 850-854 decreased 41% from 265 to 157 per 100,000 of the population per year. Decreases were 42% for ICD 850, brain concussion, 56% for ICD 800, 801, 803, cranial fractures, and 16% for ICD 851 854, structural brain injury. The percentage of cases with ICD 851-854 increased from 8.4 to 11.7% of the total. From 1979-1981 to 1985-1987 there was a 2% decrease in fatal TBI in and outside hospital (from 14.68 to 14.35 per 100,000), against a total 27% decrease to 10.67 in 1994-1996. For diagnoses ICD 851-854 and for fatal cases, significantly accelerating decreases from 1985-1987 were found only for the younger age groups. Consequently, in the period from 1979 to 1993, the mean age at injury increased by 10 years for persons hospitalised under diagnoses ICD 851-854. Decreases may be explained partly by changing admission and other hospital practices, and partly by the effect of comprehensive national preventive programs launched at the middle of the study period, the effect of which seemed to vary by age group and gender.

Sequelae after unintentional injuries to children: an exploratory study

GOAL

To determine the frequency and categories of sequelae related to accidental injuries (of all types) in childhood, a prospective follow up study was conducted on a geographically defined population near Paris, France.

METHODS

The study concerned all child residents of one health care district, aged under 15 years, and hospitalised in the two public hospitals of the district, and/or transported by mobile emergency units, after an accident, during a one year period (in 1981-82; n = 785). Initial severity was scored using the injury severity score (ISS). Sequelae were defined as established impairments (leading or not to disabilities), identified by physicians, reporting their clinical diagnosis or complaints by the child and/or the family.

RESULTS

After a follow up period of 3.6-29.2 months after the accident, six children died and 78 (10%) were lost to follow up. Among the 701 others, 73 (10.4%) presented 80 sequelae, major (limiting daily activities) in 44 children (6.3%), with no gender difference. These increased significantly with age. The main causes of major sequelae were eye injuries and sports related injuries to the limbs. ISS did not correlate well with sequelae, but the maximum abbreviated injury scale appeared to be a better predictor of long term functional prognosis.

CONCLUSION

Prospective follow up and population based studies are still needed, especially on children's injuries initially perceived as benign, such as most of the sports related injuries in our study.

Disability pensions in relation to traumatic brain injury: a population study

From a Danish national register of hospitalizations, all patients were identified who had a discharge diagnosis of traumatic brain injury between the years 1979-1993 inclusive, at ages 18-66 years inclusive. These were classified as having suffered either a concussion (n = 74,398), a cranial fracture (n = 4,452) or a cerebral contusion (n = 8,141). Patients in each of these groups were then checked in annual registers of disability pension awards between 1979-1995. Disability pensions had been awarded to 16% of the concussion group, 18% of the fracture group, and 33% of the contusion group. Date of application, grounds for the application, and the pension level awarded were noted. Analysis of the date of application for the disability pension revealed that in all groups a high proportion of the pension applications had been made prior to the injury. Among the concussion group, the pension award appeared to be independent of the injury itself. Rather, being awarded a disability pension appeared to be related to conditions which themselves are risk factors for a traumatic brain injury, e.g. chronic skeletomuscular disease and psychiatric disorders including alcoholism. Comparison with population statistics revealed that the relative risk of being assigned a low or intermediate disability pension is markedly elevated among the concussion group, especially at younger ages and among males. For the fracture and contusion groups, a clear post-injury elevation in rate was detectable, especially for highest level pensions.