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Kumar RG, Evans E, Albrecht JS, Gardner RC, Dams-O'Connor K, Thomas KS. Healthy Days at Home Among Older Medicare Beneficiaries With Traumatic Brain Injury Requiring Inpatient Rehabilitation. J Head Trauma Rehabil 2024; 39:E442-E452. [PMID: 38598697 PMCID: PMC11387144 DOI: 10.1097/htr.0000000000000954] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/12/2024]
Abstract
OBJECTIVE The objectives of this study were to characterize and identify correlates of healthy days at home (HDaH) before and after TBI requiring inpatient rehabilitation. SETTING Inpatient hospital, nursing home, and home health services. PARTICIPANTS Average of n = 631 community-dwelling fee-for-service age 66+ Medicare beneficiaries across 30 replicate samples who were hospitalized for traumatic brain injury (TBI) between 2012 and 2014 and admitted to an inpatient rehabilitation facility (IRF) within 72 hours of hospital discharge. DESIGN Retrospective study using data from Medicare claims supplemented with data from the National Trauma Databank. MAIN MEASURES The primary outcome, HDaH, was calculated as time alive not using inpatient hospital, nursing home, and home health services in the year before TBI hospitalization and after IRF discharge. RESULTS We found HDaH declined from 93.2% in the year before TBI hospitalization to 65.3% in the year after IRF discharge (73.6% among survivors only). Most variability in HDaH was: (1) in the first 3 months after discharge and (2) by discharge disposition, with persons discharged from IRF to another acute hospital having the worst prognosis for utilization and death. In negative binomial regression models, the strongest predictors of HDaH in the year after discharge were rehabilitation Functional Independence Measure mobility score ( β = 0.03; 95% CI, 0.002-0.06) and inpatient Charlson Comorbidity Index score ( β = - 0.06; 95% CI, -0.13 to 0.001). Dual Medicaid eligible was associated with less HDaH among survivors ( β = - 0.37; 95% CI, -0.66 to -0.07). CONCLUSION In this study, among community-dwelling older adults with TBI, we found a notable decrease in the proportion of time spent alive at home without higher-level care after IRF discharge compared to before TBI. The finding that physical disability and comorbidities were the biggest drivers of healthy days alive in this population suggests that a chronic disease management model is required for older adults with TBI to manage their complex health care needs.
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Affiliation(s)
- Raj G Kumar
- Author Affiliation :Department of Rehabilitation and Human Performance (Drs Kumar and Dams-O'Connor), Department of Neurology (Dr Dams-O'Connor), Icahn School of Medicine at Mount Sinai, New York, New York; Department of Physical Therapy (Dr Evans), College of Health and Rehabilitation Sciences: Sargent College, Boston University, Boston, Massachusetts; Department of Epidemiology and Public Health (Dr Albrecht), University of Maryland School of Medicine, Baltimore, Maryland; Joseph Sagol Neuroscience Center (Dr Gardner), Sheba Medical Center, Ramat Gan, Israel; and Department of Health Services, Policy, and Practice (Dr Thomas), Center for Gerontology and Healthcare Research, Brown University School of Public Health, Providence, Rhode Island
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Macheda T, Andres MR, Sanders L, Roberts KN, Shahidehpour RK, Morganti JM, Bachstetter AD. Old Age Exacerbates White Matter Neuroinflammation and Cognitive Deficits Following Closed-Head Injury, Particularly in Female Mice. Neurotrauma Rep 2024; 5:770-786. [PMID: 39184175 PMCID: PMC11342053 DOI: 10.1089/neur.2024.0074] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/27/2024] Open
Abstract
The increasing incidence of traumatic brain injury (TBI) among older adults, particularly mild injuries from falls, underscores the need to investigate age-related outcomes and potential sex differences in response to TBI. Although previous research has defined an aging-TBI signature (heightened glial responses and cognitive impairment) in open-skull moderate-to-severe TBI models, it is unknown whether this signature is also present in mild closed-head injuries (CHIs). This study explores the influences of age and sex on recovery in a mouse CHI model induced by an electromagnetic impactor device in 4-month-old and 18-month-old C57BL/6 mice. We assessed the righting reflex, body weight, behavior (radial arm water maze and active avoidance), and inflammation (GFAP, IBA1, CD45) in the neocortex, corpus callosum, and hippocampus. We observed that aged female mice exhibited more severe TBI-induced cognitive deficits. In addition, a more pronounced reactive neuroinflammatory response with age was noted within white matter regions. Conversely, gray matter regions in aged animals either showed no enhanced pathological changes in response to injury or the aged mice displayed hyporesponsive glia and signs of dystrophic glial degeneration that were not evident in their younger counterparts following CHI. These findings suggest that aging influences CHI outcomes, partially reflecting the aging-TBI signature seen in more severe injuries in white matter, while a distinct aging and mild-TBI signature was identified in gray matter. The heightened vulnerability of females to the combined effects of age and mild CHI establishes a foundation for further investigation into the mechanisms underlying the sexually dimorphic response in aging females.
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Affiliation(s)
- Teresa Macheda
- Department of Neuroscience, University of Kentucky, Lexington, Kentucky, USA
- Spinal Cord and Brain Injury Research Center, University of Kentucky, Lexington, Kentucky, USA
| | - Margaret R. Andres
- Department of Neuroscience, University of Kentucky, Lexington, Kentucky, USA
- Spinal Cord and Brain Injury Research Center, University of Kentucky, Lexington, Kentucky, USA
| | - Lydia Sanders
- Department of Neuroscience, University of Kentucky, Lexington, Kentucky, USA
- Spinal Cord and Brain Injury Research Center, University of Kentucky, Lexington, Kentucky, USA
| | - Kelly N. Roberts
- Department of Neuroscience, University of Kentucky, Lexington, Kentucky, USA
- Spinal Cord and Brain Injury Research Center, University of Kentucky, Lexington, Kentucky, USA
| | - Ryan K. Shahidehpour
- Department of Neuroscience, University of Kentucky, Lexington, Kentucky, USA
- Spinal Cord and Brain Injury Research Center, University of Kentucky, Lexington, Kentucky, USA
- Sanders-Brown Center on Aging, University of Kentucky, Lexington, Kentucky, USA
| | - Josh M. Morganti
- Department of Neuroscience, University of Kentucky, Lexington, Kentucky, USA
- Spinal Cord and Brain Injury Research Center, University of Kentucky, Lexington, Kentucky, USA
- Sanders-Brown Center on Aging, University of Kentucky, Lexington, Kentucky, USA
| | - Adam D. Bachstetter
- Department of Neuroscience, University of Kentucky, Lexington, Kentucky, USA
- Spinal Cord and Brain Injury Research Center, University of Kentucky, Lexington, Kentucky, USA
- Sanders-Brown Center on Aging, University of Kentucky, Lexington, Kentucky, USA
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Mao J, Xue J, Li Y, Zhou Q, Zhou S, Zhou Z. Factors influencing traumatic brain injuries in maxillofacial fractures: A 12-year retrospective analysis of 2841 patients. Dent Traumatol 2024; 40:435-443. [PMID: 38459650 DOI: 10.1111/edt.12942] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2023] [Revised: 02/15/2024] [Accepted: 02/18/2024] [Indexed: 03/10/2024]
Abstract
BACKGROUND/AIM Results of studies investigating the association between traumatic brain injury (TBI) and maxillofacial fractures (MFs) have varied considerably. The present study aimed to evaluate the correlation between TBIs and MFs, as well as the impact of age, sex, trauma mechanism, and season on TBIs. MATERIALS AND METHODS This 12-year retrospective study of 2841 patients used univariate and multivariate logistic regression to assess the association between MFs and other factors impacting TBIs. RESULTS Among 2841 patients, 1978 TBIs occurred in 829 (29.2%), with intracranial injuries (n = 828) is the most common. Of 829 patients with TBIs, 688 were male and 141 were female, corresponding to a male-to-female ratio of 4.9:1.0. The most common age group was 40-49 years (24.6%). Vehicles (including motor vehicles and electric vehicles) accidents were the primary causes of injuries. Multivariate regression analyses revealed an increased risk for TBIs among males (odds ratio [OR] 0.632, p < 0.001). Patients >40 years of age were at higher risk for TBIs, especially those ≥70 years (OR 3.966, p = 0.001). Vehicle accidents were a high-risk factor for TBIs (OR 6.894, p < 0.001), and winter was the most prevalent season for such injuries (OR 1.559, p = 0.002). Risk for TBI increased by 136.4% in combined midfacial and mandibular fractures (p = 0.016) and by 101.6% in multiple midfacial fractures (p = 0.045). TBIs were less common in single mandibular fractures, notably in single-angle fractures, with a risk of only 0.204-fold. CONCLUSION TBIs in MFs were significantly correlated with sex, age, aetiology, season and fracture location. Maxillofacial surgeons and emergency physicians must be aware of the possible association between TBIs and MFs to assess and manage this complicated relationship in a timely manner.
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Affiliation(s)
- Jingjing Mao
- Ningxia Medical University, Yinchuan, Ningxia, P.R. China
- Ningxia Key Laboratory of Oral Diseases Research, Yinchuan, Ningxia, P.R. China
| | - Jiawen Xue
- Ningxia Medical University, Yinchuan, Ningxia, P.R. China
| | - Yunlong Li
- Ningxia Medical University, Yinchuan, Ningxia, P.R. China
| | - Qi Zhou
- Ningxia Medical University, Yinchuan, Ningxia, P.R. China
| | - Shuo Zhou
- Ningxia Medical University, Yinchuan, Ningxia, P.R. China
| | - Zhongwei Zhou
- Department of Oral and Maxillofacial Surgery, General Hospital of Ningxia Medical University, Yinchuan, Ningxia, P.R. China
- Clinical Research Center for Oral Diseases of Ningxia, Yinchuan, Ningxia, P.R. China
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Taiwo Z, Sander AM, Juengst SB, Liu X, Novelo LL, Hammond FM, O'Neil-Pirozzi TM, Perrin PB, Gut N. Association Between Participation and Satisfaction With Life Over Time in Older Adults With Traumatic Brain Injury: A TBI Model Systems Study. J Head Trauma Rehabil 2024; 39:E190-E200. [PMID: 38453629 PMCID: PMC11227408 DOI: 10.1097/htr.0000000000000940] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/09/2024]
Abstract
OBJECTIVE To examine the association between participation and satisfaction with life at 1, 2, 5, and 10 years after traumatic brain injury (TBI) in older adults. SETTING Community. PARTICIPANTS Participants ( N = 2362) who sustained complicated mild to severe TBI, requiring inpatient rehabilitation, at age 60 years or older and had follow-up data on participation and satisfaction with life for at least 1 follow-up time point across 1, 2, 5, and 10 years. Age at each time period was categorized as 60 to 64 years, 65 to 75 years, and 75 years or older. DESIGN Secondary data analysis of a large multicenter database. MAIN MEASURES Three domains (Productivity, Social Relations, Out and About) of the Participation Assessment With Recombined Tools-Objective (PART-O); Satisfaction With Life Scale (SWLS). RESULTS SWLS increased over the 10 years after TBI and was significantly associated with greater frequency of participation across all domains. There was a significant interaction between age and PART-O Social Relations such that there was a weaker relationship between Social Relations and SWLS in the oldest group (75 years or older). There was no interaction between Productivity or Out and About and age, but greater participation in both of these domains was associated with greater life satisfaction across age groups. CONCLUSIONS These findings indicate that greater participation is associated with increased satisfaction with life in older adults, across all participation domains over the first 10 years postinjury, suggesting that rehabilitation should target improving participation even in older adults. The decreased association of social relations with satisfaction with life in the oldest age group suggests that frequency of social relations may not be as important for life satisfaction in the oldest adults, but quality may still be important.
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Affiliation(s)
- Zinat Taiwo
- H. Ben Taub Department of Physical Medicine and Rehabilitation, Baylor College of Medicine, Houston, Texas (Drs Taiwo and Sander); Brain Injury Research Center, TIRR Memorial Hermann, Houston, Texas (Drs Taiwo, Sander, and Juengst); Harris Health System, Houston, Texas (Dr Sander); Department of Physical Medicine and Rehabilitation, University of Texas Health Science Center at Houston, Houston (Drs Juengst and Gut); Department of Biostatistics and Data Science, School of Public Health, University of Texas Health Science Center at Houston, Houston (Ms Liu and Dr Novelo); Department of Physical Medicine and Rehabilitation, School of Medicine, Indiana University, Indianapolis (Dr Hammond); Department of Physical Medicine and Rehabilitation, Spaulding Rehabilitation Hospital Boston, Charlestown, Massachusetts (Dr O'Neil-Pirozzi); Department of Communication Sciences and Disorders, Northeastern University, Boston, Massachusetts (Dr O'Neil-Pirozzi); Department of Psychology, School of Data Science, University of Virginia, Charlottesville (Dr Perrin); and TBI Model Systems, Polytrauma Rehabilitation Center, Central Virginia Veterans Affairs Health Care System, Richmond (Dr Perrin)
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Shih RD, Alter SM, Solano JJ, Engstrom G, Wells M, Clayton LM, Hughes PG, Goldstein LN, Azar FK, Ouslander JG. Low Incidence of Delayed Intracranial Hemorrhage in Geriatric Emergency Department Patients on Preinjury Anticoagulation Presenting with Blunt Head Trauma. J Emerg Med 2024:S0736-4679(24)00188-4. [PMID: 39271405 DOI: 10.1016/j.jemermed.2024.06.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2024] [Revised: 05/29/2024] [Accepted: 06/02/2024] [Indexed: 09/15/2024]
Abstract
BACKGROUND Delayed intracranial hemorrhage (ICH) after head injury in older patients taking anticoagulants has been reported to be as high as 7.2%. Other studies suggest much lower rates. Its incidence and clinical management are controversial, with some recommending observation and repeat head imaging at 24 h. OBJECTIVE Our study aims to assess the incidence of delayed ICH in geriatric Emergency Department (ED) head trauma patients prescribed preinjury anticoagulants. METHODS We performed a prospective cohort study conducted at two hospital EDs from August 2019 to July 2020. All patients aged 65 years or older with acute head injury were eligible for enrollment. We conducted telephone follow-up at 14 and 60 days, and a chart review at 90 days. The primary study outcome was incidence of delayed ICH, which was defined as an initial negative head computed tomography scan followed by subsequent ICH believed to be caused by the initial traumatic event. We compared the rates of delayed ICH between patient cohorts based on anticoagulant use. RESULTS There were 3425 patients enrolled: 2300 (67.2%) were not on an anticoagulant, 249 (7%) were on preinjury warfarin, 780 (22.7%) were on a direct-acting oral anticoagulant, and 96 (2.8%) were on enoxaparin or heparin. The median age was 82 years (interquartile range 65-107), the majority were female (55.2%), and almost all were Caucasian (84.3%). An acute ICH was identified in 229 of 3425 (6.7%, 95% confidence interval 6-8%) and delayed ICH in 13 (0.4%, 95% confidence interval 0.2-0.6%). There were no differences in rates of delayed ICH between those who had been prescribed anticoagulants vs. those who had not (p = 0.45). CONCLUSIONS The incidence of delayed ICH is very low in older ED head trauma patients on prescribed pre-injury anticoagulants. Our data have important clinical implications for the management of blunt head trauma among older ED patients on anticoagulants.
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Affiliation(s)
- Richard D Shih
- Florida Atlantic University, Charles E. Schmidt College of Medicine, Boca Raton, Florida; Department of Emergency Medicine, Delray Medical Center, Delray Beach, Florida
| | - Scott M Alter
- Florida Atlantic University, Charles E. Schmidt College of Medicine, Boca Raton, Florida; Department of Emergency Medicine, Delray Medical Center, Delray Beach, Florida; Department of Emergency Medicine, Bethesda Hospital East, Boynton Beach, Florida
| | - Joshua J Solano
- Florida Atlantic University, Charles E. Schmidt College of Medicine, Boca Raton, Florida; Department of Emergency Medicine, Delray Medical Center, Delray Beach, Florida; Department of Emergency Medicine, Bethesda Hospital East, Boynton Beach, Florida
| | - Gabriella Engstrom
- Florida Atlantic University, Charles E. Schmidt College of Medicine, Boca Raton, Florida
| | - Mike Wells
- Florida Atlantic University, Charles E. Schmidt College of Medicine, Boca Raton, Florida
| | - Lisa M Clayton
- Florida Atlantic University, Charles E. Schmidt College of Medicine, Boca Raton, Florida; Department of Emergency Medicine, Delray Medical Center, Delray Beach, Florida; Department of Emergency Medicine, Bethesda Hospital East, Boynton Beach, Florida
| | - Patrick G Hughes
- Florida Atlantic University, Charles E. Schmidt College of Medicine, Boca Raton, Florida; Department of Emergency Medicine, Delray Medical Center, Delray Beach, Florida; Department of Emergency Medicine, Bethesda Hospital East, Boynton Beach, Florida
| | | | - Faris K Azar
- Florida Atlantic University, Charles E. Schmidt College of Medicine, Boca Raton, Florida; Department of Surgery, St. Mary's Medical Center, West Palm Beach, Florida
| | - Joseph G Ouslander
- Florida Atlantic University, Charles E. Schmidt College of Medicine, Boca Raton, Florida
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Deutsch A, Kumar R, Sevigny M, Potelle J, McMullen T. Trends in the Characteristics and Outcomes of Older Medicare Patients With Traumatic Brain Injury Treated in Inpatient Rehabilitation Facilities: 2013 to 2018. Arch Phys Med Rehabil 2024; 105:1058-1068. [PMID: 38417777 PMCID: PMC11144561 DOI: 10.1016/j.apmr.2024.02.716] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2023] [Revised: 01/18/2024] [Accepted: 02/12/2024] [Indexed: 03/01/2024]
Abstract
OBJECTIVE To describe the characteristics and outcomes of older (65+) Medicare beneficiaries with traumatic brain injury (TBI) treated in inpatient rehabilitation facilities between 2013 and 2018. DESIGN Descriptive study using IRF Patient Assessment Instrument (IRF-PAI) data reporting trends of the sociodemographic and clinical characteristics and outcomes of inpatient rehabilitation facilities Medicare patients with TBI. SETTING Inpatient rehabilitation facilities in the United States. PARTICIPANTS 99,804 older Medicare fee-for-service and Medicare Advantage patients with TBI (N=99,804). INTERVENTIONS Not applicable. MAIN OUTCOME MEASURES Length of stay, self-care, and mobility functional outcomes, discharge destination. RESULTS The number of older Medicare beneficiaries with TBI treated in inpatient rehabilitation facilities increased from 14,657 in 2013 to 18,791 in 2018, an increase of 28.2%. In addition to this overall increase in patients, we also found the percentage of men increased slightly (52.9% to 54.8%), there was a higher percentage of patients with tier 3 comorbidities, there was a decrease in the variability of length of stay, there was slightly more self-care and mobility improvement and a slightly higher percentage of patients discharged to the community (67.8% in 2013 and 71.6% in 2018). Newer standardized data showed that prior to the injury, more than one-third used a walker and more than three-quarters had a history of recent falls. CONCLUSIONS Between 2013 and 2018, the number of Medicare beneficiaries with TBI treated in IRFs increased by approximately 28%. The characteristics of IRF older patients with TBI changed between 2013 and 2018 toward a slightly higher proportion of men, more comorbidities, and a higher percentage being discharged home after inpatient rehabilitation.
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Affiliation(s)
- Anne Deutsch
- RTI International; Center for Rehabilitation Outcomes Research, Shirley Ryan AbilityLab; Department of Physical Medicine and Rehabilitation, Feinberg School of Medicine, Northwestern University, Chicago, IL.
| | - Raj Kumar
- Icahn School of Medicine at Mount Sinai Department of Rehabilitation and Human Performance, New York, NY
| | | | | | - Tara McMullen
- Division of Chronic and Post-Acute Care, Center for Clinical Standards and Quality (CCSQ), Centers for Medicare & Medicaid Services, Woodlawn, ML
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Winter L, Moriarty H, Robinson KM, Leiby BE, Schmidt K, Whitehouse CR, Swanson RL. Age Suppresses the Association Between Traumatic Brain Injury Severity and Functional Outcomes: A Study Using the NIDILRR TBIMS Dataset. J Head Trauma Rehabil 2024:00001199-990000000-00145. [PMID: 38652669 DOI: 10.1097/htr.0000000000000955] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/25/2024]
Abstract
OBJECTIVES Recovery from traumatic brain injury (TBI) is extremely difficult to predict, with TBI severity usually demonstrating weak predictive validity for functional or other outcomes. A possible explanation may lie in the statistical phenomenon called suppression, according to which a third variable masks the true association between predictor and outcome, making it appear weaker than it actually is. Age at injury is a strong candidate as a suppressor because of its well-established main and moderating effects on TBI outcomes. We tested age at injury as a possible suppressor in the predictive chain of effects between TBI severity and functional disability, up to 10 years post-TBI. SETTING Follow-up interviews were conducted during telephone interviews. PARTICIPANTS We used data from the 2020 NDILRR Model Systems National Dataset for 4 successive follow-up interviews: year 1 (n = 10,734), year 2 (n = 9174), year 5 (n = 6,201), and year 10 (n = 3027). DESIGN Successive cross-sectional multiple regression analyses. MAIN MEASURES Injury severity was operationalized using a categorical variable representing duration of posttrauma amnesia. The Glasgow Outcomes Scale-Extended (GOS-E) operationally defined functioning. Sociodemographic characteristics having significant bivariate correlations with GOS-E were included. RESULTS Entry of age at injury into the regression models significantly increases the association between TBI severity and functioning up to 10 years post-TBI. CONCLUSIONS Age at injury is a suppressor variable, masking the true effect of injury severity on functional outcomes. Identifying the mediators of this suppression effect is an important direction for TBI rehabilitation research.
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Affiliation(s)
- Laraine Winter
- Author Affiliations: M. Louise Fitzpatrick College of Nursing (Drs Winter and Whitehouse), Villanova University, Villanova, Pennsylvania; Research Service (Dr Winter, Dr Moriarty, and Ms Schmidt), Nursing Service (Dr Moriarty), Physical Medicine and Rehabilitation/Rehabilitation Medicine Service (Dr Robinson and Dr Swanson), Center for Neurotrauma, Neurodegeneration and Restoration (Dr Swanson), Corporal Michael J. Crescenz Veterans Affairs Medical Center, Department of Physical Medicine and Rehabilitation (Dr Robinson and Dr Swanson), Perelman School of Medicine, University of Pennsylvania, and Division of Biostatistics, Department of Pharmacology, Physiology, and Cancer Biology (Dr Leiby), Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, Pennsylvania
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Michalettos G, Clausen F, Özen I, Ruscher K, Marklund N. Impaired oligodendrogenesis in the white matter of aged mice following diffuse traumatic brain injury. Glia 2024; 72:728-747. [PMID: 38180164 DOI: 10.1002/glia.24499] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2023] [Revised: 12/13/2023] [Accepted: 12/19/2023] [Indexed: 01/06/2024]
Abstract
Senescence is a negative prognostic factor for outcome and recovery following traumatic brain injury (TBI). TBI-induced white matter injury may be partially due to oligodendrocyte demise. We hypothesized that the regenerative capacity of oligodendrocyte precursor cells (OPCs) declines with age. To test this hypothesis, the regenerative capability of OPCs in young [(10 weeks ±2 (SD)] and aged [(62 weeks ±10 (SD)] mice was studied in mice subjected to central fluid percussion injury (cFPI), a TBI model causing widespread white matter injury. Proliferating OPCs were assessed by immunohistochemistry for the proliferating cell nuclear antigen (PCNA) marker and labeled by 5-ethynyl-2'-deoxyuridine (EdU) administered daily through intraperitoneal injections (50 mg/kg) from day 2 to day 6 after cFPI. Proliferating OPCs were quantified in the corpus callosum and external capsule on day 2 and 7 post-injury (dpi). The number of PCNA/Olig2-positive and EdU/Olig2-positive cells were increased at 2dpi (p < .01) and 7dpi (p < .01), respectively, in young mice subjected to cFPI, changes not observed in aged mice. Proliferating Olig2+/Nestin+ cells were less common (p < .05) in the white matter of brain-injured aged mice, without difference in proliferating Olig2+/PDGFRα+ cells, indicating a diminished proliferation of progenitors with different spatial origin. Following TBI, co-staining for EdU/CC1/Olig2 revealed a reduced number of newly generated mature oligodendrocytes in the white matter of aged mice when compared to the young, brain-injured mice (p < .05). We observed an age-related decline of oligodendrogenesis following experimental TBI that may contribute to the worse outcome of elderly patients following TBI.
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Affiliation(s)
| | - Fredrik Clausen
- Section of Neurosurgery, Department of Medical Sciences, Uppsala University, Uppsala, Sweden
| | - Ilknur Özen
- Department of Clinical Sciences, Neurosurgery, Lund University, Lund, Sweden
| | - Karsten Ruscher
- Department of Clinical Sciences, Neurosurgery, Lund University, Lund, Sweden
- Laboratory for Experimental Brain Research, Division of Neurosurgery, Department of Clinical Sciences, Lund University, Lund, Sweden
| | - Niklas Marklund
- Department of Clinical Sciences, Neurosurgery, Lund University, Lund, Sweden
- Department of Clinical Sciences Lund, Neurosurgery, Lund University, Skåne University Hospital, Lund, Sweden
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Lenell S, Wettervik TS, Howells T, Hånell A, Lewén A, Enblad P. Cerebrovascular reactivity (PRx) and optimal cerebral perfusion pressure in elderly with traumatic brain injury. Acta Neurochir (Wien) 2024; 166:62. [PMID: 38305993 PMCID: PMC10837240 DOI: 10.1007/s00701-024-05956-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2023] [Accepted: 12/23/2023] [Indexed: 02/03/2024]
Abstract
PURPOSE Cerebral perfusion pressure (CPP) guidance by cerebral pressure autoregulation (CPA) status according to PRx (correlation mean arterial blood pressure (MAP) and intracranial pressure (ICP)) and optimal CPP (CPPopt = CPP with lowest PRx) is promising but little is known regarding this approach in elderly. The aim was to analyze PRx and CPPopt in elderly TBI patients. METHODS A total of 129 old (≥ 65 years) and 342 young (16-64 years) patients were studied using monitoring data for MAP and ICP. CPP, PRx, CPPopt, and ΔCPPopt (difference between actual CPP and CPPopt) were calculated. Logistic regression analyses with PRx and ΔCPPopt as explanatory variables for outcome. The combined effects of PRx/CPP and PRx/ΔCPPopt on outcome were visualized as heatmaps. RESULTS The elderly had higher PRx (worse CPA), higher CPPopt, and different temporal patterns. High PRx influenced outcome negatively in the elderly but less so than in younger patients. CPP close to CPPopt correlated to favorable outcome in younger, in contrast to elderly patients. Heatmap interaction analysis of PRx/ΔCPPopt in the elderly showed that the region for favorable outcome was centered around PRx 0 and ranging between both functioning and impaired CPA (PRx range - 0.5-0.5), and the center of ΔCPPopt was - 10 (range - 20-0), while in younger the center of PRx was around - 0.5 and ΔCPPopt closer to zero. CONCLUSIONS The elderly exhibit higher PRx and CPPopt. High PRx influences outcome negatively in the elderly but less than in younger patients. The elderly do not show better outcome when CPP is close to CPPopt in contrast to younger patients.
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Affiliation(s)
- Samuel Lenell
- Department of Medical Sciences, Section of Neurosurgery, Uppsala University Hospital, Uppsala University, 751 85, Uppsala, Sweden.
| | - Teodor Svedung Wettervik
- Department of Medical Sciences, Section of Neurosurgery, Uppsala University Hospital, Uppsala University, 751 85, Uppsala, Sweden
| | - Timothy Howells
- Department of Medical Sciences, Section of Neurosurgery, Uppsala University Hospital, Uppsala University, 751 85, Uppsala, Sweden
| | - Anders Hånell
- Department of Medical Sciences, Section of Neurosurgery, Uppsala University Hospital, Uppsala University, 751 85, Uppsala, Sweden
| | - Anders Lewén
- Department of Medical Sciences, Section of Neurosurgery, Uppsala University Hospital, Uppsala University, 751 85, Uppsala, Sweden
| | - Per Enblad
- Department of Medical Sciences, Section of Neurosurgery, Uppsala University Hospital, Uppsala University, 751 85, Uppsala, Sweden
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Patel RS, Krause-Hauch M, Kenney K, Miles S, Nakase-Richardson R, Patel NA. Long Noncoding RNA VLDLR-AS1 Levels in Serum Correlate with Combat-Related Chronic Mild Traumatic Brain Injury and Depression Symptoms in US Veterans. Int J Mol Sci 2024; 25:1473. [PMID: 38338752 PMCID: PMC10855201 DOI: 10.3390/ijms25031473] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2023] [Revised: 01/15/2024] [Accepted: 01/22/2024] [Indexed: 02/12/2024] Open
Abstract
More than 75% of traumatic brain injuries (TBIs) are mild (mTBI) and military service members often experience repeated combat-related mTBI. The chronic comorbidities concomitant with repetitive mTBI (rmTBI) include depression, post-traumatic stress disorder or neurological dysfunction. This study sought to determine a long noncoding RNA (lncRNA) expression signature in serum samples that correlated with rmTBI years after the incidences. Serum samples were obtained from Long-Term Impact of Military-Relevant Brain-Injury Consortium Chronic Effects of Neurotrauma Consortium (LIMBIC CENC) repository, from participants unexposed to TBI or who had rmTBI. Four lncRNAs were identified as consistently present in all samples, as detected via droplet digital PCR and packaged in exosomes enriched for CNS origin. The results, using qPCR, demonstrated that the lncRNA VLDLR-AS1 levels were significantly lower among individuals with rmTBI compared to those with no lifetime TBI. ROC analysis determined an AUC of 0.74 (95% CI: 0.6124 to 0.8741; p = 0.0012). The optimal cutoff for VLDLR-AS1 was ≤153.8 ng. A secondary analysis of clinical data from LIMBIC CENC was conducted to evaluate the psychological symptom burden, and the results show that lncRNAs VLDLR-AS1 and MALAT1 are correlated with symptoms of depression. In conclusion, lncRNA VLDLR-AS1 may serve as a blood biomarker for identifying chronic rmTBI and depression in patients.
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Affiliation(s)
- Rekha S. Patel
- Research Service, James A. Haley Veteran’s Hospital, 13000 Bruce B Downs Blvd., Tampa, FL 33612, USA; (R.S.P.); (S.M.)
| | - Meredith Krause-Hauch
- Department of Molecular Medicine, University of South Florida, Tampa, FL 33612, USA;
| | - Kimbra Kenney
- Department of Neurology, Uniformed Services University of the Health Sciences, Bethesda, MD 20814, USA;
| | - Shannon Miles
- Research Service, James A. Haley Veteran’s Hospital, 13000 Bruce B Downs Blvd., Tampa, FL 33612, USA; (R.S.P.); (S.M.)
- Department of Psychiatry & Behavioral Neurosciences, Morsani College of Medicine, University of South Florida, Tampa, FL 33620, USA
| | - Risa Nakase-Richardson
- Chief of Staff Office, James A. Haley Veteran’s Hospital, Tampa, FL 33612, USA;
- Department of Internal Medicine, Pulmonary, Critical Care and Sleep Medicine, University of South Florida, Tampa, FL 33620, USA
| | - Niketa A. Patel
- Research Service, James A. Haley Veteran’s Hospital, 13000 Bruce B Downs Blvd., Tampa, FL 33612, USA; (R.S.P.); (S.M.)
- Department of Molecular Medicine, University of South Florida, Tampa, FL 33612, USA;
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11
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Forssten SP, Ahl Hulme R, Forssten MP, Ribeiro MAF, Sarani B, Mohseni S. Predictors of outcomes in geriatric patients with moderate traumatic brain injury after ground level falls. Front Med (Lausanne) 2023; 10:1290201. [PMID: 38152301 PMCID: PMC10751787 DOI: 10.3389/fmed.2023.1290201] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2023] [Accepted: 11/02/2023] [Indexed: 12/29/2023] Open
Abstract
Introduction The elderly population constitutes one of the fastest-growing demographic groups globally. Within this population, mild to moderate traumatic brain injuries (TBI) resulting from ground level falls (GLFs) are prevalent and pose significant challenges. Between 50 and 80% of TBIs in older individuals are due to GLFs. These incidents result in more severe outcomes and extended recovery periods for the elderly, even when controlling for injury severity. Given the increasing incidence of such injuries it becomes essential to identify the key factors that predict complications and in-hospital mortality. Therefore, the aim of this study was to pinpoint the top predictors of complications and in-hospital mortality in geriatric patients who have experienced a moderate TBI following a GLF. Methods Data were obtained from the American College of Surgeons' Trauma Quality Improvement Program database. A moderate TBI was defined as a head AIS ≤ 3 with a Glasgow Coma Scale (GCS) 9-13, and an AIS ≤ 2 in all other body regions. Potential predictors of complications and in-hospital mortality were included in a logistic regression model and ranked using the permutation importance method. Results A total of 7,489 patients with a moderate TBI were included in the final analyses. 6.5% suffered a complication and 6.2% died prior to discharge. The top five predictors of complications were the need for neurosurgical intervention, the Revised Cardiac Risk Index, coagulopathy, the spine abbreviated injury severity scale (AIS), and the injury severity score. The top five predictors of mortality were head AIS, age, GCS on admission, the need for neurosurgical intervention, and chronic obstructive pulmonary disease. Conclusion When predicting both complications and in-hospital mortality in geriatric patients who have suffered a moderate traumatic brain injury after a ground level fall, the most important factors to consider are the need for neurosurgical intervention, cardiac risk, and measures of injury severity. This may allow for better identification of at-risk patients, and at the same time resulting in a more equitable allocation of resources.
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Affiliation(s)
- Sebastian Peter Forssten
- Division of Surgery, CLINTEC, Karolinska Institute, Stockholm, Sweden
- Department of Orthopedic Surgery, Örebro University Hospital, Örebro, Sweden
| | - Rebecka Ahl Hulme
- Division of Surgery, CLINTEC, Karolinska Institute, Stockholm, Sweden
- Division of Trauma and Emergency Surgery, Department of Surgery, Karolinska University Hospital, Stockholm, Sweden
| | - Maximilian Peter Forssten
- Department of Orthopedic Surgery, Faculty of Medicine and Health, Örebro University, Örebro, Sweden
- School of Medical Sciences, Örebro University, Örebro, Sweden
| | - Marcelo A. F. Ribeiro
- Pontifical Catholic University of São Paulo, São Paulo, Brazil
- Khalifa University and Gulf Medical University, Abu Dhabi, United Arab Emirates
- Department of Surgery, Sheikh Shakhbout Medical City, Mayo Clinic, Abu Dhabi, United Arab Emirates
| | - Babak Sarani
- Division of Trauma and Acute Care Surgery, George Washington University School of Medicine and Health Sciences, Washington, DC, United States
| | - Shahin Mohseni
- School of Medical Sciences, Örebro University, Örebro, Sweden
- Department of Surgery, Sheikh Shakhbout Medical City, Mayo Clinic, Abu Dhabi, United Arab Emirates
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12
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Pappadis MR, Malagaris I, Kuo YF, Leland N, Freburger J, Goodwin JS. Care patterns and predictors of community residence among older patients after hospital discharge for traumatic brain injury. J Am Geriatr Soc 2023; 71:1806-1818. [PMID: 36840390 PMCID: PMC10330166 DOI: 10.1111/jgs.18308] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2022] [Revised: 12/27/2022] [Accepted: 12/31/2022] [Indexed: 02/26/2023]
Abstract
BACKGROUND An increasing number of older adults with traumatic brain injury (TBI) require hospitalization, but it is unknown whether they return to their community following discharge. We examined community residence following acute hospital discharge for TBI in Texas and identified factors associated with 90-day community residence and readmission. METHODS We conducted a retrospective cohort study using 100% Texas Medicare claims data of patients older than 65 years hospitalized for a TBI from January 1, 2014, through December 31, 2017, and followed for 20 weeks after discharge. Discharges to short-term and long-term acute hospital, inpatient rehabilitation facility (IRF), skilled nursing facility (SNF), long-term nursing home (NH), and hospice were identified. The primary outcome was 90-day community residence. Our secondary outcome was 90-day, all-cause readmission. RESULTS In Texas, 26,985 Medicare fee-for-service patients were hospitalized for TBI (Racial and ethnic minorities: 21.1%; Females 57.3%). At 90 days and 20 weeks following discharge, 80% and 84% were living in the community respectively. Female sex (OR = 1.16 [1.08-1.25]), Hispanic ethnicity (OR = 2.01 [1.80-2.25]), "other" race (OR = 2.19 [1.73-2.77]), and prior primary care provider (PCP; OR = 1.51 [1.40-1.62]) were associated with increased likelihood of 90-day community residence. Patients aged 75+, prior NH residence, dual eligibility, prior TBI diagnosis, and moderate-to-severe injury severity were associated with decreased likelihood of 90-day community residence. Being non-Hispanic Black (HR = 1.33 [1.20-1.46]), discharge to SNF (HR = 1.56 [1.48-1.65]) or IRF (HR = 1.49 [1.40-1.59]), having prior PCP (HR = 1.23 [1.17-1.30]), dual eligibility (HR = 1.11 [1.04-1.18]), and prior TBI diagnosis (HR = 1.05 [1.01-1.10]) were associated with increased risk of 90-day readmission. Female sex and "other" race were associated with decreased risk of 90-day readmission. CONCLUSIONS Most older adults with TBI return to the community following hospital discharge. Disparities exist in returning to the community and in risk of 90-day readmission following hospital discharge. Future studies should explore how having a PCP influences post-hospital outcomes in chronic care management of older patients with TBI.
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Affiliation(s)
- Monique R. Pappadis
- Department of Population Health and Health Disparities, School of Public and Population Health, University of Texas Medical Branch (UTMB) at Galveston, Galveston, TX, USA
- Sealy Center on Aging, UTMB, Galveston, TX, USA
| | - Ioannis Malagaris
- Department of Biostatistics and Data Science, School of Public and Population Health, UTMB, Galveston, TX, USA
| | - Yong-Fang Kuo
- Sealy Center on Aging, UTMB, Galveston, TX, USA
- Department of Biostatistics and Data Science, School of Public and Population Health, UTMB, Galveston, TX, USA
| | - Natalie Leland
- Department of Occupational Therapy, School of Health and Rehabilitation Sciences, University of Pittsburgh, Pittsburgh, PA
| | - Janet Freburger
- Department of Physical Therapy, School of Health and Rehabilitation Sciences, University of Pittsburgh, Pittsburgh, PA
| | - James S. Goodwin
- Sealy Center on Aging, UTMB, Galveston, TX, USA
- Department of Internal Medicine, Division of Geriatrics, School of Medicine, UTMB, Galveston, TX
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13
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Orlando A, Coresh J, Carrick MM, Quan G, Berg GM, Dhakal L, Hamilton D, Madayag R, Lascano CHP, Bar-Or D. Significant National Declines in Neurosurgical Intervention for Mild Traumatic Brain Injury with Intracranial Hemorrhage: A 13-Year Review of the National Trauma Data Bank. Neurotrauma Rep 2023; 4:137-148. [PMID: 36941880 PMCID: PMC10024583 DOI: 10.1089/neur.2022.0077] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/19/2023] Open
Abstract
There have been large changes over the past several decades to patient demographics in those presenting with mild traumatic brain injury (mTBI) with intracranial hemorrhage (ICH; complicated mTBI) with the potential to affect the use of neurosurgical interventions. The objective of this study was to characterize long-term trends of neurosurgical interventions in patients with complicated mTBI using 13 years of the National Trauma Data Bank (NTDB). This was a retrospective cohort study of adult (≥18 years) trauma patients included in the NTDB from 2007 to 2019 who had an emergency department Glasgow Coma Scale score 13-15, an intracranial hemorrhage (ICH), and no skull fracture. Neurosurgical intervention time trends were quantified for each ICH type using mixed-effects logistic regression with random slopes and intercepts for hospitals, as well as covariates for time and 14 demographic, injury, and hospital characteristics. In total, 666,842 ICH patients across 1060 hospitals were included. The four most common hemorrhages were isolated subdural hemorrhage (36%), isolated subarachnoid hemorrhage (24%), multiple hemorrhage types (24%), and isolated unspecified hemorrhages (9%). Overall, 49,220 (7%) patients received a neurosurgical intervention. After adjustment, the odds of neurosurgical intervention significantly decreased every 10 years by the following odds ratios (odds ratio [95% confidence interval]): 0.85 [0.78, 0.93] for isolated subdural, 0.63 [0.51, 0.77] for isolated subarachnoid, 0.50 [0.41, 0.62] for isolated unspecified, and 0.79 [0.73, 0.86] for multiple hemorrhages. There were no significant temporal trends in neurosurgical intervention odds for isolated epidural hemorrhages (0.87 [0.68, 1.12]) or isolated contusions/lacerations (1.03 [0.75, 1.41]). In the setting of complicated mTBI, the four most common ICH types were associated with significant declines in the odds of neurosurgical intervention over the past decade. It remains unclear whether changing hemorrhage characteristics or practice patterns drove these trends.
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Affiliation(s)
- Alessandro Orlando
- Johns Hopkins Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland, USA
| | - Josef Coresh
- Johns Hopkins Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland, USA
| | | | - Glenda Quan
- Swedish Medical Center, Englewood, Colorado, USA
| | | | | | | | | | | | - David Bar-Or
- Medical City Plano, Plano, Texas, USA
- Swedish Medical Center, Englewood, Colorado, USA
- Wesley Medical Center, Wichita, Kansas, USA
- Penrose Hospital, Colorado Springs, Colorado, USA
- St. Anthony Hospital, Lakewood, Colorado, USA
- South Texas Health System McAllen, McAllen, Texas, USA
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14
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Byom L, Zhao AT, Yang Q, Oyesanya T, Harris G, Cary MP, Bettger JP. Predictors of cognitive gains during inpatient rehabilitation for older adults with traumatic brain injury. PM R 2023; 15:265-277. [PMID: 35233983 PMCID: PMC9433457 DOI: 10.1002/pmrj.12795] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2021] [Revised: 12/03/2021] [Accepted: 02/15/2022] [Indexed: 11/12/2022]
Abstract
INTRODUCTION Traumatic brain injury (TBI) among older adults is increasing and can affect cognition. To effectively meet the rehabilitation needs of older adults, a clearer picture is needed of patient-, clinical-, and facility-level characteristics that affect cognitive recovery during inpatient rehabilitation facility (IRF) stays. OBJECTIVE To identify patient, clinical, and facility factors associated with cognitive recovery among older adults with TBI who received IRF care. DESIGN Secondary data analysis. SETTING Uniform Data System for Medical Rehabilitation-participating IRFs in the United States. PATIENTS Patients were 65 to 99 years of age at IRF admission for TBI. Participants received IRF care between 2002 and 2018 (N = 137,583); 56.3% were male; 84.2% were white; mean age was 78.7 years. MAIN OUTCOME MEASURE Change in Functional Independence Measure Cognitive Score (FIM-Cognitive) from IRF admission to discharge, categorized as favorable (FIM-cognitive score gains ≥3 points) or poor (FIM-cognitive score gains <3 points) cognitive outcomes. INTERVENTIONS Not applicable. RESULTS Patients had greater odds of favorable cognitive recovery if they were female (adjusted odds ratio [aOR] 1.05, 95% confidence interval [CI] 1.05-1.08), had higher motor functioning at IRF admission (aOR 1.03, 95% CI 1.03-1.04), longer length of stay (aOR 1.07, 95% CI 1.06-1.07), or received care at a freestanding IRF (vs. hospital rehab unit) (aOR 1.57, 95% CI 1.52-1.61). Patients who were older (aOR 0.99, 95% CI 0.98-0.99), Black (aOR 0.79, 95% CI 0.75-0.83), Hispanic or Latino (aOR 0.97, 95% CI 0.91-1.02), or were part of another racial or ethnic group (aOR 0.85, 95% CI 0.81-0.90) (vs. White), had high-cost comorbid conditions (aOR 0.71, 95% CI 0.65-0.76), or who had higher cognitive functioning at IRF admission (aOR 0.90, 95% CI 0.90-0.91) had lower odds of favorable cognitive recovery. CONCLUSIONS Patient (age, sex, race, ethnicity), clinical (level of functioning at IRF admission, length of stay) and facility (e.g., freestanding IRF) factors contributed to the cognitive recoveries of older adults during IRF stays.
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Affiliation(s)
- Lindsey Byom
- Division of Speech and Hearing Sciences, University of North Carolina-Chapel Hill
| | | | | | | | | | | | - Janet Prvu Bettger
- Duke University School of Nursing
- Duke-Margolis Center for Health Policy
- Duke Department of Orthopaedic Surgery
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15
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Coffeng SM, Foks KA, van den Brand CL, Jellema K, Dippel DWJ, Jacobs B, van der Naalt J. Evaluation of Clinical Characteristics and CT Decision Rules in Elderly Patients with Minor Head Injury: A Prospective Multicenter Cohort Study. J Clin Med 2023; 12:jcm12030982. [PMID: 36769631 PMCID: PMC9917997 DOI: 10.3390/jcm12030982] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2022] [Revised: 01/10/2023] [Accepted: 01/25/2023] [Indexed: 01/31/2023] Open
Abstract
Age is variably described as a minor or major risk factor for traumatic intracranial lesions after head injury. However, at present, no specific CT decision rule is available for elderly patients with minor head injury (MHI). The aims of this prospective multicenter cohort study were to assess the performance of existing CT decision rules for elderly MHI patients and to compare the clinical and CT characteristics of elderly patients with the younger MHI population. Thirty-day mortality between two age groups (cutoff ≥ 60 years), along with clinical and CT characteristics, was evaluated with four CT decision rules: the National Institute for Health and Care Excellence (NICE) guideline, the Canadian CT Head Rule (CCHR), the New Orleans Criteria (NOC), and the CT Head Injury Patients (CHIP) rule. Of the 5517 MHI patients included, 2310 were aged ≥ 60 years. Elderly patients experienced loss of consciousness (17% vs. 32%) and posttraumatic amnesia (23% vs. 31%) less often, but intracranial lesions (13% vs. 10%), neurological deterioration (1.8% vs. 0.2%), and 30-day mortality (2.0% vs. 0.1%) were more frequent than in younger patients (all p < 0.001). Elderly patients with age as their only risk factor showed intracranial lesions in 5% (NOC and CHIP) to 8% (CCHR and NICE) of cases. The sensitivity of decision rules in the elderly patients was 60% (CCHR) to 97% (NOC) when age was excluded as a risk factor. Current risk factors considered when evaluating elderly patients show lower sensitivity to identify intracranial abnormalities, despite more frequent intracranial lesions. Until age-specific CT decision rules are developed, it is advisable to scan every elderly patient with an MHI.
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Affiliation(s)
- Sophie M. Coffeng
- Department of Emergency Medicine, University of Groningen, University Medical Center Groningen, 9713 GZ Groningen, The Netherlands
- Correspondence:
| | - Kelly A. Foks
- Department of Neurology, Erasmus MC University Medical Center Rotterdam, 3015 GD Rotterdam, The Netherlands
| | - Crispijn L. van den Brand
- Department of Emergency Medicine, Erasmus MC University Medical Center Rotterdam, 3015 GD Rotterdam, The Netherlands
| | - Korné Jellema
- Department of Neurology, Haaglanden Medical Center, 2512 VA The Hague, The Netherlands
| | - Diederik W. J. Dippel
- Department of Neurology, Erasmus MC University Medical Center Rotterdam, 3015 GD Rotterdam, The Netherlands
| | - Bram Jacobs
- Department of Neurology, University of Groningen, University Medical Center Groningen, 9713 GZ Groningen, The Netherlands
| | - Joukje van der Naalt
- Department of Neurology, University of Groningen, University Medical Center Groningen, 9713 GZ Groningen, The Netherlands
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16
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Bailey MD, Gambert S, Gruber-Baldini A, Guralnik J, Kozar R, Qato DM, Shardell M, Albrecht JS. Traumatic Brain Injury and Risk of Long-Term Nursing Home Entry among Older Adults: An Analysis of Medicare Administrative Claims Data. J Neurotrauma 2023; 40:86-93. [PMID: 35793112 PMCID: PMC10162579 DOI: 10.1089/neu.2022.0003] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023] Open
Abstract
Traumatic brain injury (TBI) is a leading cause of injury-related disability among older adults, and there is increasing interest in post-discharge management as this population grows. We evaluated the association between TBI and long-term nursing home (NH) entry among a nationally representative sample of older adults. We identified 207,355 adults aged ≥65 years who received a diagnosis of either a TBI, non-TBI trauma, or were uninjured between January 2008 and June 2015 from a 5% sample of Medicare beneficiaries. The NH entry was operationalized as the first NH admission that resulted in a stay ≥100 days. Time to NH entry was calculated as the difference between the NH entry date and the index date (the date of TBI, non-TBI trauma, or inpatient/outpatient visit in the uninjured group). We used cause-specific Cox proportional hazards models with stabilized inverse probability of exposure weights to model time to NH entry as a function of injury in the presence of death as a competing risk and generated hazard ratios (HR) and 95% confidence intervals (CI). After excluding beneficiaries living in a NH at index, there were 60,600 TBI, 63,762 non-TBI trauma, and 69,893 uninjured beneficiaries in the sample. In weighted models, beneficiaries with TBI entered NHs at higher rates relative to the non-TBI trauma (HR 1.15; 95% CI 1.10, 1.20) and uninjured (HR 1.67; 95% CI 1.60, 1.74) groups. Future research should focus on interventions to retain older adult TBI survivors within the community.
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Affiliation(s)
- M. Doyinsola Bailey
- Department of Epidemiology and Public Health, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Steven Gambert
- Department of Medicine, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Ann Gruber-Baldini
- Department of Epidemiology and Public Health, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Jack Guralnik
- Department of Epidemiology and Public Health, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Rosemary Kozar
- R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Danya M. Qato
- Department of Pharmaceutical Health Services Research, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Michelle Shardell
- Department of Epidemiology and Public Health, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Jennifer S. Albrecht
- Department of Epidemiology and Public Health, University of Maryland School of Medicine, Baltimore, Maryland, USA
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17
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Traumatic brain injuries are ignored or discriminated in prospective clinical trials on shoulder fractures: a systematic review. INTERNATIONAL ORTHOPAEDICS 2023; 47:17-50. [PMID: 36435944 DOI: 10.1007/s00264-022-05642-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/04/2022] [Accepted: 10/10/2022] [Indexed: 11/28/2022]
Abstract
PURPOSE Current literature suggests a significant epidemiological association between traumatic brain injury (TBI) and proximal upper limb fractures in addition to major clinical consequences. A systematic review was conducted to assess how TBI is taken into consideration in interventional studies on shoulder fractures. METHODS The following data sources were used: MEDLINE, EMBASE, EBM Reviews, CINAHL, and OpenGrey databases. Study selection included interventional randomized clinical trials and prospective cohort studies on shoulder fractures published in English or French between 2008 and 2020. Studies on pathologic fractures, chronic fracture complications, nonhuman subjects, and biomechanics were excluded. Articles were reviewed by two independent authors according to the PRISMA guidelines. Baseline characteristics, exclusion criteria, and input relevant to TBI were recorded. Methodological quality was assessed with the Cochrane risk of bias tool for randomized clinical trials and the Newcastle-Ottawa Scale for cohort studies. RESULTS One-hundred-thirteen studies met the inclusion criteria. None discussed the possible impact of TBI on their results. Only three (2.7%) studies considered TBI relevant and included these patients in their cohort. Furthermore, 43/113 (38.1%) excluded patients with injuries or mechanisms strongly related to traumatic brain injuries: head injuries (4); moderate and/or severe TBI (7); high energy traumas (3); Polytrauma subjects (33). CONCLUSION TBI are ignored or discriminated in prospective clinical trials on shoulder fractures. The exclusion of these cases impacts generalizability as their prevalence is significant. Considering the major impact of TBI on important outcomes, its presence should always be assessed to ensure high quality evidence. LEVEL OF EVIDENCE Systematic Review, Therapeutic Level II.
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18
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Maas AIR, Menon DK, Manley GT, Abrams M, Åkerlund C, Andelic N, Aries M, Bashford T, Bell MJ, Bodien YG, Brett BL, Büki A, Chesnut RM, Citerio G, Clark D, Clasby B, Cooper DJ, Czeiter E, Czosnyka M, Dams-O’Connor K, De Keyser V, Diaz-Arrastia R, Ercole A, van Essen TA, Falvey É, Ferguson AR, Figaji A, Fitzgerald M, Foreman B, Gantner D, Gao G, Giacino J, Gravesteijn B, Guiza F, Gupta D, Gurnell M, Haagsma JA, Hammond FM, Hawryluk G, Hutchinson P, van der Jagt M, Jain S, Jain S, Jiang JY, Kent H, Kolias A, Kompanje EJO, Lecky F, Lingsma HF, Maegele M, Majdan M, Markowitz A, McCrea M, Meyfroidt G, Mikolić A, Mondello S, Mukherjee P, Nelson D, Nelson LD, Newcombe V, Okonkwo D, Orešič M, Peul W, Pisică D, Polinder S, Ponsford J, Puybasset L, Raj R, Robba C, Røe C, Rosand J, Schueler P, Sharp DJ, Smielewski P, Stein MB, von Steinbüchel N, Stewart W, Steyerberg EW, Stocchetti N, Temkin N, Tenovuo O, Theadom A, Thomas I, Espin AT, Turgeon AF, Unterberg A, Van Praag D, van Veen E, Verheyden J, Vyvere TV, Wang KKW, Wiegers EJA, Williams WH, Wilson L, Wisniewski SR, Younsi A, Yue JK, Yuh EL, Zeiler FA, Zeldovich M, Zemek R. Traumatic brain injury: progress and challenges in prevention, clinical care, and research. Lancet Neurol 2022; 21:1004-1060. [PMID: 36183712 PMCID: PMC10427240 DOI: 10.1016/s1474-4422(22)00309-x] [Citation(s) in RCA: 255] [Impact Index Per Article: 127.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2022] [Accepted: 07/22/2022] [Indexed: 02/06/2023]
Abstract
Traumatic brain injury (TBI) has the highest incidence of all common neurological disorders, and poses a substantial public health burden. TBI is increasingly documented not only as an acute condition but also as a chronic disease with long-term consequences, including an increased risk of late-onset neurodegeneration. The first Lancet Neurology Commission on TBI, published in 2017, called for a concerted effort to tackle the global health problem posed by TBI. Since then, funding agencies have supported research both in high-income countries (HICs) and in low-income and middle-income countries (LMICs). In November 2020, the World Health Assembly, the decision-making body of WHO, passed resolution WHA73.10 for global actions on epilepsy and other neurological disorders, and WHO launched the Decade for Action on Road Safety plan in 2021. New knowledge has been generated by large observational studies, including those conducted under the umbrella of the International Traumatic Brain Injury Research (InTBIR) initiative, established as a collaboration of funding agencies in 2011. InTBIR has also provided a huge stimulus to collaborative research in TBI and has facilitated participation of global partners. The return on investment has been high, but many needs of patients with TBI remain unaddressed. This update to the 2017 Commission presents advances and discusses persisting and new challenges in prevention, clinical care, and research. In LMICs, the occurrence of TBI is driven by road traffic incidents, often involving vulnerable road users such as motorcyclists and pedestrians. In HICs, most TBI is caused by falls, particularly in older people (aged ≥65 years), who often have comorbidities. Risk factors such as frailty and alcohol misuse provide opportunities for targeted prevention actions. Little evidence exists to inform treatment of older patients, who have been commonly excluded from past clinical trials—consequently, appropriate evidence is urgently required. Although increasing age is associated with worse outcomes from TBI, age should not dictate limitations in therapy. However, patients injured by low-energy falls (who are mostly older people) are about 50% less likely to receive critical care or emergency interventions, compared with those injured by high-energy mechanisms, such as road traffic incidents. Mild TBI, defined as a Glasgow Coma sum score of 13–15, comprises most of the TBI cases (over 90%) presenting to hospital. Around 50% of adult patients with mild TBI presenting to hospital do not recover to pre-TBI levels of health by 6 months after their injury. Fewer than 10% of patients discharged after presenting to an emergency department for TBI in Europe currently receive follow-up. Structured follow-up after mild TBI should be considered good practice, and urgent research is needed to identify which patients with mild TBI are at risk for incomplete recovery. The selection of patients for CT is an important triage decision in mild TBI since it allows early identification of lesions that can trigger hospital admission or life-saving surgery. Current decision making for deciding on CT is inefficient, with 90–95% of scanned patients showing no intracranial injury but being subjected to radiation risks. InTBIR studies have shown that measurement of blood-based biomarkers adds value to previously proposed clinical decision rules, holding the potential to improve efficiency while reducing radiation exposure. Increased concentrations of biomarkers in the blood of patients with a normal presentation CT scan suggest structural brain damage, which is seen on MR scanning in up to 30% of patients with mild TBI. Advanced MRI, including diffusion tensor imaging and volumetric analyses, can identify additional injuries not detectable by visual inspection of standard clinical MR images. Thus, the absence of CT abnormalities does not exclude structural damage—an observation relevant to litigation procedures, to management of mild TBI, and when CT scans are insufficient to explain the severity of the clinical condition. Although blood-based protein biomarkers have been shown to have important roles in the evaluation of TBI, most available assays are for research use only. To date, there is only one vendor of such assays with regulatory clearance in Europe and the USA with an indication to rule out the need for CT imaging for patients with suspected TBI. Regulatory clearance is provided for a combination of biomarkers, although evidence is accumulating that a single biomarker can perform as well as a combination. Additional biomarkers and more clinical-use platforms are on the horizon, but cross-platform harmonisation of results is needed. Health-care efficiency would benefit from diversity in providers. In the intensive care setting, automated analysis of blood pressure and intracranial pressure with calculation of derived parameters can help individualise management of TBI. Interest in the identification of subgroups of patients who might benefit more from some specific therapeutic approaches than others represents a welcome shift towards precision medicine. Comparative-effectiveness research to identify best practice has delivered on expectations for providing evidence in support of best practices, both in adult and paediatric patients with TBI. Progress has also been made in improving outcome assessment after TBI. Key instruments have been translated into up to 20 languages and linguistically validated, and are now internationally available for clinical and research use. TBI affects multiple domains of functioning, and outcomes are affected by personal characteristics and life-course events, consistent with a multifactorial bio-psycho-socio-ecological model of TBI, as presented in the US National Academies of Sciences, Engineering, and Medicine (NASEM) 2022 report. Multidimensional assessment is desirable and might be best based on measurement of global functional impairment. More work is required to develop and implement recommendations for multidimensional assessment. Prediction of outcome is relevant to patients and their families, and can facilitate the benchmarking of quality of care. InTBIR studies have identified new building blocks (eg, blood biomarkers and quantitative CT analysis) to refine existing prognostic models. Further improvement in prognostication could come from MRI, genetics, and the integration of dynamic changes in patient status after presentation. Neurotrauma researchers traditionally seek translation of their research findings through publications, clinical guidelines, and industry collaborations. However, to effectively impact clinical care and outcome, interactions are also needed with research funders, regulators, and policy makers, and partnership with patient organisations. Such interactions are increasingly taking place, with exemplars including interactions with the All Party Parliamentary Group on Acquired Brain Injury in the UK, the production of the NASEM report in the USA, and interactions with the US Food and Drug Administration. More interactions should be encouraged, and future discussions with regulators should include debates around consent from patients with acute mental incapacity and data sharing. Data sharing is strongly advocated by funding agencies. From January 2023, the US National Institutes of Health will require upload of research data into public repositories, but the EU requires data controllers to safeguard data security and privacy regulation. The tension between open data-sharing and adherence to privacy regulation could be resolved by cross-dataset analyses on federated platforms, with the data remaining at their original safe location. Tools already exist for conventional statistical analyses on federated platforms, however federated machine learning requires further development. Support for further development of federated platforms, and neuroinformatics more generally, should be a priority. This update to the 2017 Commission presents new insights and challenges across a range of topics around TBI: epidemiology and prevention (section 1 ); system of care (section 2 ); clinical management (section 3 ); characterisation of TBI (section 4 ); outcome assessment (section 5 ); prognosis (Section 6 ); and new directions for acquiring and implementing evidence (section 7 ). Table 1 summarises key messages from this Commission and proposes recommendations for the way forward to advance research and clinical management of TBI.
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Affiliation(s)
- Andrew I R Maas
- Department of Neurosurgery, Antwerp University Hospital and University of Antwerp, Edegem, Belgium
| | - David K Menon
- Division of Anaesthesia, University of Cambridge, Addenbrooke’s Hospital, Cambridge, UK
| | - Geoffrey T Manley
- Department of Neurological Surgery, University of California, San Francisco, CA, USA
| | - Mathew Abrams
- International Neuroinformatics Coordinating Facility, Karolinska Institutet, Stockholm, Sweden
| | - Cecilia Åkerlund
- Department of Physiology and Pharmacology, Section of Perioperative Medicine and Intensive Care, Karolinska Institutet, Stockholm, Sweden
| | - Nada Andelic
- Division of Clinical Neuroscience, Department of Physical Medicine and Rehabilitation, Oslo University Hospital and University of Oslo, Oslo, Norway
| | - Marcel Aries
- Department of Intensive Care, Maastricht UMC, Maastricht, Netherlands
| | - Tom Bashford
- Division of Anaesthesia, University of Cambridge, Addenbrooke’s Hospital, Cambridge, UK
| | - Michael J Bell
- Critical Care Medicine, Neurological Surgery and Pediatrics, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Yelena G Bodien
- Department of Neurology and Department of Physical Medicine and Rehabilitation, Harvard Medical School, Boston, MA, USA
| | - Benjamin L Brett
- Department of Neurosurgery, Medical College of Wisconsin, Milwaukee, WI, USA
| | - András Büki
- Department of Neurosurgery, Faculty of Medicine and Health Örebro University, Örebro, Sweden
- Department of Neurosurgery, Medical School; ELKH-PTE Clinical Neuroscience MR Research Group; and Neurotrauma Research Group, Janos Szentagothai Research Centre, University of Pecs, Pecs, Hungary
| | - Randall M Chesnut
- Department of Neurological Surgery and Department of Orthopaedics and Sports Medicine, University of Washington, Harborview Medical Center, Seattle, WA, USA
| | - Giuseppe Citerio
- School of Medicine and Surgery, Universita Milano Bicocca, Milan, Italy
- NeuroIntensive Care, San Gerardo Hospital, Azienda Socio Sanitaria Territoriale (ASST) Monza, Monza, Italy
| | - David Clark
- Brain Physics Lab, Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, Addenbrooke’s Hospital, Cambridge, UK
| | - Betony Clasby
- Department of Sociological Studies, University of Sheffield, Sheffield, UK
| | - D Jamie Cooper
- School of Public Health and Preventive Medicine, Monash University and The Alfred Hospital, Melbourne, VIC, Australia
| | - Endre Czeiter
- Department of Neurosurgery, Medical School; ELKH-PTE Clinical Neuroscience MR Research Group; and Neurotrauma Research Group, Janos Szentagothai Research Centre, University of Pecs, Pecs, Hungary
| | - Marek Czosnyka
- Brain Physics Lab, Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, Addenbrooke’s Hospital, Cambridge, UK
| | - Kristen Dams-O’Connor
- Department of Rehabilitation and Human Performance and Department of Neurology, Brain Injury Research Center, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Véronique De Keyser
- Department of Neurosurgery, Antwerp University Hospital and University of Antwerp, Edegem, Belgium
| | - Ramon Diaz-Arrastia
- Department of Neurology and Center for Brain Injury and Repair, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Ari Ercole
- Division of Anaesthesia, University of Cambridge, Addenbrooke’s Hospital, Cambridge, UK
| | - Thomas A van Essen
- Department of Neurosurgery, Leiden University Medical Center, Leiden, Netherlands
- Department of Neurosurgery, Medical Center Haaglanden, The Hague, Netherlands
| | - Éanna Falvey
- College of Medicine and Health, University College Cork, Cork, Ireland
| | - Adam R Ferguson
- Brain and Spinal Injury Center, Department of Neurological Surgery, Weill Institute for Neurosciences, University of California San Francisco and San Francisco Veterans Affairs Healthcare System, San Francisco, CA, USA
| | - Anthony Figaji
- Division of Neurosurgery and Neuroscience Institute, University of Cape Town, Cape Town, South Africa
| | - Melinda Fitzgerald
- Curtin Health Innovation Research Institute, Curtin University, Bentley, WA, Australia
- Perron Institute for Neurological and Translational Sciences, Nedlands, WA, Australia
| | - Brandon Foreman
- Department of Neurology and Rehabilitation Medicine, University of Cincinnati Gardner Neuroscience Institute, University of Cincinnati, Cincinnati, OH, USA
| | - Dashiell Gantner
- School of Public Health and Preventive Medicine, Monash University and The Alfred Hospital, Melbourne, VIC, Australia
| | - Guoyi Gao
- Department of Neurosurgery, Shanghai General Hospital, Shanghai Jiaotong University School of Medicine
| | - Joseph Giacino
- Department of Physical Medicine and Rehabilitation, Harvard Medical School and Spaulding Rehabilitation Hospital, Charlestown, MA, USA
| | - Benjamin Gravesteijn
- Department of Public Health, Erasmus MC University Medical Center Rotterdam, Rotterdam, Netherlands
| | - Fabian Guiza
- Department and Laboratory of Intensive Care Medicine, University Hospitals Leuven and KU Leuven, Leuven, Belgium
| | - Deepak Gupta
- Department of Neurosurgery, Neurosciences Centre and JPN Apex Trauma Centre, All India Institute of Medical Sciences, New Delhi, India
| | - Mark Gurnell
- Metabolic Research Laboratories, Institute of Metabolic Science, University of Cambridge, Cambridge, UK
| | - Juanita A Haagsma
- Department of Public Health, Erasmus MC University Medical Center Rotterdam, Rotterdam, Netherlands
| | - Flora M Hammond
- Department of Physical Medicine and Rehabilitation, Indiana University School of Medicine, Rehabilitation Hospital of Indiana, Indianapolis, IN, USA
| | - Gregory Hawryluk
- Section of Neurosurgery, GB1, Health Sciences Centre, University of Manitoba, Winnipeg, MB, Canada
| | - Peter Hutchinson
- Brain Physics Lab, Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, Addenbrooke’s Hospital, Cambridge, UK
| | - Mathieu van der Jagt
- Department of Intensive Care, Erasmus MC University Medical Center Rotterdam, Rotterdam, Netherlands
| | - Sonia Jain
- Biostatistics Research Center, Herbert Wertheim School of Public Health, University of California, San Diego, CA, USA
| | - Swati Jain
- Brain Physics Lab, Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, Addenbrooke’s Hospital, Cambridge, UK
| | - Ji-yao Jiang
- Department of Neurosurgery, Shanghai Renji Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Hope Kent
- Department of Psychology, University of Exeter, Exeter, UK
| | - Angelos Kolias
- Brain Physics Lab, Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, Addenbrooke’s Hospital, Cambridge, UK
| | - Erwin J O Kompanje
- Department of Intensive Care, Erasmus MC University Medical Center Rotterdam, Rotterdam, Netherlands
| | - Fiona Lecky
- Centre for Urgent and Emergency Care Research, Health Services Research Section, School of Health and Related Research, University of Sheffield, Sheffield, UK
| | - Hester F Lingsma
- Department of Public Health, Erasmus MC University Medical Center Rotterdam, Rotterdam, Netherlands
| | - Marc Maegele
- Cologne-Merheim Medical Center, Department of Trauma and Orthopedic Surgery, Witten/Herdecke University, Cologne, Germany
| | - Marek Majdan
- Institute for Global Health and Epidemiology, Department of Public Health, Faculty of Health Sciences and Social Work, Trnava University, Trnava, Slovakia
| | - Amy Markowitz
- Department of Neurological Surgery, University of California, San Francisco, CA, USA
| | - Michael McCrea
- Department of Neurosurgery and Neurology, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Geert Meyfroidt
- Department and Laboratory of Intensive Care Medicine, University Hospitals Leuven and KU Leuven, Leuven, Belgium
| | - Ana Mikolić
- Department of Public Health, Erasmus MC University Medical Center Rotterdam, Rotterdam, Netherlands
| | - Stefania Mondello
- Department of Biomedical and Dental Sciences and Morphofunctional Imaging, University of Messina, Messina, Italy
| | - Pratik Mukherjee
- Department of Radiology and Biomedical Imaging, University of California San Francisco, San Francisco, CA, USA
| | - David Nelson
- Section for Anesthesiology and Intensive Care, Department of Physiology and Pharmacology, Karolinska Institutet, Stockholm, Sweden
| | - Lindsay D Nelson
- Department of Neurosurgery and Neurology, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Virginia Newcombe
- Division of Anaesthesia, University of Cambridge, Addenbrooke’s Hospital, Cambridge, UK
| | - David Okonkwo
- Department of Neurological Surgery, University of Pittsburgh, Pittsburgh, PA, USA
| | - Matej Orešič
- School of Medical Sciences, Örebro University, Örebro, Sweden
| | - Wilco Peul
- Department of Neurosurgery, Leiden University Medical Center, Leiden, Netherlands
| | - Dana Pisică
- Department of Public Health, Erasmus MC University Medical Center Rotterdam, Rotterdam, Netherlands
- Department of Neurosurgery, Erasmus MC University Medical Center Rotterdam, Rotterdam, Netherlands
| | - Suzanne Polinder
- Department of Public Health, Erasmus MC University Medical Center Rotterdam, Rotterdam, Netherlands
| | - Jennie Ponsford
- Monash-Epworth Rehabilitation Research Centre, Turner Institute for Brain and Mental Health, School of Psychological Sciences, Monash University, Melbourne, VIC, Australia
| | - Louis Puybasset
- Department of Anesthesiology and Intensive Care, APHP, Sorbonne Université, Hôpital Pitié-Salpêtrière, Paris, France
| | - Rahul Raj
- Department of Neurosurgery, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Chiara Robba
- Department of Anaesthesia and Intensive Care, Policlinico San Martino IRCCS for Oncology and Neuroscience, Genova, Italy, and Dipartimento di Scienze Chirurgiche e Diagnostiche, University of Genoa, Italy
| | - Cecilie Røe
- Division of Clinical Neuroscience, Department of Physical Medicine and Rehabilitation, Oslo University Hospital and University of Oslo, Oslo, Norway
| | - Jonathan Rosand
- Center for Genomic Medicine, Massachusetts General Hospital, Boston, MA, USA
| | | | - David J Sharp
- Department of Brain Sciences, Imperial College London, London, UK
| | - Peter Smielewski
- Brain Physics Lab, Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, Addenbrooke’s Hospital, Cambridge, UK
| | - Murray B Stein
- Department of Psychiatry and Department of Family Medicine and Public Health, UCSD School of Medicine, La Jolla, CA, USA
| | - Nicole von Steinbüchel
- Institute of Medical Psychology and Medical Sociology, University Medical Center Goettingen, Goettingen, Germany
| | - William Stewart
- Department of Neuropathology, Queen Elizabeth University Hospital and University of Glasgow, Glasgow, UK
| | - Ewout W Steyerberg
- Department of Biomedical Data Sciences Leiden University Medical Center, Leiden, Netherlands
| | - Nino Stocchetti
- Department of Pathophysiology and Transplantation, Milan University, and Neuroscience ICU, Fondazione IRCCS Ca Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Nancy Temkin
- Departments of Neurological Surgery, and Biostatistics, University of Washington, Seattle, WA, USA
| | - Olli Tenovuo
- Department of Rehabilitation and Brain Trauma, Turku University Hospital, and Department of Neurology, University of Turku, Turku, Finland
| | - Alice Theadom
- National Institute for Stroke and Applied Neurosciences, Faculty of Health and Environmental Studies, Auckland University of Technology, Auckland, New Zealand
| | - Ilias Thomas
- School of Medical Sciences, Örebro University, Örebro, Sweden
| | - Abel Torres Espin
- Department of Neurological Surgery, University of California, San Francisco, CA, USA
| | - Alexis F Turgeon
- Department of Anesthesiology and Critical Care Medicine, Division of Critical Care Medicine, Université Laval, CHU de Québec-Université Laval Research Center, Québec City, QC, Canada
| | - Andreas Unterberg
- Department of Neurosurgery, Heidelberg University Hospital, Heidelberg, Germany
| | - Dominique Van Praag
- Departments of Clinical Psychology and Neurosurgery, Antwerp University Hospital, and University of Antwerp, Edegem, Belgium
| | - Ernest van Veen
- Department of Public Health, Erasmus MC University Medical Center Rotterdam, Rotterdam, Netherlands
| | | | - Thijs Vande Vyvere
- Department of Radiology, Faculty of Medicine and Health Sciences, Department of Rehabilitation Sciences (MOVANT), Antwerp University Hospital, and University of Antwerp, Edegem, Belgium
| | - Kevin K W Wang
- Department of Psychiatry, University of Florida, Gainesville, FL, USA
| | - Eveline J A Wiegers
- Department of Public Health, Erasmus MC University Medical Center Rotterdam, Rotterdam, Netherlands
| | - W Huw Williams
- Centre for Clinical Neuropsychology Research, Department of Psychology, University of Exeter, Exeter, UK
| | - Lindsay Wilson
- Division of Psychology, University of Stirling, Stirling, UK
| | - Stephen R Wisniewski
- University of Pittsburgh Graduate School of Public Health, Pittsburgh, Pennsylvania, USA
| | - Alexander Younsi
- Department of Neurosurgery, Heidelberg University Hospital, Heidelberg, Germany
| | - John K Yue
- Department of Neurological Surgery, University of California, San Francisco, CA, USA
| | - Esther L Yuh
- Department of Radiology and Biomedical Imaging, University of California San Francisco, San Francisco, CA, USA
| | - Frederick A Zeiler
- Departments of Surgery, Human Anatomy and Cell Science, and Biomedical Engineering, Rady Faculty of Health Sciences and Price Faculty of Engineering, University of Manitoba, Winnipeg, MB, Canada
| | - Marina Zeldovich
- Institute of Medical Psychology and Medical Sociology, University Medical Center Goettingen, Goettingen, Germany
| | - Roger Zemek
- Departments of Pediatrics and Emergency Medicine, University of Ottawa, Children’s Hospital of Eastern Ontario, ON, Canada
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Jeon YK, Jeong J, Shin SD, Song KJ, Kim YJ, Hong KJ, Ro YS, Park JH. The effect of age on in-hospital mortality among elderly people who sustained fall-related traumatic brain injuries at home: A retrospective study of a multicenter emergency department-based injury surveillance database. Injury 2022; 53:3276-3281. [PMID: 35907679 DOI: 10.1016/j.injury.2022.07.036] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/08/2021] [Revised: 07/20/2022] [Accepted: 07/21/2022] [Indexed: 02/02/2023]
Abstract
BACKGROUND People older than 65 years tend to have traumatic brain injuries (TBIs) more frequently and have a higher mortality rate after TBI than younger individuals. The aim of this study was to determine the effects of age on in-hospital mortality among patients who had fall-related TBIs at home, emphasizing the effect of specific locations in the house on the outcome. METHODS This cross-sectional study was conducted using the Emergency Department-based Injury In-Depth Surveillance (EDIIS) database in South Korea. Patients aged 65 years or older with a slip or fall injury, accidental injury at home, and no major diagnosis other than TBI were included. The primary outcome was in-hospital mortality. Subgroup analysis was conducted to determine the effect of locations on the relationship between age and in-hospital mortality. RESULTS Of the 2,571,442 patients in the EDIIS database, 9,747 were included in this study. The most common injury location was room or bedroom (29.1%), followed by living room or kitchen (23.0%), bathroom (20.2%), stairs (15.8%), and outdoor spaces of the house (11.9%). There was a significant association between increased in-hospital mortality and oldest old age. The stairs or outdoor spaces of the house was significantly associated with in-hospital mortality compared to rooms inside the house. The oldest age group showed a higher association with in-hospital mortality than the young-old group, especially in the bathroom, stairs, and outdoor spaces of the house. CONCLUSIONS Elderly individuals over the age of 85 are the most vulnerable to fall-related TBI mortality at home. A fall prevention strategy for the oldest-old is needed, especially for the bathroom, stairs, and the ancillary space outside the house.
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Affiliation(s)
- Yoo Kyung Jeon
- Department of Emergency Medicine, Seoul National University Bundang Hospital, Seongnam-si, Korea
| | - Joo Jeong
- Department of Emergency Medicine, Seoul National University Bundang Hospital, Seongnam-si, Korea; Laboratory of Emergency Medical Services, Seoul National University Hospital Biomedical Research Institute, Seoul, Korea.
| | - Sang Do Shin
- Department of Emergency Medicine, Seoul National University College of Medicine, Seoul, Korea; Laboratory of Emergency Medical Services, Seoul National University Hospital Biomedical Research Institute, Seoul, Korea
| | - Kyoung Jun Song
- Department of Emergency Medicine, Seoul National University Boramae Medical Center, Seoul, Korea; Laboratory of Emergency Medical Services, Seoul National University Hospital Biomedical Research Institute, Seoul, Korea
| | - Yu Jin Kim
- Department of Emergency Medicine, Seoul National University Bundang Hospital, Seongnam-si, Korea; Laboratory of Emergency Medical Services, Seoul National University Hospital Biomedical Research Institute, Seoul, Korea
| | - Ki Jeong Hong
- Department of Emergency Medicine, Seoul National University Hospital, Seoul, Korea; Laboratory of Emergency Medical Services, Seoul National University Hospital Biomedical Research Institute, Seoul, Korea
| | - Young Sun Ro
- Department of Emergency Medicine, Seoul National University Hospital, Seoul, Korea; Laboratory of Emergency Medical Services, Seoul National University Hospital Biomedical Research Institute, Seoul, Korea
| | - Jeong Ho Park
- Department of Emergency Medicine, Seoul National University Hospital, Seoul, Korea; Laboratory of Emergency Medical Services, Seoul National University Hospital Biomedical Research Institute, Seoul, Korea
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The Impact of Preinjury Antiplatelet and Anticoagulant Use on Elderly Patients with Moderate or Severe Traumatic Brain Injury Following Traumatic Acute Subdural Hematoma. World Neurosurg 2022; 166:e521-e527. [PMID: 35843581 DOI: 10.1016/j.wneu.2022.07.042] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2022] [Revised: 07/09/2022] [Accepted: 07/09/2022] [Indexed: 12/15/2022]
Abstract
BACKGROUND Although it is often assumed that preinjury anticoagulant (AC) or antiplatelet (AP) use is associated with poorer outcomes among those with acute subdural hematoma (aSDH), previous studies have had varied results. This study examines the impact of preinjury AC and AP therapy on aSDH thickness, 30-day mortality, and extended Glasgow Outcome Scale at 6 months in elderly patients (aged ≥65). METHODS A level 1 trauma center registry was interrogated to identify consecutive elderly patients who presented with moderate or severe traumatic brain injury (TBI) and associated traumatic aSDH between the first of January 2013 and the first of January 2018. Relevant demographic, clinical, and radiological data were retrieved from institutional medical records. The 3 primary outcome measures were aSDH thickness on initial computed tomography scan, 30-day mortality, and unfavorable outcome at 6 months (extended Glasgow Outcome Scale). RESULTS One hundred thirty-two elderly patients were admitted with moderate or severe TBI and traumatic aSDH. The mean (±SD) age was 78.39 (±7.87) years, and a majority of patients (59.8%, n = 79) were male. There was a statistically significant difference in mean aSDH thickness, but there were no significant differences in 30-day mortality (P = 0.732) and unfavorable outcome between the AP, AC, combined AP and AC, and no antithrombotic exposure groups (P = 0.342). CONCLUSIONS Further studies with larger sample sizes are necessary to confirm these observations, but our findings do not support the preconceived notion in clinical practice that antithrombotic use is associated with poor outcomes in elderly patients with moderate or severe TBI.
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Lupton JR, Davis‐O'Reilly C, Jungbauer RM, Newgard CD, Fallat ME, Brown JB, Mann NC, Jurkovich GJ, Bulger E, Gestring ML, Lerner EB, Chou R, Totten AM. Mechanism of injury and special considerations as predictive of serious injury: A systematic review. Acad Emerg Med 2022; 29:1106-1117. [PMID: 35319149 PMCID: PMC9545392 DOI: 10.1111/acem.14489] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2021] [Revised: 03/17/2022] [Accepted: 03/19/2022] [Indexed: 12/14/2022]
Abstract
OBJECTIVES The Centers for Disease Control and Prevention's field triage guidelines (FTG) are routinely used by emergency medical services personnel for triaging injured patients. The most recent (2011) FTG contains physiologic, anatomic, mechanism, and special consideration steps. Our objective was to systematically review the criteria in the mechanism and special consideration steps that might be predictive of serious injury or need for a trauma center. METHODS We conducted a systematic review of the predictive utility of mechanism and special consideration criteria for predicting serious injury. A research librarian searched in Ovid Medline, EMBASE, and the Cochrane databases for studies published between January 2011 and February 2021. Eligible studies were identified using a priori inclusion and exclusion criteria. Studies were excluded if they lacked an outcome for serious injury, such as measures of resource use, injury severity scores, mortality, or composite measures using a combination of outcomes. Given the heterogeneity in populations, measures, and outcomes, results were synthesized qualitatively focusing on positive likelihood ratios (LR+) whenever these could be calculated from presented data or adjusted odds ratios (aOR). RESULTS We reviewed 2418 abstracts and 315 full-text publications and identified 42 relevant studies. The factors most predictive of serious injury across multiple studies were death in the same vehicle (LR+ 2.2-7.4), ejection (aOR 3.2-266.2), extrication (LR+ 1.1-6.6), lack of seat belt use (aOR 4.4-11.3), high speeds (aOR 2.0-2.9), concerning crash variables identified by vehicle telemetry systems (LR+ 4.7-22.2), falls from height (LR+ 2.4-5.9), and axial load or diving (aOR 2.5-17.6). Minor or inconsistent predictors of serious injury were vehicle intrusion (LR+ 0.8-7.2), cardiopulmonary or neurologic comorbidities (LR+ 0.8-3.1), older age (LR+ 0.6-6.8), or anticoagulant use (LR+ 1.1-1.8). CONCLUSIONS Select mechanism and special consideration criteria contribute positively to appropriate field triage of potentially injured patients.
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Affiliation(s)
- Joshua R. Lupton
- Department of Emergency MedicineOregon Health & Science UniversityPortlandOregonUSA
| | - Cynthia Davis‐O'Reilly
- Pacific Northwest Evidence‐based Practice Center, Department of Medical Informatics and Clinical EpidemiologyOregon Health & Science UniversityPortlandOregonUSA
| | - Rebecca M. Jungbauer
- Pacific Northwest Evidence‐based Practice Center, Department of Medical Informatics and Clinical EpidemiologyOregon Health & Science UniversityPortlandOregonUSA
| | - Craig D. Newgard
- Department of Emergency MedicineOregon Health & Science UniversityPortlandOregonUSA
| | - Mary E. Fallat
- Department of SurgeryUniversity of Louisville School of MedicineLouisvilleKentuckyUSA
| | - Joshua B. Brown
- Department of SurgeryUniversity of Pittsburgh Medical CenterPittsburghPennsylvaniaUSA
| | - N. Clay Mann
- Department of PediatricsUniversity of UtahSalt Lake CityUtahUSA
| | | | - Eileen Bulger
- Department of SurgeryUniversity of WashingtonSeattleWashingtonUSA
| | - Mark L. Gestring
- Department of SurgeryUniversity of RochesterRochesterNew YorkUSA
| | - E. Brooke Lerner
- Department of Emergency MedicineUniversity at BuffaloBuffaloNew YorkUSA
| | - Roger Chou
- Pacific Northwest Evidence‐based Practice Center, Department of Medical Informatics and Clinical EpidemiologyOregon Health & Science UniversityPortlandOregonUSA
| | - Annette M. Totten
- Pacific Northwest Evidence‐based Practice Center, Department of Medical Informatics and Clinical EpidemiologyOregon Health & Science UniversityPortlandOregonUSA
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22
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Abstract
OBJECTIVE Older age is often identified as a risk factor for poor outcome from traumatic brain injury (TBI). However, this relates predominantly to mortality following moderate-severe TBI. It remains unclear whether increasing age exerts risk on the expected recovery from mild TBI (mTBI). In this systematic review of mTBI in older age (60+ years), a focus was to identify outcome through several domains - cognition, psychological health, and life participation. METHODS Fourteen studies were identified for review, using PRISMA guidelines. Narrative synthesis is provided for all outcomes, from acute to long-term time points, and a meta-analysis was conducted for data investigating life participation. RESULTS By 3-month follow-up, preliminary findings indicate that older adults continue to experience selective cognitive difficulties, but given the data it is possible these difficulties are due to generalised trauma or preexisting cognitive impairment. In contrast, there is stronger evidence across time points that older adults do not experience elevated levels of psychological distress following injury and endorse fewer psychological symptoms than younger adults. Meta-analysis, based on the Glasgow Outcome Scale at 6 months+ post-injury, indicates that a large proportion (67%; 95% CI 0.569, 0.761) of older adults can achieve good functional recovery, similar to younger adults. Nevertheless, individual studies using alternative life participation measures suggest more mixed rates of recovery. CONCLUSIONS Although our initial review suggests some optimism in recovery from mTBI in older age, there is an urgent need for more investigations in this under-researched but growing demographic. This is critical for ensuring adequate health service provision, if needed.
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Yu WY, Hwang HF, Lin MR. Gender Differences in Personal and Situational Risk Factors for Traumatic Brain Injury Among Older Adults. J Head Trauma Rehabil 2022; 37:220-229. [PMID: 34320549 DOI: 10.1097/htr.0000000000000708] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To investigate differences between older men and women in Taiwan in personal and situational risk factors for sustaining a traumatic brain injury (TBI) versus soft-tissue injury (STI) due to a fall. DESIGN Matched case-control study. PARTICIPANTS AND SETTINGS Cases were defined as patients with a primary diagnosis of TBI due to a fall and were identified from those 60 years or older who visited the emergency department (ED) of 3 university-affiliated hospitals in 2015. Matched by the same hospital ED, gender, and time of falling, 3 controls who had no TBI and who had sustained only soft-tissue injury (STI) due to falling were selected for comparison with each case. Personal factors and situational exposures were compared between the control and case groups. In total, 96 cases and 288 controls in men and 72 cases and 216 controls in women participated in this study. MAIN MEASURES Personal factors (sociodemographic and lifestyle factors, medical characteristics, and functional abilities) and situational exposures (location, activities before the fall, center-of-mass change, type of fall, falling direction, protective response, and impact during the fall). RESULTS In men, after adjusting for other variables, older age (odds ratio [OR] = 1.04), regular alcohol use (OR = 2.03), an indoor fall (OR = 1.92), activity of getting in/out of bed (OR = 2.56), a fall due to dizziness (OR = 4.09), and falling backward (OR = 2.95) were independently associated with a higher odds of TBI. In women, an older age (OR = 1.03), the presence of Parkinson disease (OR = 10.4), activities of toileting (OR = 2.50), getting in/out of bed (OR = 4.90), and negotiating stairs (OR = 7.13), a fall due to dizziness (OR = 5.05), and falling backward (OR = 2.61) were independently associated with a higher odds of TBI. CONCLUSIONS Our results demonstrated similarities and differences in personal and situational risk factors for fall-related TBIs versus STIs between older men and women, and gender differences should be considered when developing intervention strategies.
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Affiliation(s)
- Wen-Yu Yu
- Department of Emergency Medicine, Taipei Medical University Hospital, Taipei, Taiwan, ROC (Dr Yu); Institute of Injury Prevention and Control, College of Public Health and Nutrition, Taipei Medical University, Taipei, Taiwan, ROC (Drs Yu and Lin); and Department of Nursing, National Taipei University of Nursing and Health Sciences, Taipei, Taiwan, ROC (Dr Hwang)
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Winter L, Mensinger JL, Moriarty HJ, Robinson KM, McKay M, Leiby BE. Age Moderates the Effect of Injury Severity on Functional Trajectories in Traumatic Brain Injury: A Study Using the NIDILRR Traumatic Brain Injury Model Systems National Dataset. J Clin Med 2022; 11:jcm11092477. [PMID: 35566607 PMCID: PMC9104127 DOI: 10.3390/jcm11092477] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2022] [Revised: 04/18/2022] [Accepted: 04/25/2022] [Indexed: 12/04/2022] Open
Abstract
Age is a risk factor for a host of poor outcomes following traumatic brain injury (TBI), with some evidence suggesting that age is also a source of excess disability. We tested the extent to which age moderates the effect of injury severity on functional trajectories over 15 years post injury. Data from 11,442 participants from the 2020 National Institute of Disability and Independent Living Rehabiitation Research (NIDILRR) Traumatic Brain Injury Model Systems (TBIMS) National Dataset were analyzed using linear mixed effects models. Injury severity was operationally defined using a composite of Glasgow Coma Scale scores, structural imaging findings, and the number of days with post-trauma amnesia. Functioning was measured using the Glasgow Outcomes Scale-Extended. Age at injury was the hypothesized moderator. Race, ethnicity, sex, education, and marital status served as covariates. The results showed a significant confounder-adjusted effect of injury severity and age of injury on the linear slope in functioning. The age effect was strongest for those with mild TBI. Thus, the effects of injury severity on functional trajectory were found to be moderated by age. To optimize outcomes, TBI rehabilitation should be developed specifically for older patients. Age should also be a major focus in TBI research.
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Affiliation(s)
- Laraine Winter
- Nursing Service, Corporal Michael J. Crescenz Veterans Affairs Medical Center, Philadelphia, PA 19104, USA;
- M. Louise Fitzpatrick College of Nursing, Villanova University, Villanova, PA 19085, USA;
- Correspondence:
| | - Janell L. Mensinger
- Department of Clinical and School Psychology, College of Psychology, Nova Southeastern University, Fort Lauderdale, FL 33314, USA; or
| | - Helene J. Moriarty
- Nursing Service, Corporal Michael J. Crescenz Veterans Affairs Medical Center, Philadelphia, PA 19104, USA;
- M. Louise Fitzpatrick College of Nursing, Villanova University, Villanova, PA 19085, USA;
| | - Keith M. Robinson
- Department of Physical Medicine and Rehabilitation, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104, USA;
| | - Michelle McKay
- M. Louise Fitzpatrick College of Nursing, Villanova University, Villanova, PA 19085, USA;
| | - Benjamin E. Leiby
- Division of Biostatistics, Department of Pharmacology and Experimental Therapeutics, Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, PA 19107, USA;
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Pierre-Louis YS, Perla KMR, Perez GM, Jean-Charles S, Tang O, Nwaiwu CA, Weil R, Shah NS, Heffernan DS, Moreira C. The Insurance Coverage Paradox – Characterizing Outcomes among Dual-Eligible Hemorrhagic Stroke Patients. J Clin Neurosci 2022; 97:99-105. [DOI: 10.1016/j.jocn.2021.12.023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2021] [Revised: 11/04/2021] [Accepted: 12/21/2021] [Indexed: 11/29/2022]
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Kumar RG, Zhang W, Evans E, Dams-O’Connor K, Thomas KS. Research Letter: Characterization of Older Adults Hospitalized With Traumatic Brain Injury Admitted to Long-Term Acute Care Hospitals. J Head Trauma Rehabil 2022; 37:89-95. [PMID: 33782352 PMCID: PMC8915921 DOI: 10.1097/htr.0000000000000685] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
OBJECTIVE To describe patient, hospital, and geographic characteristics of older adult Medicare beneficiaries hospitalized with traumatic brain injury (TBI) and admitted to long-term acute care hospitals (LTACHs). SETTING Acute hospital and LTACH facilities. PARTICIPANTS In total, 15 148 Medicare beneficiaries 65 years and older with an acute TBI hospitalization who were discharged to an LTACH. DESIGN This retrospective cohort study used data from Centers for Medicare & Medicaid Services' Medicare Enrollment and Provider Analysis and Review data files from 2011 to 2016. MAIN MEASURES Patient variables (age, sex, premorbid health burden, medical complications and procedures), hospital variables (for-profit status, bed size), and state/regional geographic variation associated with LTACH TBI admission. RESULTS Older adult Medicare beneficiaries admitted to LTACH facilities following TBI hospitalization were on average 77.1 years old and predominantly White males. In total, 94.6% of the sample had 2+ multimorbidities present during acute hospitalization. Average acute hospital length of stay of the sample was 19.4 days, and rates of acute mechanical ventilation of any duration and tracheostomy procedures were 56.6% and 40%, respectively. Only 4.1% of patients seen in LTACHs were discharged home after LTACH stay; the primary discharge disposition was skilled nursing facilities (41.3%). Geographic analyses indicated that selected Southern and Midwestern states had the greatest number of LTACH facilities and proportion of LTACH admissions. CONCLUSIONS There has been limited characterization of the hospitalized TBI population admitted to LTACHs. Our findings among older adult Medicare beneficiaries suggest this population is highly medically complex and are seldom discharged home after their LTACH stay. There are also notable geographic variations in LTACH TBI admissions across the United States. More research is warranted to understand long-term functional outcomes among this population.
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Affiliation(s)
- Raj G. Kumar
- Department of Rehabilitation and Human Performance, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Wenhan Zhang
- Department of Health Services, Policy, and Practice, Center for Gerontology and Healthcare Research, Brown University School of Public Health, Providence, Rhode Island
| | - Emily Evans
- Department of Health Services, Policy, and Practice, Center for Gerontology and Healthcare Research, Brown University School of Public Health, Providence, Rhode Island
| | - Kristen Dams-O’Connor
- Department of Rehabilitation and Human Performance, Icahn School of Medicine at Mount Sinai, New York, New York
- Department of Neurology, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Kali S. Thomas
- Department of Health Services, Policy, and Practice, Center for Gerontology and Healthcare Research, Brown University School of Public Health, Providence, Rhode Island
- Providence VA Medical Center, Providence, Rhode Island
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Yang C, Lang L, He Z, Hui J, Jiang J, Gao GY, Feng JF. Epidemiological Characteristics of Older Patients with Traumatic Brain Injury in China. J Neurotrauma 2022; 39:850-859. [PMID: 35171687 DOI: 10.1089/neu.2021.0275] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Increasing traumatic brain injury (TBI) among older adults constitutes a substantial socioeconomic burden, in step with the growing aging global population. Here, we aimed to investigate the profile of geriatric TBI in the CENTER-TBI China registry, a prospective observational study conducted in 56 centers of 22 provinces across China. Patients admitted to the hospital with a clinical diagnosis of TBI were enrolled in the study. Data on demographic characteristics, injury, clinical features, treatments, and survival at discharge were collected and assessed. The primary endpoint was survival state at discharge. We analyzed a total of 2415 patients aged ≥65 years, accounting for 18.34% of the overall population. The median age was 72 years (interquartile range [IQR]: 68-78), and 1588 (65.76%) were men. Incidental falls (n=1044, 43.23%) were the leading cause of TBI, followed by road traffic injuries (n=1034, 42.82%). Roads and homes were the main sites of injury. The median Glasgow Coma Scale (GCS) score was 13 (IQR: 9-15); 1397 (57.85%) patients had mild TBI (GCS 13-15), while 530 (21.95%) and 488 (20.21%) presented with moderate (GCS 9-12) and severe TBI (sTBI; GCS 3-8), respectively. A total of 546 (22.61%) patients underwent intracranial surgery. The overall in-hospital mortality rate was 8.24% (n=199), and most survivors were transferred home. This study revealed that the demographic patterns and injury mechanisms are changing among elderly patients with TBI in China. More attention should be given to the high incidence of geriatric TBI to improve prevention and management strategies.
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Affiliation(s)
- Chun Yang
- Ren Ji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai 200127, People's Republic of China., Department of Neurosurgery, 160 Pujian Road, Shanghai, Shanghai, China, 200127;
| | - Lijian Lang
- Shanghai Jiao Tong University School of Medicine Affiliated Renji Hospital, 71140, Neurosurgery, Shanghai, Shanghai, China;
| | - Zhenghui He
- Shanghai Jiao Tong University School of Medicine Affiliated Renji Hospital, 71140, Neurosurgery, Shanghai, Shanghai, China;
| | - Jiyuan Hui
- Shanghai Jiao Tong University School of Medicine Affiliated Renji Hospital, 71140, Neurosurgery, Shanghai, Shanghai, China;
| | - Jiyao Jiang
- Shanghai Jiao Tong University School of Medicine Affiliated Renji Hospital, 71140, Department of Neurosurgery, Shanghai, China.,Shanghai Institute of Head Trauma, Shanghai, China;
| | - Guo-Yi Gao
- Shanghai General Hospital, 12482, Department of Neurosurgery, Shanghai, China;
| | - Jun-Feng Feng
- Renji hospital, Shanghai Jiaotong University, Neurosurgery Department, No.1630, Dongfang Road, Shanghai, China, 200127;
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28
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Tracy BM, Victor M, Smith RN, Hinrichs MJ, Gelbard RB. Examining the accuracy of the AM-PAC "6-clicks" at predicting discharge disposition in traumatic brain injury. Brain Inj 2022; 36:52-58. [PMID: 35113734 DOI: 10.1080/02699052.2022.2034967] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022]
Abstract
OBJECTIVE To assess the accuracy of the AM-PAC "6-Clicks" in predicting discharge dispositions among severely injured patients with an acute traumatic brain injury (TBI). METHODS We performed a retrospective review of patients with a TBI who presented to our trauma center from 2016 through 2018 and received a "6-Clicks" assessment. Outcomes were hospital length of stay (LOS) and discharge disposition: home, inpatient rehabilitation facility (IRF), subacute location (SL), or death/hospice. Subgroup analyses evaluated patients with concomitant mobility-limiting injuries (CM-LI). RESULTS There were 432 patients with a TBI; 42.6% (n = 184) had CM-LI. CM-LI patients had lower "6-Clicks" scores compared to patients with an isolated TBI (9 vs 14, p < .0001) and a longer hospital LOS (16.5 d vs 9 d, p < .0001). Increasing "6-Clicks" scores were associated with a home discharge (OR 1.21, 95% CI 1.15-1.28, p < .0001) while decreasing scores were predictive of an IRF or SL discharge or death/hospice. Increasing scores correlated with decreasing hospital LOS for the cohort (β - 8.93, 95% CI -10.24 - -7.62, p < .0001). CONCLUSION Among patients with an acute TBI, increasing "6 Clicks" scores were associated with a shorter hospital LOS and greater likelihood of home discharge. Decreasing mobility scores correlated with discharge to an IRF, SL, and death/hospice.
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Affiliation(s)
- Brett M Tracy
- Department of Surgery, Division of Trauma, Critical Care, Burn, The Ohio State University Wexner Medical Center; Columbus, Ohio, USA
| | - Melissa Victor
- Department of Behavioral, Social, and Health Education Sciences, Emory University Rollins School of Public Health; Atlanta, Georgia, USA
| | - Randi N Smith
- Department of Behavioral, Social, and Health Education Sciences, Emory University Rollins School of Public Health; Atlanta, Georgia, USA.,Department of Surgery, Division of Acute Care Surgery at Grady Memorial Hospital; Atlanta, Emory University School of Medicine, Georgia, USA
| | - Mark J Hinrichs
- Department of Rehabilitation Medicine at Grady Memorial Hospital; Atlanta, Emory University School of Medicine, Georgia, USA
| | - Rondi B Gelbard
- Department of Surgery, Division of Acute Care Surgery; Birmingham, University of Alabama at Birmingham, AL, USA
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Neurointensive care of traumatic brain injury in the elderly-age-specific secondary insult levels and optimal physiological levels to target need to be defined. Acta Neurochir (Wien) 2022; 164:117-128. [PMID: 34757477 PMCID: PMC8761120 DOI: 10.1007/s00701-021-05047-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2021] [Accepted: 10/25/2021] [Indexed: 10/26/2022]
Abstract
BACKGROUND Elderly patients with traumatic brain injury increase. Current targets and secondary insult definitions during neurointensive care (NIC) are mostly based on younger patients. The aim was therefore to study the occurrence of predefined secondary insults and the impact on outcome in different ages with particular focus on elderly. METHODS Patients admitted to Uppsala 2008-2014 were included. Patient characteristics, NIC management, monitoring data, and outcome were analyzed. The percentage of monitoring time for ICP, CPP, MAP, and SBP above-/below-predefined thresholds was calculated. RESULTS Five hundred seventy patients were included, 151 elderly ≥ 65 years and 419 younger 16-64 years. Age ≥ 65 had significantly higher percentage of CPP > 100, MAP > 120, and SBP > 180 and age 16-64 had higher percentage of ICP ≥ 20, CPP ≤ 60, and MAP ≤ 80. Age ≥ 65 contributed independently to the different secondary insult patterens. When patients in all ages were analyzed, low percentage of CPP > 100 and SBP > 180, respectively, was significant predictors of favorable outcome and high percentage of ICP ≥ 20, CPP > 100, SBP ≤ 100, and SBP > 180, respectively, was predictors of death. Analysis of age interaction showed that patients ≥ 65 differed and had a higher odds for favorable outcome with large proportion of good monitoring time with SBP > 180. CONCLUSIONS Elderly ≥ 65 have different patterns of secondary insults/physiological variables, which is independently associated to age. The finding that SBP > 180 increased the odds of favorable outcome in the elderly but decreased the odds in younger patients may indicate that blood pressure should be treated differently depending on age.
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30
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Kumar RG, Zhong X, Whiteneck GG, Mazumdar M, Hammond FM, Egorova N, Lercher K, Dams-O'Connor K. Development and Validation of a Functionally Relevant Comorbid Health Index in Adults Admitted to Inpatient Rehabilitation for Traumatic Brain Injury. J Neurotrauma 2022; 39:67-75. [PMID: 34779252 PMCID: PMC8917887 DOI: 10.1089/neu.2021.0180] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023] Open
Abstract
Several studies have characterized comorbidities among individuals with traumatic brain injury (TBI); however, there are few validated TBI comorbidity indices. Widely used indices (e.g., Elixhauser Comorbidity Index [ECI]) were developed in other patient populations and anchor to mortality or healthcare utilization, not functioning, and notably exclude conditions known to co-occur with TBI. The objectives of this study were to develop and validate a functionally relevant TBI comorbidity index (Fx-TBI-CI) and to compare prognostication of the Fx-TBI-CI with the ECI. We used data from the eRehabData database to divide the sample randomly into a training sample (N = 21,292) and an internal validation sample (N = 9166). We used data from the TBI Model Systems National Database as an external validation sample (N = 1925). We used least absolute shrinkage and selection operator (LASSO) regression to narrow the list of functionally relevant conditions from 39 to 12. In internal validation, the Fx-TBI-CI explained 14.1% incremental variance over an age and sex model predicting the Functional Independence Measure (FIM) Motor subscale at inpatient rehabilitation discharge, compared with 2.4% explained by the ECI. In external validation, the Fx-TBI-CI explained 4.9% incremental variance over age and sex and 3.8% over age, sex, and Glasgow Coma Scale score,compared with 2.1% and 1.6% incremental variance, respectively, explained by the ECI. An unweighted Sum Condition Score including the same conditions as the Fx-TBI-CI conferred similar prognostication. Although the Fx-TBI-CI had only modest incremental variance over demographics and injury severity in predicting functioning in external validation, the Fx-TBI-CI outperformed the ECI in predicting post-TBI function.
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Affiliation(s)
- Raj G. Kumar
- Department of Rehabilitation and Human Performance, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Xiaobo Zhong
- Institute for Healthcare Delivery Science, Mount Sinai Health System, New York, New York, USA.,Department of Population Health Science and Policy, and Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | | | - Madhu Mazumdar
- Institute for Healthcare Delivery Science, Mount Sinai Health System, New York, New York, USA.,Department of Population Health Science and Policy, and Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Flora M. Hammond
- Department of Physical Medicine and Rehabilitation, Indiana University School of Medicine, Indianapolis, Indiana, USA.,Rehabilitation Hospital of Indiana, Indianapolis, Indiana, USA
| | - Natalia Egorova
- Department of Population Health Science and Policy, and Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Kirk Lercher
- Department of Rehabilitation and Human Performance, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Kristen Dams-O'Connor
- Department of Rehabilitation and Human Performance, Icahn School of Medicine at Mount Sinai, New York, New York, USA.,Department of Neurology, Icahn School of Medicine at Mount Sinai, New York, New York, USA.,Address correspondence to: Kristen Dams-O'Connor, PhD, Icahn School of Medicine at Mount Sinai, One Gustave L. Levy Place, Box 1163, New York, NY 10029, USA kristen.dams-o'
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Dell KC, Staph J, Hillary FG. Traumatic brain injury in the homeless: health, injury mechanisms, and hospital course. Brain Inj 2021; 35:1192-1200. [PMID: 34460346 DOI: 10.1080/02699052.2021.1958009] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
Primary ObjectiveEstablished literature demonstrates that homeless individuals experience both greater disease burden and risk of experiencing traumatic brain injury (TBI) than the general population. Similarly, shared risk factors for both homelessness and/or TBI may exacerbate the risk of repetitive neurotrauma within homeless populations.Research DesignWe leveraged a state-wide trauma registry, the Pennsylvania Trauma Outcome Study (PTOS), to characterize 609 patients discharged to homeless (58% TBI, 42% orthopedic injury (OI)) in comparison to 609 randomly sampled adult patients discharged to home.Methods and ProceduresWe implemented Chi-square tests to examine preexisting health conditions (PECs), hospital course, and injury mechanisms for both patient groups.Main Outcomes and ResultsHomelessness affects a greater proportion of nonwhite patients, and homeless patients present for care with increased frequencies of psychiatric and substance use PECs, and alcohol-positive TBI. Furthermore, assault impacts a larger proportion of homeless patients, and the window for overnight assault risk resulting in TBI is extended for these patients compared to patients discharged to home.ConclusionGiven the shifting conceptualization of TBI as a chronic condition, identifying homeless patients on admission to trauma centers, rather than retrospectively at discharge, can enhance understanding of the challenges facing the homeless as they age with both a complex neurotrauma history and multimorbidity.
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Affiliation(s)
- Kristine C Dell
- Department of Psychology, The Pennsylvania State University, University Park, Pennsylvania, United States
| | - Jason Staph
- Department of Psychology, The Pennsylvania State University, University Park, Pennsylvania, United States
| | - Frank G Hillary
- Department of Psychology, The Pennsylvania State University, University Park, Pennsylvania, United States.,Department of Neurology, Hershey Medical Center, Hershey, Pennsylvania, United States
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Platelet dysfunction in patients with traumatic intracranial hemorrhage: Do desmopressin and platelet therapy help or harm? Am J Surg 2021; 223:131-136. [PMID: 34446216 DOI: 10.1016/j.amjsurg.2021.07.050] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2021] [Revised: 07/27/2021] [Accepted: 07/28/2021] [Indexed: 01/15/2023]
Abstract
BACKGROUND Pre-injury anti-platelet use has been associated with increased risk of progression of traumatic intracranial hemorrhage (TICH) and worse outcomes. VerifyNow® assays assess platelet inhibition due to aspirin/clopidogrel. This study assesses the outcomes of patients with TICH and platelet dysfunction treated with desmopressin and/or platelets. METHODS We performed a retrospective chart review of patients with mild TICH at a level 1 trauma center 1/1/2013-6/1/2016. Patients with documented platelet dysfunction who received desmopressin and/or platelets were compared to those who were untreated. Primary outcomes were progression of TICH and neurologic outcomes at discharge. RESULTS Of 565 patients with a mild TICH, 200 patients had evidence of platelet dysfunction (a positive VerifyNow® assay). Patients had similar baseline demographics, injury characteristics, and rate of TICH progression; but patients who received desmopressin and/or platelets had worse Glasgow Outcomes Score at discharge. CONCLUSION Treatment of patients with mild TICH and platelet dysfunction with desmopressin and/or platelets did not affect TICH progression but correlated with worse neurologic status at discharge.
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Hosomi S, Kitamura T, Sobue T, Ogura H, Shimazu T. Sex and age differences in isolated traumatic brain injury: a retrospective observational study. BMC Neurol 2021; 21:261. [PMID: 34225691 PMCID: PMC8256599 DOI: 10.1186/s12883-021-02305-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2021] [Accepted: 06/22/2021] [Indexed: 11/12/2022] Open
Abstract
Background Among the many factors that may influence traumatic brain injury (TBI) progression, sex is one of the most controversial. The objective of this study was to investigate sex differences in TBI-associated morbidity and mortality using data from the largest trauma registry in Japan. Methods This retrospective, population-based observational study included patients with isolated TBI, who were registered in a nationwide database between 2004 and 2018. We excluded patients with extracranial injury (Abbreviated Injury Scale score ≥ 3) and removed potential confounding factors, such as non-neurological causes of mortality. Patients were stratified by age and mortality and post-injury complications were compared between males and females. Results A total of 51,726 patients with isolated TBI were included (16,901 females and 34,825 males). Mortality across all ages was documented in 12.01% (2030/16901) and 12.76% (4445/34825) of males and females, respectively. The adjusted odds ratio (OR) of TBI mortality for males compared to females was 1.32 (95% confidence interval [CI], 1.22–1.42]. Males aged 10–19 years and ≥ 60 years had a significantly higher mortality than females in the same age groups (10–19 years: adjusted OR, 1.97 [95% CI, 1.08–3.61]; 60–69 years: adjusted OR, 1.24 [95% CI, 1.02–1.50]; 70–79 years: adjusted OR, 1.20 [95% CI, 1.03–1.40]; 80–89 years: adjusted OR, 1.50 [95% CI, 1.31–1.73], and 90–99 years: adjusted OR, 1.72 [95% CI, 1.28–2.32]). In terms of the incidence of post-TBI neurologic and non-neurologic complications, the crude ORs were 1.29 (95% CI, 1.19–1.39) and 1.14 (95% CI, 1.07–1.22), respectively, for males versus females. This difference was especially evident among elderly patients (neurologic complications: OR, 1.27 [95% CI, 1.14–1.41]; non-neurologic complications: OR, 1.29 [95% CI, 1.19–1.39]). Conclusions In a nationwide sample of patients with TBI in Japan, males had a higher mortality than females. This disparity was particularly evident among younger and older generations. Furthermore, elderly males experienced more TBI complications than females of the same age. Supplementary Information The online version contains supplementary material available at 10.1186/s12883-021-02305-6.
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Affiliation(s)
- Sanae Hosomi
- Department of Traumatology and Acute Critical Medicine, Osaka University Graduate School of Medicine, 215, Yamada-oka, Suita, Japan. .,Division of Environmental Medicine and Population Sciences, Department of Social and Environmental Medicine, Osaka University Graduate School of Medicine, 215, Yamada-oka, Suita, Japan.
| | - Tetsuhisa Kitamura
- Division of Environmental Medicine and Population Sciences, Department of Social and Environmental Medicine, Osaka University Graduate School of Medicine, 215, Yamada-oka, Suita, Japan
| | - Tomotaka Sobue
- Division of Environmental Medicine and Population Sciences, Department of Social and Environmental Medicine, Osaka University Graduate School of Medicine, 215, Yamada-oka, Suita, Japan
| | - Hiroshi Ogura
- Department of Traumatology and Acute Critical Medicine, Osaka University Graduate School of Medicine, 215, Yamada-oka, Suita, Japan
| | - Takeshi Shimazu
- Department of Traumatology and Acute Critical Medicine, Osaka University Graduate School of Medicine, 215, Yamada-oka, Suita, Japan
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Hughes PG, Alter SM, Greaves SW, Mazer BA, Solano JJ, Shih RD, Clayton LM, Trinh NQ, Lottenberg L, Hughes MJ. Acute and Delayed Intracranial Hemorrhage in Head-Injured Patients on Warfarin versus Direct Oral Anticoagulant Therapy. J Emerg Trauma Shock 2021; 14:123-127. [PMID: 34759629 PMCID: PMC8527063 DOI: 10.4103/jets.jets_139_20] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2020] [Revised: 11/24/2020] [Accepted: 12/22/2020] [Indexed: 11/06/2022] Open
Abstract
INTRODUCTION Direct oral anticoagulant (DOAC) use for thrombosis treatment and prophylaxis is a popular alternative to warfarin. This study compares rates of traumatic intracranial hemorrhage (ICH) for patients on anticoagulant therapies and the effect of combined anticoagulant and antiplatelet therapies. METHODS A retrospective observational study of trauma patients was conducted at two level I trauma centers. Patients aged ≥18 years with preinjury use of an anticoagulant (warfarin, rivaroxaban, apixaban, or dabigatran) who sustained a blunt head injury within the past day were included. Patients were evaluated by head CT to evaluate for ICH. RESULTS Three hundred and eighty-eight patients were included (140 on warfarin, 149 on a DOAC, and 99 on combined anticoagulant and antiplatelet therapies). Seventy-nine patients (20.4%) had an acute ICH, while 16 patients (4.1%) had a delayed ICH found on routine repeat CT. Those on combination therapy were not at increased risk of acute ICH (relative risk [RR] 0.90, confidence interval [CI]: 0.56-1.44; P > 0.5) or delayed ICH (RR 2.19, CI: 0.84-5.69; P = 0.10) compared to anticoagulant use only. Those on warfarin were at increased risk of acute ICH (RR 1.75, CI: 1.10-2.78, P = 0.015), but not delayed ICH (RR 0.99, CI 0.27-3.59, P > 0.5), compared to those on DOACs. No delayed ICH patients died or required neurosurgical intervention. CONCLUSION Patients on warfarin had a higher rate of acute ICH, but not delayed ICH, compared to those on DOACs. Given the low rate of delayed ICH with no resultant morbidity or mortality, routine observation and repeat head CT on patients with no acute ICH may not be necessary.
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Affiliation(s)
- Patrick G. Hughes
- Division of Emergency Medicine, Florida Atlantic University, Charles E. Schmidt College of Medicine, Boca Raton, FL, USA
| | - Scott M. Alter
- Division of Emergency Medicine, Florida Atlantic University, Charles E. Schmidt College of Medicine, Boca Raton, FL, USA
| | - Spencer W. Greaves
- Division of Emergency Medicine, Florida Atlantic University, Charles E. Schmidt College of Medicine, Boca Raton, FL, USA
| | - Benjamin A. Mazer
- Division of Emergency Medicine, Florida Atlantic University, Charles E. Schmidt College of Medicine, Boca Raton, FL, USA
| | - Joshua J. Solano
- Division of Emergency Medicine, Florida Atlantic University, Charles E. Schmidt College of Medicine, Boca Raton, FL, USA
| | - Richard D. Shih
- Division of Emergency Medicine, Florida Atlantic University, Charles E. Schmidt College of Medicine, Boca Raton, FL, USA
| | - Lisa M. Clayton
- Division of Emergency Medicine, Florida Atlantic University, Charles E. Schmidt College of Medicine, Boca Raton, FL, USA
| | - Nhat Q. Trinh
- Department of Emergency Medicine, Sparrow Hospital, Lansing, MI, USA
| | - Lawrence Lottenberg
- Department of Surgery, Florida Atlantic University, Charles E. Schmidt College of Medicine, Boca Raton, MI, USA
- St. Mary’s Medical Center, West Palm Beach, FL, USA
| | - Mary J. Hughes
- Department of Osteopathic Medical Specialties, Michigan State University College of Osteopathic Medicine, East Lansing, MI, USA
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Anderson MC, Evans E, Zonfrillo MR, Thomas KS. Rural/urban differences in discharge from rehabilitation in older adults with traumatic brain injury. J Am Geriatr Soc 2021; 69:1601-1608. [PMID: 33675540 PMCID: PMC8192484 DOI: 10.1111/jgs.17065] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2020] [Revised: 01/13/2021] [Accepted: 01/26/2021] [Indexed: 11/30/2022]
Abstract
BACKGROUND/OBJECTIVES Rates of traumatic brain injury (TBI) among older adults and treatment of this population in nursing homes are increasing. The objective of this study is to examine differences in the quality of care and outcomes of older adults with TBI in rural and urban settings by (1) comparing the rates of successful community discharge; and (2) reasons for not achieving successful discharge among patients in rural and urban environments. DESIGN Retrospective national cohort study of skilled nursing facility (SNF) patients using Medicare inpatient claims linked with Minimum Data Set assessments. Demographic, health, and facility characteristics were compared between rural and urban settings using descriptive statistics. Logistic regression with state random effects was used to identify characteristics that predicted successful discharge. SETTING U.S. skilled nursing facilities (n = 11,771). PARTICIPANTS Medicare beneficiaries aged 66 and older discharged to a SNF following hospitalization for TBI between 2011 and 2015 (n = 61,021). MEASUREMENTS Successful community discharge defined as discharge from SNF within 100 days of admission and remaining in the community for ≥30 days without dying or admission to an inpatient healthcare facility. RESULTS Unadjusted rates of successful discharge were significantly lower for patients in rural settings compared with patients in urban settings (52.1% vs 58.5%, p < 0.01). Patients in rural settings had lower adjusted odds (odds ratio 0.84, 95% confidence interval = 0.80-0.89) of successful discharge. Reasons for not discharging successfully differed between rural and urban settings with rural patients less likely to discharge from SNF within 100 days though also less likely to be rehospitalized within 30 days of SNF discharge. CONCLUSION Given the low overall rate of successful community discharge and worse outcomes among rural patients, further research to explore interventions to improve SNF care and discharge planning in this population is warranted.
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Affiliation(s)
| | - Emily Evans
- Brown University School of Public Health, Department of Health Services, Policy and Practice
| | - Mark R. Zonfrillo
- Warren Alpert Medical School of Brown University, Departments of Emergency Medicine and Pediatrics
| | - Kali S. Thomas
- Brown University School of Public Health, Department of Health Services, Policy and Practice
- Providence VA Medical Center
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Evans E, Krebill C, Gutman R, Resnik L, Zonfrillo MR, Lueckel SN, Zhang W, Kumar RG, Dams-O'Connor K, Thomas KS. Functional motor improvement during inpatient rehabilitation among older adults with traumatic brain injury. PM R 2021; 14:417-427. [PMID: 34018693 DOI: 10.1002/pmrj.12644] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2020] [Revised: 04/21/2021] [Accepted: 05/07/2021] [Indexed: 11/07/2022]
Abstract
BACKGROUND Older adults comprise an increasingly large proportion of patients with traumatic brain injury (TBI) receiving care in inpatient rehabilitation facilities (IRF). However, high rates of comorbidities and evidence of declining preinjury health among older adults who sustain TBI raise questions about their ability to benefit from IRF care. OBJECTIVES To describe the proportion of older adults with TBI who exhibited minimal detectable change (MDC) and a minimally clinically important difference (MCID) in motor function from IRF admission to discharge; and to identify characteristics associated with clinically meaningful improvement in motor function and better discharge functional status. DESIGN This retrospective cohort study used Medicare administrative data probabilistically linked to the National Trauma Data Bank to estimate the proportion of patients whose motor function improved during inpatient rehabilitation and identify factors associated with meaningful improvement in motor function and motor function at discharge. SETTING Inpatient rehabilitation facilities in the United States. PATIENTS Fee-for-service Medicare beneficiaries with TBI. MAIN OUTCOME MEASURES Minimal Detectable Change (MDC) and Minimally Clinically Important Difference (MCID) in the Functional Independence Measure motor (FIM-M) score from admission to discharge, and FIM-M score at IRF discharge. RESULTS From IRF admission to discharge 84% of patients achieved the MDC threshold, and 68% of patients achieved the MCID threshold for FIM-M scores. Factors associated with a higher probability of achieving the MCID for FIM-M scores included better admission motor and cognitive function, lower comorbidity burden, and a length of stay longer than 10 days but only among individuals with lower admission motor function. Older age was associated with a lower FIM-M discharge score, but not the probability of achieving the MCID in FIM-M score. CONCLUSION Older adults with TBI have the potential to improve their motor function with IRF care. Baseline functional status and comorbidity burden, rather than acute injury severity, should be used to guide care planning.
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Affiliation(s)
- Emily Evans
- Department of Health Services, Policy and Practice, Center for Gerontology and Healthcare Research, Brown University School of Public Health, Providence, Rhode Island, USA
| | - Cicely Krebill
- Warren Alpert School of Medicine of Brown University, Providence, Rhode Island, USA
| | - Roee Gutman
- Department of Biostatistics, Brown University School of Public Health, Providence, Rhode Island, USA
| | - Linda Resnik
- Department of Health Services, Policy and Practice, Center for Gerontology and Healthcare Research, Brown University School of Public Health and Providence VA Medical Center, Providence, Rhode Island, USA
| | - Mark R Zonfrillo
- Departments of Emergency Medicine and Pediatrics, Warren Alpert School of Medicine of Brown University, Providence, Rhode Island, USA
| | - Stephanie N Lueckel
- Division of Acute Care Surgery and Surgical Critical Care, Rhode Island Hospital, Warren Alpert School of Medicine of Brown University, Providence, Rhode Island, USA
| | - Wenhan Zhang
- Center for Gerontology and Healthcare Research, Brown University School of Public Health, Providence, Rhode Island, USA
| | - Raj G Kumar
- Department of Rehabilitation and Human Performance, Icahn School of Medicine at Mount Sinai, New York, USA
| | - Kristen Dams-O'Connor
- Department of Rehabilitation and Human Performance, Icahn School of Medicine at Mount Sinai, New York, USA
- Department of Neurology, Icahn School of Medicine at Mount Sinai, New York, USA
| | - Kali S Thomas
- Department of Health Services, Policy and Practice, Center for Gerontology and Healthcare Research, Brown University School of Public Health and Providence VA Medical Center, Providence, Rhode Island, USA
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Evans E, Gutman R, Resnik L, Zonfrillo MR, Lueckel SN, Kumar RG, DeVone F, Dams-O'Connor K, Thomas KS. Successful Community Discharge Among Older Adults With Traumatic Brain Injury in Skilled Nursing Facilities. J Head Trauma Rehabil 2021; 36:E186-E198. [PMID: 33528173 PMCID: PMC8096636 DOI: 10.1097/htr.0000000000000638] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE To identify patient, injury, and functional status characteristics associated with successful discharge to the community following a skilled nursing facility (SNF) stay among older adults hospitalized following traumatic brain injury (TBI). SETTING Skilled nursing facilities. PARTICIPANTS Medicare fee-for-service beneficiaries admitted to an SNF after hospitalization for TBI. DESIGN Retrospective cohort study using Medicare administrative data merged with the National Trauma Data Bank using a multilayered Bayesian record linkage approach. MAIN OUTCOME MEASURE Successful community discharge: discharged alive within 100 days of SNF admission and remaining in the community for 30 days or more without dying or admission to a healthcare facility. RESULTS Medicaid enrollment, incontinence, decreased independence with activities of daily living, and cognitive impairment were associated with lower odds of successful discharge, whereas race "other" was associated with higher odds of successful discharge. Injury factors including worse injury severity (Glasgow Coma Scale and Abbreviated Injury Scale scores) and fall-related injury mechanism were not associated with successful discharge. CONCLUSION Among older adults with TBI who discharge to an SNF, sociodemographic and functional status characteristics are associated with successful discharge and may be useful to clinicians for discharge planning. Acute injury severity indices may have limited utility in predicting discharge disposition once a patient is admitted to an SNF for post-acute care.
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Affiliation(s)
- Emily Evans
- Department of Health Services, Policy and Practice Center for Gerontology and Healthcare Research, Brown School of Public Health (Drs Evans, Resnik, and Thomas) and Department of Biostatistics (Dr Gutman and Mr DeVone), Brown University School of Public Health, Providence, Rhode Island; Providence VA Medical Center, Providence, Rhode Island (Drs Resnik and Thomas); Departments of Emergency Medicine and Pediatrics (Dr Zonfrillo) and Division of Acute Care Surgery and Surgical Critical Care, Rhode Island Hospital (Dr Lueckel), Warren Alpert School of Medicine of Brown University, Providence, Rhode Island; and Department of Rehabilitation and Human Performance (Drs Kumar and Dams-O'Connor) and Department of Neurology (Dr Dams-O'Connor), Icahn School of Medicine at Mount Sinai, New York City, New York
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Miller GF, Daugherty J, Waltzman D, Sarmiento K. Predictors of traumatic brain injury morbidity and mortality: Examination of data from the national trauma data bank: Predictors of TBI morbidity & mortality. Injury 2021; 52:1138-1144. [PMID: 33551263 PMCID: PMC8107124 DOI: 10.1016/j.injury.2021.01.042] [Citation(s) in RCA: 30] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/27/2020] [Revised: 01/21/2021] [Accepted: 01/23/2021] [Indexed: 02/02/2023]
Abstract
BACKGROUND There is evidence to suggest that traumatic brain injuries (TBI) are increasing in the United States. It is important to examine predictors of TBI outcomes to formulate better prevention and care strategies. RESEARCH DESIGN National Trauma Data Bank (NTDB) data from 2016 were used to report the percentage of TBI by age, sex, race/ethnicity, health insurance status, intent/mechanism of injury, Glasgow Coma Scale (GCS), disposition at emergency department, and trauma center level. Logistic regression models were run to estimate the adjusted odds ratios of patient and facility characteristics on length of hospital stay and in-hospital mortality (analyzed in 2020). RESULTS There were 236,873 patients with TBI in the NTDB in 2016. Most patients with a TBI were male, non-Hispanic white, and had sustained a TBI due to an unintentional injury. After adjusting for other factors, individuals age 0-17, those who self-pay, and those with intentional injuries had increased odds of a shorter hospital stay. Older individuals, non-Hispanic black or Hispanic patients, those who had sustained an intentional injury, and those who were not seen in a Level I trauma center had higher odds of mortality following their TBI. CONCLUSIONS Public health professionals' promotion of fall and other TBI prevention efforts and the development of strategies to improve access to Level I trauma centers, may decrease adverse TBI health outcomes. This may be especially important for older adults and other vulnerable populations.
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Affiliation(s)
- Gabrielle F Miller
- Division of Injury Prevention, National Center for Injury Prevention and Control, CDC, Atlanta GA, USA.
| | - Jill Daugherty
- Division of Injury Prevention, National Center for Injury Prevention and Control, CDC, Atlanta GA, USA.
| | - Dana Waltzman
- Division of Injury Prevention, National Center for Injury Prevention and Control, CDC, Atlanta GA, USA.
| | - Kelly Sarmiento
- Division of Injury Prevention, National Center for Injury Prevention and Control, CDC, Atlanta GA, USA.
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Clare D, Zink KL. Geriatric Trauma. Emerg Med Clin North Am 2021; 39:257-271. [PMID: 33863458 DOI: 10.1016/j.emc.2021.01.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
Geriatric trauma patients will continue to increase in prevalence as the population ages, and many specific considerations need to be made to provide appropriate care to these patients. This article outlines common presentations of trauma in geriatric patients, with consideration to baseline physiologic function and patterns of injury that may be more prevalent in geriatric populations. Additionally, the article explores specific evidence-based management practices, the significance of trauma team and geriatrician involvement, and disposition decisions.
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Affiliation(s)
- Drew Clare
- Department of Emergency Medicine, University of Florida, 655 W 8th st, Jacksonville, FL 32209, USA.
| | - Korie L Zink
- Johns Hopkins University, 1830 E. Monument St, St 6-100, Baltimore, MD 21224, USA. https://twitter.com/koriezinkmd
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Shibahashi K, Hoda H, Ishida T, Sugiyama K, Okura Y, Hamabe Y. Older Adults with Traumatic Brain Injury in the Most Aged and Most Rapidly Aging Country: An Analysis of the Nationwide Trauma Registry of Japan. World Neurosurg 2021; 150:e570-e576. [PMID: 33746100 DOI: 10.1016/j.wneu.2021.03.059] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2021] [Revised: 03/10/2021] [Accepted: 03/11/2021] [Indexed: 11/18/2022]
Abstract
BACKGROUND Despite the increasing numbers of older adults with traumatic brain injury (TBI), minimal data are available to support the development of treatment strategies. We aimed to comprehensively describe the incidence, characteristics, outcomes, and predictive accuracy of the severity indicators among older adults with TBI. METHODS Using the Japan Trauma Data Bank, we identified patients aged ≥18 years with TBI from 2004 to 2019. The patients were grouped according to age, and their baseline characteristics, radiological findings, severity, complications, and in-hospital mortality were assessed. Receiver operating characteristic curves were used to assess the accuracy of severity indicators for predicting in-hospital mortality. RESULTS Of the 94,180 patients who met the inclusion criteria, 50,990 (54.1%) were older adults (aged ≥65 years). Their proportion had increased at 2.1% annually, which exceeded the 0.5% annual increase in the general population. The proportion of women and the prevalence of comorbidities increased significantly with age. Traffic accidents were the leading cause of TBI among young adults, and falling at ground level was the leading cause for those aged ≥75 years. The radiological findings were significantly different among the age groups. The proportion of acute epidural hemorrhage, skull fracture, and diffuse axonal injury decreased and that of acute subdural hemorrhage increased with age. The predictive accuracy of the Glasgow coma scale, revised trauma score, and injury severity score decreased with increasing age. CONCLUSIONS The proportion of older patients with TBI increased more quickly than did the proportion of older people in the general population. The characteristics and predictive accuracy of the severity indicators differed significantly among the different age groups. TBI studies that focus on older patients are necessary.
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Affiliation(s)
- Keita Shibahashi
- Tertiary Emergency Medical Center, Tokyo Metropolitan Bokutoh Hospital, Tokyo, Japan.
| | - Hidenori Hoda
- Tertiary Emergency Medical Center, Tokyo Metropolitan Bokutoh Hospital, Tokyo, Japan
| | - Takuto Ishida
- Tertiary Emergency Medical Center, Tokyo Metropolitan Bokutoh Hospital, Tokyo, Japan
| | - Kazuhiro Sugiyama
- Tertiary Emergency Medical Center, Tokyo Metropolitan Bokutoh Hospital, Tokyo, Japan
| | - Yoshihiro Okura
- Tertiary Emergency Medical Center, Tokyo Metropolitan Bokutoh Hospital, Tokyo, Japan
| | - Yuichi Hamabe
- Tertiary Emergency Medical Center, Tokyo Metropolitan Bokutoh Hospital, Tokyo, Japan
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Fakhry SM, Morse JL, Garland JM, Wilson NY, Shen Y, Wyse RJ, Watts DD. Antiplatelet and anticoagulant agents have minimal impact on traumatic brain injury incidence, surgery, and mortality in geriatric ground level falls: A multi-institutional analysis of 33,710 patients. J Trauma Acute Care Surg 2021; 90:215-223. [PMID: 33060534 DOI: 10.1097/ta.0000000000002985] [Citation(s) in RCA: 24] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Falls are the leading cause of traumatic brain injury (TBI) and TBI-related deaths for older persons (age, ≥65 years). Antiplatelet and/or anticoagulant therapy (antithrombotics [ATs]) is generally felt to increase this risk, but the literature is inconsistent. The purpose of this study was to determine the impact of AT use on the rate, severity, and outcomes of TBI in older patients following ground level falls. METHODS Ground level fall patients from 90 hospitals' trauma registries were selected. Patients were excluded if younger than 65 years or had an Abbreviated Injury Scale score of >2 in a region other than head. Electronic medical record data for preinjury AT therapy were obtained. Patients were grouped by regimen for no AT, single, or multiple agents. Groups were compared on rates of diagnosed TBI, TBI surgery, and mortality. RESULTS There were 33,710 patients (35% male; mean age, 80.5 years; mean Glasgow Coma Scale, 14.6), with 47.6% on single or combination AT therapy. The proportion of patients with TBI diagnoses did not differ between those on no AT (21.25%) versus AT (21.61%; p = 0.418). Apixaban (15.7%; p < 0.001) and rivaroxaban (13.19%; p = 0.011) were associated with lower rates of TBI, and acetylsalicylic acid-clopidogrel was associated with a higher TBI rate (24.34%; p = 0.002) versus no AT. acetylsalicylic acid-clopidogrel was associated with a higher cranial surgery rate (2.9%; p = 0.006) versus no AT (1.96%), but surgery rates were similar for all other regimens. No regimen was associated with higher mortality. CONCLUSION In this large multicenter study, the intake of ATs in older patients with ground level falls was associated with inconsistent effects on risk of TBI and no significant increases in mortality, indicating that AT use may have negligible impact on patient clinical management. A large, confirmatory, prospective study is needed because the commonly held belief that ATs uniformly increase the risk of traumatic intracranial bleeding and mortality is not supported. LEVEL OF EVIDENCE Therapeutic/care management, level II.
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Affiliation(s)
- Samir M Fakhry
- From the Center for Trauma and Acute Care Surgery Research, Clinical Operations Group, HCA Healthcare, Nashville, Tennessee
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Age-Related Changes in the Association Between Traumatic Brain Injury and Dementia in Older Men and Women. J Head Trauma Rehabil 2020; 36:E139-E146. [PMID: 33201033 DOI: 10.1097/htr.0000000000000624] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To investigate age-related changes in the association between traumatic brain injury (TBI) and dementia in older men and women separately. SETTING A total of 243 general practices in the UK. PARTICIPANTS This study included 4760 patients who received a first TBI diagnosis between 1995 and 2010 (index date), and 4760 patients without TBI who were matched to those with TBI by age, sex, index year, Charlson Comorbidity Index, alcohol dependence, and physician (index date: a randomly selected visit date). DESIGN Retrospective cohort study. MAIN MEASURES Incidence of dementia in the decade following index date. RESULTS Within 10 years of index date, 8.8% of men with TBI and 4.8% of those without TBI were diagnosed with dementia, while the respective figures were 9.0% and 6.7% in women (P values < .01). There was a significant association between TBI and dementia in men (hazard ratio [HR] = 2.29, 95% confidence interval [CI]: 1.64-3.19) and in women (HR = 1.33, 95% CI: 1.07-1.64). Furthermore, the association between TBI and dementia was significant in men aged 60 to 70 (HR = 2.51, 95% CI: 1.27-4.96) and 71 to 80 years (HR = 3.00, 95% CI: 1.82-4.93), whereas the relationship was only significant and potentially unreliable in women aged 81 to 90 years (HR = 1.49, 95% CI: 1.03-2.14). CONCLUSIONS The age-related relationship between TBI and dementia differed between men and women. More research of a prospective nature and including behavioral data is needed to better understand these differences.
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Comorbid Conditions Among Adults 50 Years and Older With Traumatic Brain Injury: Examining Associations With Demographics, Healthcare Utilization, Institutionalization, and 1-Year Outcomes. J Head Trauma Rehabil 2020; 34:224-232. [PMID: 30829819 DOI: 10.1097/htr.0000000000000470] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
OBJECTIVES To assess the relationship of acute complications, preexisting chronic diseases, and substance abuse with clinical and functional outcomes among adults 50 years and older with moderate-to-severe traumatic brain injury (TBI). DESIGN Prospective cohort study. PARTICIPANTS Adults 50 years and older with moderate-to-severe TBI (n = 2134). MEASURES Clusters of comorbid health conditions empirically derived from non-injury International Classification of Diseases, Ninth Revision codes, demographic/injury variables, and outcome (acute and rehabilitation length of stay [LOS], Functional Independence Measure efficiency, posttraumatic amnesia [PTA] duration, institutionalization, rehospitalization, and Glasgow Outcome Scale-Extended (GOS-E) at 1 year). RESULTS Individuals with greater acute hospital complication burden were more often middle-aged men, injured in motor vehicle accidents, and had longer LOS and PTA. These same individuals experienced higher rates of 1-year rehospitalization and greater odds of unfavorable GOS-E scores at 1 year. Those with greater chronic disease burden were more likely to be rehospitalized at 1 year. Individuals with more substance abuse burden were most often younger (eg, middle adulthood), black race, less educated, injured via motor vehicle accidents, and had an increased risk for institutionalization. CONCLUSION Preexisting health conditions and acute complications contribute to TBI outcomes. This work provides a foundation to explore effects of comorbidity prevention and management on TBI recovery in older adults.
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Evans E, Kosar CM, Thomas KS. Positive Beliefs and the Likelihood of Successful Community Discharge From Skilled Nursing Facilities. Arch Phys Med Rehabil 2020; 102:480-487. [PMID: 32991871 DOI: 10.1016/j.apmr.2020.09.375] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2020] [Revised: 08/07/2020] [Accepted: 09/01/2020] [Indexed: 10/23/2022]
Abstract
OBJECTIVES To examine the association of patient and direct-care staff beliefs about patients' capability to increase independence with activities of daily living (ADL) and the probability of successful discharge to the community after a skilled nursing facility (SNF) stay. DESIGN Retrospective cohort study of SNF patients using 100% Medicare inpatient claims and Minimum Data Set resident assessment data. Linear probability models were used to estimate the probability of successful discharge based on patient and staff beliefs about the patient's ability to improve in function, as well as patient and staff beliefs together. Estimates were adjusted for demographics, health status, functional characteristics, and SNF fixed effects. PARTICIPANTS Fee-for-service Medicare beneficiaries (N=526,432) aged 66 years or older who were discharged to an SNF after hospitalization for stroke, hip fracture, or traumatic brain injury. INTERVENTIONS Not applicable. MAIN OUTCOME MEASURES Successful community discharge (discharged alive within 90d of SNF admission and remaining in the community for ≥30d without dying or health care facility readmission). RESULTS Patients with positive beliefs about their capability to increase independence with ADLs had a higher adjusted probability of successful discharge than patients with negative beliefs (positive, 63.8%; negative, 57.8%; difference, 6.0%, 95% confidence interval [CI], 5.4-6.6). This remained true regardless of staff beliefs, but the difference in successful discharge probability between patients with positive and negative beliefs was larger when staff had positive beliefs. Conversely, the association between staff beliefs and successful discharge varied based on patient beliefs. If patients had positive beliefs, the difference in the probability of successful discharge between positive and negative staff beliefs was 2.5% (95% CI, 1.0-4.0). If patients had negative beliefs, the difference between positive and negative staff beliefs was -4.6% (95% CI, -6.0 to -3.2). CONCLUSIONS Patients' beliefs have a significant association with the probability of successful discharge. Understanding patients' beliefs is critical to appropriate goal-setting, discharge planning, and quality SNF care.
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Affiliation(s)
- Emily Evans
- Department of Health Services, Policy, and Practice, Center for Gerontology and Healthcare Research, Brown School of Public Health, Providence, RI.
| | - Cyrus M Kosar
- Department of Health Services, Policy, and Practice, Center for Gerontology and Healthcare Research, Brown School of Public Health, Providence, RI
| | - Kali S Thomas
- Department of Health Services, Policy, and Practice, Center for Gerontology and Healthcare Research, Brown School of Public Health, Providence, RI; Providence VA Medical Center, Providence, RI
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Posti JP, Sipilä JOT, Luoto TM, Rautava P, Kytö V. A decade of geriatric traumatic brain injuries in Finland: population-based trends. Age Ageing 2020; 49:779-785. [PMID: 32134443 DOI: 10.1093/ageing/afaa037] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2019] [Indexed: 01/18/2023] Open
Abstract
BACKGROUND we investigated trends of traumatic brain injury (TBI)-related hospitalisations, deaths, acute neurosurgical operations (ANO), and lengths of hospital stay (LOS) in patients aged ≥70 years in Finland using a population-based cohort. METHODS nationwide databases were searched for all admissions with a TBI diagnosis as well as later deaths for persons ≥70 years of age during 2004-2014. RESULTS the study period included 20,259 TBI-related hospitalisations (mean age = 80.7 years, men = 48.9%). The incidence of TBI-related hospitalisations was 283/100,000 person-years with an estimated overall annual increase of 2.9% (95% CI: 0.4-5.9%). There was an annual decrease of 2.2% in in-hospital mortality (IHM) in men (95% CI: 0.1-4.3%), with no change in women or overall. There was an annual decrease of 1.1% in odds for ANOs among hospitalised overall (95% CI: 0.1-2.1%) and of 1.4% in men (95% CI: 0.0-2.7%), while no change was observed in women. LOS decreased annually by 2.5% (95% CI: 2.1-2.9%). The incidence of TBI-related deaths was 70/100,000 person-years with an estimated annual increase of 1.6% in women (95% CI: 0.2-2.9%), but no change in men or overall. Mean ages of TBI-related admissions and deaths increased (P < 0.001). INTERPRETATION the incidence rate of geriatric TBI-related hospitalisations increased, especially in women, but LOS and the rate of ANOs among hospitalised decreased. The overall TBI-related mortality remained stable, and IHM decreased in men, while in women, the overall mortality increased and IHM remained stable. However, the overall incidence rates of TBI-related hospitalisations and deaths and the number of cases of IHM were still higher in men.
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Affiliation(s)
- Jussi P Posti
- Division of Clinical Neurosciences, Department of Neurosurgery, Turku University Hospital, Turku, Finland
- Turku Brain Injury Centre, Turku University Hospital, Turku, Finland
- Department of Clinical Neurosciences, University of Turku, Finland
| | - Jussi O T Sipilä
- Department of Clinical Neurosciences, University of Turku, Finland
- Division of Clinical Neurosciences, Department of Neurology, Turku University Hospital, Turku, Finland
- Department of Neurology, Siun sote, North Karelia Central Hospital, Joensuu, Finland
| | - Teemu M Luoto
- Department of Neurosurgery, Tampere University Hospital, Tampere University, Tampere, Finland
| | - Päivi Rautava
- Clinical Research Center, Turku University Hospital, Turku, Finland
- Department of Public Health, University of Turku, Turku, Finland
| | - Ville Kytö
- Research Centre of Applied and Preventive Cardiovascular Medicine, University of Turku, Turku, Finland
- Heart Centre, Turku University Hospital, University of Turku, Turku, Finland
- Center for Population Health Research, Turku University Hospital, University of Turku, Turku, Finland
- Administative Center, Hospital District of Southwest Finland, Turku, Finland
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46
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Paldor I, Peso D, Sviri GE. Decompressive craniectomy in elderly patients with traumatic brain injury. J Clin Neurosci 2020; 78:269-272. [PMID: 32334961 DOI: 10.1016/j.jocn.2020.03.030] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2020] [Accepted: 03/20/2020] [Indexed: 11/18/2022]
Affiliation(s)
- Iddo Paldor
- Rambam (Maimonides) Health Care Campus, Technion - Israel Institute of Technology, Haifa, Israel
| | - Dana Peso
- Rambam (Maimonides) Health Care Campus, Technion - Israel Institute of Technology, Haifa, Israel
| | - Gill E Sviri
- Rambam (Maimonides) Health Care Campus, Technion - Israel Institute of Technology, Haifa, Israel
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47
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Hammond FM, Baker-Sparr CA, Dahdah MN, Dams-O'Connor K, Dreer LE, O'Neil-Pirozzi TM, Novack TA. Predictors of 1-Year Global Outcomes After Traumatic Brain Injury Among Older Adults: A NIDILRR Traumatic Brain Injury Model Systems Study. J Aging Health 2020; 31:68S-96S. [PMID: 31718413 DOI: 10.1177/0898264318819197] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
Objective: To assess predictors of global function and driving status among older adults (50 years and older) who survived 1 year following inpatient rehabilitation for moderate-to-severe traumatic brain injury (TBI). Methods: Functional status at 1-year post-TBI was determined for 1,845 individuals. The relationship age category to function was studied using associations and predictive modeling. Results: The final model accounted for 34% variance in Glasgow Outcome Scale-Extended (GOS-E) among 60- to 69-year-olds and 70- to 79-year-olds, and 25% variance in 50- to 59-year-olds and 80+-year-olds. FIM Motor at rehabilitation discharge made the greatest contribution to GOS-E variance across all age groups. Inpatient rehabilitation discharge to nursing home or adult home and rehospitalization were associated with a one-level decrease in GOS-E. Alcohol use predicted lower GOS-E among the 70- to 79-year-olds. Gender, ethnicity, and rehospitalizations were negatively associated driving. Discussion: Rehabilitation approaches to older adults with TBI may help maximize function and, thereby, improve later outcomes and decrease rehospitlaizations. Such strategies may include longer and more intensive acute rehabilitation with greater patient engagement and enhanced transitions of care.
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Affiliation(s)
- Flora M Hammond
- Indiana University School of Medicine, Indianapolis, USA.,Rehabilitation Hospital of Indianapolis, IN, USA
| | | | - Marie N Dahdah
- North Texas Traumatic Brain Injury Model System, Dallas, TX, USA
| | | | | | - Therese M O'Neil-Pirozzi
- Spaulding Rehabilitation Hospital, Charlestown, MA, USA.,Northeastern University, Boston, MA, USA
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48
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Long-Term Impact of Mild Traumatic Brain Injuries on Multiple Functional Outcomes and Epigenetics: A Pilot Study with College Students. APPLIED SCIENCES-BASEL 2020. [DOI: 10.3390/app10124131] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
People who suffer a mild traumatic brain injury (mTBI) have heterogeneous symptoms and disease trajectories, which make it difficult to precisely assess long-term complications. This pilot study assessed and compared deficits in cognitive, psychosocial, visual functions, and balance performance between college students with and without histories of mTBI. Global DNA methylation ratio (5-mC%) in blood was also compared as a peripheral epigenetic marker. Twenty-five volunteers participated, including 14 healthy controls (64.3% females; mean age of 22.0) and 11 mTBI cases (27.3% females; mean age of 28.7 years) who self-reported mTBI history (63.6% multiple; 2.5 ± 1.29 injuries) with 7.1 years on average elapsed following the last injury. Every participant was assessed for cognitive (executive function, memory, and processing speed), psychological (depression, anxiety, and sleep disturbances), and visual function (by King–Devick and binocular accommodative tests); force-plate postural balance performance; and blood 5-mC% levels. Students with mTBI showed poorer episodic memory, severe anxiety, and higher blood 5-mC% ratio, compared to controls (all p’s < 0.05), which were still significant after adjusting for age. No differences were detected in sleep problems (after adjusting for age), visual function, and postural balance. These findings identified changes in multiple functions and peripheral epigenetics long after mTBI.
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49
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Maiden MJ, Cameron PA, Rosenfeld JV, Cooper DJ, McLellan S, Gabbe BJ. Long-Term Outcomes after Severe Traumatic Brain Injury in Older Adults. A Registry-based Cohort Study. Am J Respir Crit Care Med 2020; 201:167-177. [PMID: 31657946 DOI: 10.1164/rccm.201903-0673oc] [Citation(s) in RCA: 32] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
Rationale: Older adults (≥65 yr old) account for an increasing proportion of patients with severe traumatic brain injury (TBI), yet clinical trials and outcome studies contain relatively few of these patients.Objectives: To determine functional status 6 months after severe TBI in older adults, changes in this status over 2 years, and outcome covariates.Methods: This was a registry-based cohort study of older adults who were admitted to hospitals in Victoria, Australia, between 2007 and 2016 with severe TBI. Functional status was assessed with Glasgow Outcome Scale Extended (GOSE) 6, 12, and 24 months after injury. Cohort subgroups were defined by admission to an ICU. Features associated with functional outcome were assessed from the ICU subgroup.Measurements and Main Results: The study included 540 older adults who had been hospitalized with severe TBI over the 10-year period; 428 (79%) patients died in hospital, and 456 (84%) died 6 months after injury. There were 277 patients who had not been admitted to an ICU; at 6 months, 268 (97%) had died, 8 (3%) were dependent (GOSE 2-4), and 1 (0.4%) was functionally independent (GOSE 5-8). There were 263 patients who had been admitted to an ICU; at 6 months, 188 (73%) had died, 39 (15%) were dependent, and 32 (12%) were functionally independent. These proportions did not change over longer follow-up. The only clinical features associated with a lower rate of functional independence were Injury Severity Score ≥25 (adjusted odds ratio, 0.24 [95% confidence interval, 0.09-0.67]; P = 0.007) and older age groups (P = 0.017).Conclusions: Severe TBI in older adults is a condition with very high mortality, and few recover to functional independence.
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Affiliation(s)
- Matthew J Maiden
- Intensive Care Unit, Barwon Health, Geelong, Australia.,Intensive Care Unit, Royal Adelaide Hospital, Adelaide, Australia.,Discipline of Acute Care Medicine, University of Adelaide, Adelaide, Australia
| | - Peter A Cameron
- Emergency and Trauma Centre.,School of Public Health and Preventive Medicine and
| | - Jeffrey V Rosenfeld
- Department of Neurosurgery, and.,Department of Surgery, Monash University, Melbourne, Australia.,Department of Surgery, F. Edward Hébert School of Medicine, Uniformed Services University of the Health Sciences, Bethesda, Maryland; and
| | - D James Cooper
- Intensive Care Unit, The Alfred Hospital, Prahran, Australia.,School of Public Health and Preventive Medicine and
| | | | - Belinda J Gabbe
- School of Public Health and Preventive Medicine and.,Health Data Research UK, Swansea University Medical School, Swansea University, Singleton Park, United Kingdom
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50
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Kumar RG, Ornstein KA, Bollens-Lund E, Watson EM, Ankuda CK, Kelley AS, Dams-O'Connor K. Lifetime history of traumatic brain injury is associated with increased loneliness in adults: A US nationally representative study. Int J Geriatr Psychiatry 2020; 35:553-563. [PMID: 31994215 DOI: 10.1002/gps.5271] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/15/2019] [Accepted: 01/21/2020] [Indexed: 11/11/2022]
Abstract
BACKGROUND/OBJECTIVES An estimated 55 million individuals worldwide live with chronic disability associated with traumatic brain injury (TBI), which may include cognitive, behavioral, and social impairments. Reduced participation in social activities is common after TBI; however, few studies have evaluated loneliness among survivors of TBI. The current study aimed to evaluate the association between history of TBI and loneliness and to identify mediators of this association. METHODS/DESIGN Retrospective cohort study. Nationally representative sample of N = 724 adults over age 50 years (Health and Retirement Study). Loneliness was evaluated using the 11-item Revised University of California Los Angeles (R-UCLA) Loneliness Scale (range 11-33). Lifetime history of TBI evaluated retrospectively using the Ohio State University TBI Identification Method. We included the following covariates: age, sex, race, and education; and mediators: depressive symptoms, number of comorbidities, chronic pain, difficulty with activities of daily living, and social network index. RESULTS History of TBI was associated with a 1.28-point (95% CI, 0.46-2.11; P < .05; Cohen's D = 0.284) increase in R-UCLA Loneliness Scale scores after covariate adjustment. Individuals with more recent injuries (within 10 years) and multiple lifetime TBIs reported the highest loneliness scores. In the structural equation model, depressive symptoms partially mediated the relationship between TBI and loneliness. All models were adjusted for US population sampling weights. CONCLUSIONS History of TBI was associated with greater loneliness compared with individuals without TBI in a representative sample of US adults. Managing depressive symptoms and medical consequences of TBI may be a target to ameliorate reporting of loneliness in this population.
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Affiliation(s)
- Raj G Kumar
- Department of Rehabilitation Medicine, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Katherine A Ornstein
- Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Evan Bollens-Lund
- Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Eric M Watson
- Department of Rehabilitation Medicine, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Claire K Ankuda
- Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Amy S Kelley
- Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Kristen Dams-O'Connor
- Department of Rehabilitation Medicine, Icahn School of Medicine at Mount Sinai, New York, NY.,Department of Neurology, Icahn School of Medicine at Mount Sinai, New York, NY
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