Costs of Nonfatal Traumatic Brain Injury in the United States, 2016

Prevalence of tinnitus following non-blast related traumatic brain injury: a systematic review of literature

OBJECTIVES

To establish the prevalence of tinnitus in adults who have sustained non-blast related traumatic brain injury (TBI), as well as the prevalence of tinnitus following TBI in the absence of hearing loss.

METHODS

A systematic search was carried out using MEDLINE, EMBASE, PsycINFO, CINAHL from January 1st 1990 to August 14th 2023. TBI, tinnitus and auditory findings were extracted from all eligible studies, and a descriptive synthesis performed. This systematic review was registered with PROSPERO (Registration number: CRD42022377637).

RESULTS

Based on the Oxford Centre of Evidence-Based Medicine (OCEBM) (2011) criteria, the highest quality evidence identified was at Level 2b, with the bulk of the included studies predominantly populating the lower evidence tiers. While there was a substantial variability in the methods used to establish and report the presence of tinnitus, its occurrence following TBI was evident in adults with and without hearing loss.

CONCLUSION

The need for prospective, longitudinal research into tinnitus following non-blast related TBI is evident. Such comprehensive studies hold the potential to inform and enhance the clinical diagnosis and management of this patient population.

Repetitive mild traumatic brain injury impairs norepinephrine system function and psychostimulant responsivity

Traumatic brain injury (TBI) is a complex pathophysiological process that results in a variety of neurotransmitter, behavioral, and cognitive deficits. The locus coeruleus-norepinephrine (LC-NE) system is a critical regulator of arousal levels and higher executive processes affected by TBI including attention, working memory, and decision making. LC-NE axon injury and impaired signaling within the prefrontal cortex (PFC) is a potential contributor to the neuropsychiatric symptoms after single, moderate to severe TBI. The majority of TBIs are mild, yet long-term cognitive deficits and increased susceptibility for further injury can accumulate after each repetitive mild TBI. As a potential treatment for restoring cognitive function and daytime sleepiness after injury psychostimulants, including methylphenidate (MPH) that increase levels of NE within the PFC, are being prescribed "off-label". The impact of mild and repetitive mild TBI on the LC-NE system remains limited. Therefore, we determined the extent of LC-NE and arousal dysfunction and response to therapeutic doses of MPH in rats following experimentally induced single and repetitive mild TBI. Microdialysis measures of basal NE efflux from the medial PFC and arousal measures were significantly lower after repetitive mild TBI. Females showed higher baseline PFC-NE efflux than males following single and repetitive mild TBI. In response to MPH challenge, males exhibited a blunted PFC-NE response and persistent arousal levels following repetitive mild TBI. These results provide critical insight into the role of catecholamine system dysfunction associated with cognitive deficits following repeated injury, outcome differences between sex/gender, and lack of success of MPH as an adjunctive therapy to improve cognitive function following injury.

Enhancing cognitive recovery in chronic traumatic brain injury through simultaneous allosteric modulation of α7 nicotinic acetylcholine and α5 GABAA receptors

Traumatic brain injury (TBI) leads to changes in the neural circuitry of the hippocampus that result in chronic learning and memory deficits. However, effective therapeutic strategies to ameliorate these chronic learning and memory impairments after TBI are limited. Two pharmacological targets for enhancing cognition are nicotinic acetylcholine receptors (nAChRs) and GABAA receptors (GABAARs), both of which regulate hippocampal network activity to form declarative memories. A promising compound, 522-054, both allosterically enhances α7 nAChRs and inhibits α5 subunit-containing GABAARs. Administration of 522-054 enhances long-term potentiation (LTP) and cognitive functioning in non-injured animals. In this study, we assessed the effects of 522-054 on hippocampal synaptic plasticity and learning and memory deficits in the chronic post-TBI recovery period. Adult male Sprague Dawley rats received moderate parasagittal fluid-percussion brain injury or sham surgery. At 12 wk after injury, we assessed basal synaptic transmission and LTP at the Schaffer collateral-CA1 synapse of the hippocampus. Bath application of 522-054 to hippocampal slices reduced deficits in basal synaptic transmission and recovered TBI-induced impairments in LTP. Moreover, treatment of animals with 522-054 at 12 wk post-TBI improved cue and contextual fear memory and water maze acquisition and retention without a measurable effect on cortical or hippocampal atrophy. These results suggest that dual allosteric modulation of α7 nAChR and α5 GABAAR signaling may be a potential therapy for treating cognitive deficits during chronic recovery from TBI.

Efficacy of N-Methyl-D-Aspartate (NMDA) Receptor Antagonists in Treating Traumatic Brain Injury-Induced Brain Edema: A Systematic Review and Meta-analysis of Animal Studies

Traumatic brain injury leads to glutamate release, which overstimulates N-methyl-D-aspartate (NMDA) receptors, leading to neurotoxicity and cytotoxic edema. NMDA receptor antagonists may offer neuroprotection by blocking this pathway. The objective of this systematic review is to assess the efficacy of NMDA receptor antagonists for traumatic brain injury-induced brain edema in rodent models. This systematic review followed Cochrane Handbook guidelines and registered its protocol in PROSPERO (ID: CRD42023440934). Here, we included controlled rodent animal models comparing NMDA antagonist use with a placebo treatment. Outcome measures included the reduction of cerebral edema, Neurobehavioral Severity Scale, and adverse effects. The search strategy used Medical Subject Headings terms related to traumatic brain injury and NMDA receptor antagonists. The Collaborative Approach to Meta Analysis and Review of Animal Experimental Studies (CAMARADES) checklist and Systematic Review Centre for Laboratory Animal Experimentation's (SYRCLE's) tools were used to measure the quality and bias of included studies. The synthesis of results was presented in a meta-analysis of standard mean difference. Sixteen studies were included, with the predominant drugs being ifenprodil, MK-801, magnesium, and HU-211. The subjects consisted of Sprague-Dawley or Sabra rats. The analysis showed a significant reduction in brain edema with NMDA antagonist treatment (Standardized mean difference [SMD] - 1.17, 95% confidence interval [CI] - 1.59 to - 0.74, p < 0.01), despite high heterogeneity (I2 = 72%). Neurobehavioral Severity Scale also significantly improved (mean difference - 3.32, 95% CI - 4.36 to - 2.28, p < 0.01) in animals receiving NMDA antagonists. Administration within 1 h after injury showed a modest enhancement in reducing brain edema compared with the baseline (SMD - 1.23, 95% CI - 1.69 to - 0.77, p < 0.01). Studies met standards for animal welfare and model appropriateness. Although baseline comparability and selective reporting bias were generally addressed, key biases such as randomization, allocation concealment, and blinding were often unreported. Overall, NMDA antagonists exhibit promising efficacy in the treatment of traumatic brain injury. Notably, our systematic review consistently demonstrated a significant reduction in brain edema with compounds including HU-211 and NPS 150.

It Is Time for Medicare to Cover Driving Safety Assessments

This Viewpoint advocates for Medicare coverage of driving assessments for older individuals.

New insights into metabolism dysregulation after TBI

Traumatic brain injury (TBI) remains a leading cause of death and disability that places a great physical, social, and financial burden on individuals and the health system. In this review, we summarize new research into the metabolic changes described in clinical TBI trials, some of which have already shown promise for informing injury classification and staging. We focus our discussion on derangements in glucose metabolism, cell respiration/mitochondrial function and changes to ketone and lipid metabolism/oxidation to emphasize potentially novel biomarkers for clinical outcome prediction and intervention and offer new insights into possible underlying mechanisms from preclinical research of TBI pathology. Finally, we discuss nutrition supplementation studies that aim to harness the gut/microbiome-brain connection and manipulate systemic/cellular metabolism to improve post-TBI recovery. Taken together, this narrative review summarizes published TBI-associated changes in glucose and lipid metabolism, highlighting potential metabolite biomarkers for clinical use, the cellular processes linking these markers to TBI pathology as well as the limitations and future considerations for TBI "omics" work.

Early depletion of gut microbiota shape oligodendrocyte response after traumatic brain injury

White matter injury (WMI) is thought to be a major contributor to long-term cognitive dysfunctions after traumatic brain injury (TBI). This damage occurs partly due to apoptotic death of oligodendrocyte lineage cells (OLCs) after the injury, triggered directly by the trauma or in response to degenerating axons. Recent research suggests that the gut microbiota modulates the inflammatory response through the regulation of peripheral immune cell infiltration after TBI. Additionally, T-cells directly impact OLCs differentiation and proliferation. Therefore, we hypothesized that the gut microbiota plays a critical role in regulating the OLC response to WMI influencing T-cells differentiation and activation. Gut microbial depletion early after TBI chronically reduced re-myelination, acutely decreased OLCs proliferation, and was associated with increased myelin debris accumulation. Surprisingly, the absence of T-cells in gut microbiota depleted mice restored OLC proliferation and remyelination after TBI. OLCs co-cultured with T-cells derived from gut microbiota depleted mice resulted in impaired proliferation and increased expression of MHC-II compared with T cells from control-injured mice. Furthermore, MHC-II expression in OLCs appears to be linked to impaired proliferation under gut microbiota depletion and TBI conditions. Collectively our data indicates that depletion of the gut microbiota after TBI impaired remyelination, reduced OLCs proliferation with concomitantly increased OLC MHCII expression, and required the presence of T cells. This data suggests that T cells are an important mechanistic link by which the gut microbiota modulate the oligodendrocyte response and white matter recovery after TBI.

Evidence Against a Traumatic Brain Injury "July Effect": An Analysis of 3 160 452 Patients From the National Inpatient Sample

BACKGROUND AND OBJECTIVES

The "July Effect" hypothesizes increased morbidity and mortality after the addition of inexperienced physicians at the beginning of an academic year. However, the impact of newer members on neurosurgical teams managing patients with traumatic brain injury (TBI) has yet to be examined. This study conducted a nationwide analysis to evaluate the existence of the "July Effect" in the setting of patients with TBI.

METHODS

The Healthcare Cost and Utilization Project Central Distributor's National Inpatient Sample data set was queried for patients with TBI using International Classification of Diseases (ICD)-9 and ICD-10 codes. Discharges were included for diagnoses of traumatic epidural, subdural, or subarachnoid hemorrhages. Only patients treated at teaching hospitals were included to ensure resident involvement in care. Patients were grouped into July admission and non-July admission cohorts. A subgroup of patients with neurotrauma undergoing any form of cranial surgery was created. Perioperative variables were recorded. Rates of different complications were assayed. Groups were compared using χ2 tests (qualitative variables) and t-tests or Mann-Whitney U-tests (quantitative variables). Logistic regression was used for binary variables. Gamma log-linked regression was used for continuous variables.

RESULTS

The National Inpatient Sample database yielded a weighted average of 3 160 452 patients, of which 312 863 (9.9%) underwent surgical management. Patients admitted to the hospital in July had a 5% decreased likelihood of death (P = .027), and a 5.83% decreased likelihood of developing a complication (P < .001) compared with other months of the year. July admittance to a hospital showed no significant impact on mean length of stay (P = .392) or routine discharge (P = .147). Among patients with TBI who received surgical intervention, July admittance did not significantly affect the likelihood of death (P = .053), developing a complication (P = .477), routine discharge (P = .986), or mean length of stay (P = .385).

CONCLUSION

The findings suggested that there is no "July Effect" on patients with TBI treated at teaching hospitals in the United States.

Reducing low-value interhospital transfers for mild traumatic brain injury

BACKGROUND

The modified Brain Injury Guidelines (mBIG) were developed to stratify traumatic brain injuries (TBIs) and improve health care utilization by selectively requiring repeat imaging, intensive care unit admission, and neurosurgical (NSG) consultation. The goal of this study is to assess safety and potential resource savings associated with the application of mBIG on interhospital patient transfers for TBI.

METHODS

Adult patients with TBI transferred to our Level I trauma center from January 2017 to December 2022 meeting mBIG inclusion criteria were retrospectively stratified into mBIG1, mBIG2, and mBIG3 based on initial clinicoradiological factors. At the time, our institution routinely admitted patients with TBI and intracranial hemorrhage (ICH) to the intensive care unit and obtained a repeat head computed tomography with NSG consultation, independent of TBI severity or changes in neurological examination. The primary outcome was progression of ICH on repeat imaging and/or NSG intervention. Secondary outcomes included length of stay and financial charges. Subgroup analysis on isolated TBI without significant extracranial injury was performed.

RESULTS

Over the 6-year study period, 289 patients were classified into mBIG1 (61; 21.1%), mBIG2 (69; 23.9%), and mBIG3 (159; 55.0%). Of mBIG1 patients, 2 (2.9%) had radiological progression to mBIG2 without clinical decline, and none required NSG intervention. Of mBIG2, 2 patients (3.3%) progressed to mBIG3, and both required NSG intervention. More than 35% of transferred patients had minor isolated TBI. For mBIG1 and mBIG2, the median hospitalization charges per patient were $152,296 and $149,550, respectively, and the median length of stay was 4 and 5 days, respectively, with the majority downgraded from the intensive care unit within 48 hours.

CONCLUSION

Clinically significant progression of ICH occurred infrequently in 1.5% of patients with mBIG1 and mBIG2 injuries. More than 35% of interfacility transfers for minor isolated TBI meeting mBIG1 and 2 criteria are low value and may potentially be safely deferred in an urban health care setting.

LEVEL OF EVIDENCE

Therapeutic/Care Management; Level IV.

A Comprehensive and Broad Approach to Resting-State Functional Connectivity in Adult Patients with Mild Traumatic Brain Injury

BACKGROUND AND PURPOSE

Several recent works using resting-state fMRI suggest possible alterations of resting-state functional connectivity after mild traumatic brain injury. However, the literature is plagued by various analysis approaches and small study cohorts, resulting in an inconsistent array of reported findings. In this study, we aimed to investigate differences in whole-brain resting-state functional connectivity between adult patients with mild traumatic brain injury within 1 month of injury and healthy control subjects using several comprehensive resting-state functional connectivity measurement methods and analyses.

MATERIALS AND METHODS

A total of 123 subjects (72 patients with mild traumatic brain injury and 51 healthy controls) were included. A standard fMRI preprocessing pipeline was used. ROI/seed-based analyses were conducted using 4 standard brain parcellation methods, and the independent component analysis method was applied to measure resting-state functional connectivity. The fractional amplitude of low-frequency fluctuations was also measured. Group comparisons were performed on all measurements with appropriate whole-brain multilevel statistical analysis and correction.

RESULTS

There were no significant differences in age, sex, education, and hand preference between groups as well as no significant correlation between all measurements and these potential confounders. We found that each resting-state functional connectivity measurement revealed various regions or connections that were different between groups. However, after we corrected for multiple comparisons, the results showed no statistically significant differences between groups in terms of resting-state functional connectivity across methods and analyses.

CONCLUSIONS

Although previous studies point to multiple regions and networks as possible mild traumatic brain injury biomarkers, this study shows that the effect of mild injury on brain resting-state functional connectivity has not survived after rigorous statistical correction. A further study using subject-level connectivity analyses may be necessary due to both subtle and variable effects of mild traumatic brain injury on brain functional connectivity across individuals.

Traumatic Brain Injury: A Comprehensive Review of Biomechanics and Molecular Pathophysiology

Traumatic brain injury (TBI) is a critical public health concern with profound consequences for affected individuals. This comprehensive literature review delves into TBI intricacies, encompassing primary injury biomechanics and the molecular pathophysiology of the secondary injury cascade. Primary TBI involves a complex interplay of forces, including impact loading, blast overpressure, and impulsive loading, leading to diverse injury patterns. These forces can be categorized into inertial (e.g., rotational acceleration causing focal and diffuse injuries) and contact forces (primarily causing focal injuries like skull fractures). Understanding their interactions is crucial for effective injury management. The secondary injury cascade in TBI comprises multifaceted molecular and cellular responses, including altered ion concentrations, dysfunctional neurotransmitter networks, oxidative stress, and cellular energy disturbances. These disruptions impair synaptic function, neurotransmission, and neuroplasticity, resulting in cognitive and behavioral deficits. Moreover, neuroinflammatory responses play a pivotal role in exacerbating damage. As we endeavor to bridge the knowledge gap between biomechanics and molecular pathophysiology, further research is imperative to unravel the nuanced interplay between mechanical forces and their consequences at the molecular and cellular levels, ultimately guiding the development of targeted therapeutic strategies to mitigate the debilitating effects of TBI. In this study, we aim to provide a concise review of the bridge between biomechanical processes causing primary injury and the ensuing molecular pathophysiology of secondary injury, while detailing the subsequent clinical course for this patient population. This knowledge is crucial for advancing our understanding of TBI and developing effective interventions to improve outcomes for those affected.

Gut Microbiota Shape Oligodendrocyte Response after Traumatic Brain Injury

White matter injury (WMI) is thought to be a major contributor to long-term cognitive dysfunctions after traumatic brain injury (TBI). This damage occurs partly due to apoptotic death of oligodendrocyte lineage cells (OLCs) after the injury, triggered directly by the trauma or in response to degenerating axons. Recent research suggests that the gut microbiota modulates the inflammatory response through the modulation of peripheral immune cell infiltration after TBI. Additionally, T-cells directly impact OLCs differentiation and proliferation. Therefore, we hypothesized that the gut microbiota plays a critical role in regulating the OLC response to WMI influencing T-cells differentiation and activation. Gut microbial depletion early after TBI chronically reduced re-myelination, acutely decreased OLCs proliferation, and was associated with increased myelin debris accumulation. Surprisingly, the absence of T-cells in gut microbiota depleted mice restored OLC proliferation and remyelination after TBI. OLCs co-cultured with T-cells derived from gut microbiota depleted mice resulted in impaired proliferation and increased expression of MHC-II compared with T cells from control-injured mice. Furthermore, MHC-II expression in OLCs appears to be linked to impaired proliferation under gut microbiota depletion and TBI conditions. Collectively our data indicates that depletion of the gut microbiota after TBI impaired remyelination, reduced OLCs proliferation with concomitantly increased OLC MHCII expression and required the presence of T cells. This data suggests that T cells are an important mechanistic link by which the gut microbiota modulate the oligodendrocyte response and white matter recovery after TBI.

Management of Head Trauma

Traumatic brain injury (TBI) represents a heterogenous spectrum of disease. It is essential to rapidly assess a patient's neurologic status and implement measures to prevent secondary brain injury. Intracranial hypertension, a common sequela of TBI, is managed in a tiered and systematic fashion, starting with the least invasive and moving toward the most invasive. TBI has long-lasting effects on patients and their families and represents a substantial financial and social influence on society. Research regarding the prognosis and treatment of TBI is essential to limit the influence of this widespread disease.

Racial/Ethnic and Geographic Disparities in Comorbid Traumatic Brain Injury-Renal Failure in US Veterans and Associated Veterans Affairs Resource Costs, 2000-2020

Studies have identified disparities by race/ethnicity and geographic status among veterans with traumatic brain injury (TBI) and renal failure (RF). We examined the association of race/ethnicity and geographic status with RF onset in veterans with and without TBI, and the impact of disparities on Veterans Health Administration resource costs.

METHODS

Demographics by TBI and RF status were assessed. We estimated Cox proportional hazards models for progression to RF and generalized estimating equations for inpatient, outpatient, and pharmacy cost annually and time since TBI + RF diagnosis, stratified by age.

RESULTS

Among 596,189 veterans, veterans with TBI progressed faster to RF than those without TBI (HR 1.96). Non-Hispanic Black veterans (HR 1.41) and those in US territories (HR 1.71) progressed faster to RF relative to non-Hispanic Whites and those in urban mainland areas. Non-Hispanic Blacks (-$5,180), Hispanic/Latinos ($-4,984), and veterans in US territories (-$3,740) received fewer annual total VA resources. This was true for all Hispanic/Latinos, while only significant for non-Hispanic Black and US territory veterans < 65 years. For veterans with TBI + RF, higher total resource costs only occurred ≥ 10 years after TBI + RF diagnosis ($32,361), independent of age. Hispanic/Latino veterans ≥ 65 years received $8,248 less than non-Hispanic Whites and veterans living in US territories < 65 years received $37,514 less relative to urban veterans.

CONCLUSION

Concerted efforts to address RF progression in veterans with TBI, especially in non-Hispanic Blacks and those in US territories, are needed. Importantly, culturally appropriate interventions to improve access to care for these groups should be a priority of the Department of Veterans Affairs priority for these groups.

The effect of traumatic head injuries on the outcome of middle-aged and geriatric orthopedic trauma patients

BACKGROUND

The purpose of this study is to characterize the effects of head injuries amongst the middle-aged and geriatric populations on hospital quality measures, costs, and outcomes in an orthopedic trauma setting.

METHODS

Patients with head and orthopedic injuries aged >55 treated at an academic medical center from October 2014-April 2021 were reviewed for their Abbreviated Injury Score for Head and Neck (AIS-H), baseline demographics, injury characteristics, hospital quality measures and outcomes. Univariate comparative analyses were conducted across AIS-H groups with additional regression analyses controlling for confounding variables. All statistical analyses were conducted with a Bonferroni adjusted alpha.

RESULTS

A total of 1,051 patients were included. The mean age was 74 years, and median AIS-H score was 2 (range 1-6). While outcomes worsened and costs increased as AIS-H scores increased, the most drastic (and clinically relevant) rise occurs between scores 2-3. Patients who sustained a head injury warranting an AIS-H score of 3 experienced a significantly higher rate of major complications, need for ICU admission, inpatient and 1-year mortality with longer lengths of stay and higher total costs despite no differences in demographics or injury characteristics. Regression analysis found a higher AIS-H score was independently associated with greater mortality risk.

CONCLUSION

AIS-H scores >2 correlate with significantly worse outcomes and higher hospital costs. Concomitant head injuries impact both outcomes and direct variable costs for middle-aged and geriatric orthopedic trauma patients. Clinicians, hospitals, and payers should consider the significant effect of head injuries on the hospitalization of these patients.

Current state of neuroprotective therapy using antibiotics in human traumatic brain injury and animal models

TBI is a leading cause of death and disability in young people and older adults worldwide. There is no gold standard treatment for TBI besides surgical interventions and symptomatic relief. Post-injury infections, such as lower respiratory tract and surgical site infections or meningitis are frequent complications following TBI. Whether the use of preventive and/or symptomatic antibiotic therapy improves patient mortality and outcome is an ongoing matter of debate. In contrast, results from animal models of TBI suggest translational perspectives and support the hypothesis that antibiotics, independent of their anti-microbial activity, alleviate secondary injury and improve neurological outcomes. These beneficial effects were largely attributed to the inhibition of neuroinflammation and neuronal cell death. In this review, we briefly outline current treatment options, including antibiotic therapy, for patients with TBI. We then summarize the therapeutic effects of the most commonly tested antibiotics in TBI animal models, highlight studies identifying molecular targets of antibiotics, and discuss similarities and differences in their mechanistic modes of action.

Gut microbial regulation of innate and adaptive immunity after traumatic brain injury

Acute care management of traumatic brain injury is focused on the prevention and reduction of secondary insults such as hypotension, hypoxia, intracranial hypertension, and detrimental inflammation. However, the imperative to balance multiple clinical concerns simultaneously often results in therapeutic strategies targeted to address one clinical concern causing unintended effects in other remote organ systems. Recently the bidirectional communication between the gastrointestinal tract and the brain has been shown to influence both the central nervous system and gastrointestinal tract homeostasis in health and disease. A critical component of this axis is the microorganisms of the gut known as the gut microbiome. Changes in gut microbial populations in the setting of central nervous system disease, including traumatic brain injury, have been reported in both humans and experimental animal models and can be further disrupted by off-target effects of patient care. In this review article, we will explore the important role gut microbial populations play in regulating brain-resident and peripheral immune cell responses after traumatic brain injury. We will discuss the role of bacterial metabolites in gut microbial regulation of neuroinflammation and their potential as an avenue for therapeutic intervention in the setting of traumatic brain injury.

Community-based exercise program, self-reported health-related symptoms, and quality of life in persons with traumatic brain injury 45 + years old

BACKGROUND

Individuals with moderate to severe traumatic brain injury (msTBI) have reported a lack of motivation, lack of time, and fatigue as perceived barriers to exercise.

OBJECTIVE

To evaluate the effects of an exercise program on self-reported health-related symptoms and quality of life in persons 45-years and older with msTBI.

METHODS

Post-hoc analysis of a prospective community-based 12-week exercise program of 20 adults, age 45-80 years, with msTBI. Ten were in aerobic exercise training (AET) program and 10 in a stretching and toning (SAT) program. The AET group was instructed to exercise based on their estimated maximal heart rate (HR) for 150 minutes weekly. The SAT group was to stretch for the same target time without significantly increasing HR or level of exertion. Outcome measures were Traumatic Brain Injury Quality of Life (TBI-QOL) for global, cognitive, emotional, and social health, Patient Health Questionnaire-9 (PHQ-9) for depressive symptoms, and Pittsburgh Sleep Quality Index (PSQI) for sleep quality.

RESULTS

AET was associated with improved self-reported cognitive health and sleep compared to SAT. Moderate to large, positive effect sizes were also observed in the AET group in the QOL categories of global, emotional, and social health, and depressive symptoms.

CONCLUSIONS

This study offers preliminary evidence that AET may improve health-related QOL, especially for cognition and sleep, in middle-aged and older adults with msTBI.

Acute effects of an isometric neck warm-up programme on neck performance characteristics and ultrasound-based morphology

OBJECTIVE

Athletic performance can be enhanced immediately after an isometric warm-up, a phenomenon termed post-activation performance enhancement (PAPE). While isometric warm-ups can improve lower extremity sprint and jump performance, neck-specific isometric warm-ups need development and validation for mild traumatic brain disorders and neck pain. This study examined acute effects of isometric warm-ups on neck performance and morphology.

METHODS

Arm 1: Twenty-six adults (13 M:13F) completed neck performance testing before and after a 10-minute neck isometric warm-up or stationary bike (sham) between two visits. Testing included visual-motor reaction time, peak force, rate of force development, force steadiness, and force replication/proprioception measured by a 6-axis load cell. An inclinometer assessed range-of-motion. Paired t-tests and two-way ANOVA examined effects of neck/bike warm-up and interaction effects, respectively. Arm 2: 24 adults (11 M:13F) completed ultrasound scans of cervical muscles: before 20-minute rest (sham), and before/after a 5-min neck isometric warm-up. Longus colli cross-sectional area and sternocleidomastoid/upper trapezius thickness and stiffness, and cervical extensors thickness was assessed. One-way ANOVA compared morphological values at sham, before, and after warm-up. Significance was set at p < 0.05.

RESULTS

Isometric neck warm-up increased rate of force development in flexion (p = 0.022), extension (p = 0.001-0.003), right lateral flexion (p = 0.004-0.032), left lateral flexion (p = 0.005-0.014), while peak force improved only in left lateral flexion (p = 0.032). Lateral flexion range-of-motion increased after neck warm-up (p = 0.003-0.026). Similarly, longus colli cross-sectional area (p = 0.016) and sternocleidomastoid thickness (p = 0.004) increased.

CONCLUSIONS

Increased neck performance characteristics and morphology are likely due to PAPE effects of isometric neck warm-up. For coaches and athletes, simple isometric contractions could be added to existing warm-ups to reduce prevalence, incidence, and severity of mild traumatic brain injuries and neck pain.

Efferocytosis is restricted by axon guidance molecule EphA4 via ERK/Stat6/MERTK signaling following brain injury

BACKGROUND

Efferocytosis is a process that removes apoptotic cells and cellular debris. Clearance of these cells alleviates neuroinflammation, prevents the release of inflammatory molecules, and promotes the production of anti-inflammatory cytokines to help maintain tissue homeostasis. The underlying mechanisms by which this occurs in the brain after injury remain ill-defined.

METHODS

We used GFP bone marrow chimeric knockout (KO) mice to demonstrate that the axon guidance molecule EphA4 receptor tyrosine kinase is involved in suppressing MERTK in the brain to restrict efferocytosis of resident microglia and peripheral-derived monocyte/macrophages.

RESULTS

Single-cell RNAseq identified MERTK expression, the primary receptor involved in efferocytosis, on monocytes, microglia, and a subset of astrocytes in the damaged cortex following brain injury. Loss of EphA4 on infiltrating GFP-expressing immune cells improved functional outcome concomitant with enhanced efferocytosis and overall protein expression of p-MERTK, p-ERK, and p-Stat6. The percentage of GFP+ monocyte/macrophages and resident microglia engulfing NeuN+ or TUNEL+ cells was significantly higher in KO chimeric mice. Importantly, mRNA expression of Mertk and its cognate ligand Gas6 was significantly elevated in these mice compared to the wild-type. Analysis of cell-specific expression showed that p-ERK and p-Stat6 co-localized with MERTK-expressing GFP + cells in the peri-lesional area of the cortex following brain injury. Using an in vitro efferocytosis assay, co-culturing pHrodo-labeled apoptotic Jurkat cells and bone marrow (BM)-derived macrophages, we demonstrate that efferocytosis efficiency and mRNA expression of Mertk and Gas6 was enhanced in the absence of EphA4. Selective inhibitors of ERK and Stat6 attenuated this effect, confirming that EphA4 suppresses monocyte/macrophage efferocytosis via inhibition of the ERK/Stat6 pathway.

CONCLUSIONS

Our findings implicate the ERK/Stat6/MERTK axis as a novel regulator of apoptotic debris clearance in brain injury that is restricted by peripheral myeloid-derived EphA4 to prevent the resolution of inflammation.

Overview of Hypothermia, Its Role in Neuroprotection, and the Application of Prophylactic Hypothermia in Traumatic Brain Injury

The current standard of practice is to maintain normothermia in traumatic brain injury (TBI) patients despite the theoretical benefits of hypothermia and numerous animal studies with promising results. While targeted temperature management or induced hypothermia to support neurological function is recommended for a select patient population postcardiac arrest, similar guidelines have not been instituted for TBI. In this review, we will examine the pathophysiology of TBI and discuss the benefits and risks of induced hypothermia in this patient population. In addition, we provide an overview of the largest randomized controlled trials testing-induced hypothermia. Our literature review on hypothermia returned a myriad of studies and trials, many of which have inconclusive results. The aim of this review was to recognize the effects of hypothermia, summarize the latest trials, address the inconsistencies, and discuss future directions for the study of hypothermia in TBI.

Pediatric traumatic brain injuries in war zones: a systematic literature review

Background

Pediatric casualties in war zones are a devastating consequence of armed conflicts, causing significant challenges for affected children, especially in the context of poor access to care. This study aimed to understand traumatic brain injuries (TBIs) in this high-risk population and to identify and provide information for the stakeholders, as well as to recognize severe long-term consequences and develop strategies to prevent them, thus minimizing their burden while aiding in the management of these cases.

Methods

We carried out a systematic literature review following PRISMA guidelines to identify publications discussing traumatic brain injuries in children in the context of war zones, and we analyzed all the collected data.

Results

Our study showed that head injuries were the most common casualty in war zones; male and female children were affected, and the mean age was 8-10 years. Most children were reported to be from Afghanistan, and blasts were the most common mechanism of injury. The mortality fluctuated from 3 to 47%.

Conclusion

There is a lack of evidence-based information regarding the characterization, approach, and management of children with TBI in conflict zones. While the world finds ways to live in peace, there is an urgency to research, train, and deploy enough specialists to these areas, if governments are serious about improving outcomes for this population.

Efferocytosis is restricted by axon guidance molecule EphA4 via ERK/Stat6/Mertk signaling following brain injury

Background

Efferocytosis is a process that removes apoptotic cells and cellular debris. Clearance of these cells alleviates neuroinflammation and prevents the release of inflammatory molecules and promotes the production of anti-inflammatory cytokines to help maintain tissue homeostasis. The underlying mechanisms by which this occurs in the brain after injury remains ill-defined.

Methods

We demonstrate using GFP bone marrow chimeric knockout (KO) mice, that the axon guidance molecule EphA4 receptor tyrosine kinase is involved in suppressing Mertk signaling in the brain to restrict the function of efferocytosis on resident microglia and peripheral-derived monocyte/macrophages.

Results

Single-cell RNAseq identified Mertk expression, the primary receptor involved in efferocytosis, on monocytes, microglia, and a subset of astrocytes in the damaged cortex following brain injury. Loss of EphA4 on infiltrating GFP-expressing immune cells improved functional outcome concomitant with enhanced efferocytosis, and overall protein expression of p-Mertk, p-ERK, and p-Stat6. The percentage of GFP+ monocyte/macrophages and resident microglia engulfing NeuN+ or TUNEL+ cells was significantly higher in KO chimeric mice. Importantly, mRNA expression of Mertk and its cognate ligand Gas6 was significantly elevated in these mice compared to wild-type. Analysis of cell-specific expression showed that p-ERK and p-Stat6 co-localized with Mertk-expressing GFP + cells in the peri-lesional area of the cortex following brain injury. Using an in vitro efferocytosis assay, co-culturing pHrodo-labeled apoptotic Jurkat cells and bone marrow (BM)-derived macrophages, we demonstrate that efferocytosis efficiency and mRNA expression of Mertk and Gas6 was enhanced in the absence of EphA4. Select inhibitors of ERK and Stat6 attenuated this effect confirming that EphA4 suppresses monocyte/macrophage efferocytosis via inhibition of the ERK/Stat6 pathway.

Conclusions

Our findings implicate the Mertk/ERK/Stat6 axis as a novel regulator of apoptotic debris clearance in brain injury that is restricted by peripheral myeloid-derived EphA4 to prevent the resolution of inflammation.

Current State of Diffusion-Weighted Imaging and Diffusion Tensor Imaging for Traumatic Brain Injury Prognostication

Advanced imaging techniques are needed to assist in providing a prognosis for patients with traumatic brain injury (TBI), particularly mild TBI (mTBI). Diffusion tensor imaging (DTI) is one promising advanced imaging technique, but has shown variable results in patients with TBI and is not without limitations, especially when considering individual patients. Efforts to resolve these limitations are being explored and include developing advanced diffusion techniques, creating a normative database, improving study design, and testing machine learning algorithms. This article will review the fundamentals of DTI, providing an overview of the current state of its utility in evaluating and providing prognosis in patients with TBI.

Cofilin Inhibitor Protects against Traumatic Brain Injury-Induced Oxidative Stress and Neuroinflammation

Microglial activation and failure of the antioxidant defense mechanisms are major hallmarks in different brain injuries, particularly traumatic brain injury (TBI). Cofilin is a cytoskeleton-associated protein involved in actin binding and severing. In our previous studies, we identified the putative role of cofilin in mediating microglial activation and apoptosis in ischemic and hemorrhagic conditions. Others have highlighted the involvement of cofilin in ROS production and the resultant neuronal death; however, more studies are needed to delineate the role of cofilin in oxidative stress conditions. The present study aims to investigate the cellular and molecular effects of cofilin in TBI using both in vitro and in vivo models as well as the first-in-class small-molecule cofilin inhibitor (CI). An in vitro H2O2-induced oxidative stress model was used in two different types of cells, human neuroblastoma (SH-SY5Y) and microglia (HMC3), along with an in vivo controlled cortical impact model of TBI. Our results show that treatment with H2O2 increases the expression of cofilin and slingshot-1 (SSH-1), an upstream regulator of cofilin, in microglial cells, which was significantly reduced in the CI-treated group. Cofilin inhibition significantly attenuated H2O2-induced microglial activation by reducing the release of proinflammatory mediators. Furthermore, we demonstrate that CI protects against H2O2-induced ROS accumulation and neuronal cytotoxicity, activates the AKT signaling pathway by increasing its phosphorylation, and modulates mitochondrial-related apoptogenic factors. The expression of NF-E2-related factor 2 (Nrf2) and its associated antioxidant enzymes were also increased in CI-treated SY-SY5Y. In the mice model of TBI, CI significantly activated the Nrf2 and reduced the expression of oxidative/nitrosative stress markers at the protein and gene levels. Together, our data suggest that cofilin inhibition provides a neuroprotective effect in in vitro and in vivo TBI mice models by inhibiting oxidative stress and inflammatory responses, the pivotal mechanisms involved in TBI-induced brain damage.

Traumatic Brain Injury and Psychopathic Traits in Justice-Involved Adult Women

Studies have documented associations between traumatic brain injury (TBI) and mental disorders. The relationship between psychopathic personality and TBI remains poorly understood, though both are associated with similar characteristics (e.g., low empathy, aggression, disturbances in social/moral behavior). Yet, it is not clear whether assessment of psychopathic features is influenced by presence versus absence of TBI, and which aspects of TBI may be associated with psychopathic traits. This study examined the psychopathy-TBI association in justice-involved women (N = 341) with structural equation modeling. We tested if measurement invariance of psychopathic traits was evident among those with versus without TBI and which TBI variables (number, severity, age at first TBI) predicted psychopathic features in conjunction with symptoms of psychopathology, IQ, and age. Results provided evidence of measurement invariance, and more women with TBI, compared to those without, met criteria for psychopathy. Younger age of TBI and TBI severity predicted interpersonal-affective psychopathic features.

The role of spectrin breakdown products in patients with traumatic brain injury: a systematic review and meta-analysis

BACKGROUND

Spectrin Breakdown Products (SBDPs) accumulate in the brain after traumatic brain injury (TBI) and are expected to become a potentially promising biomarker of TBI.

OBJECTIVE

This systematic review and meta-analysis were undertaken to evaluate the role of SBDPs in the diagnosis and prognosis of TBI.

METHODS

We systematically searched the following databases up to 31 October 2022: Ovid MEDLINE, PubMed, EMBASE, Cochrane Library, and Web of Science Database, and studies were only included if they had sufficient data on SBDP concentrations in TBI patients. We calculated the standardized mean differences (SMDs) and 95% confidence intervals (CIs) for continuous outcomes and assessed the potential publication bias by using Egger's test and funnel plots. The statistical analysis was conducted by RevMan 5.4 and Stata 17.

RESULTS

Of 1429 identified studies, 10 studies involving 417 participants were included in our systematic review and meta-analysis. The results demonstrated that serum and cerebrospinal fluid (CSF) SBDP concentrations were significantly increased in TBI compared to controls (SBDP120: SMD = 1.42, 95% CI = 0.71 ~ 2.12, P < 0.00001; SBDP145: SMD = 1.32, 95% CI = 0.78 ~ 1.86, P < 0.00001; SBDP150: SMD = 1.39, 95% CI = 0.97 ~ 1.80, P < 0.00001), and CSF SBDPs were significantly associated with poor functional outcomes (PFO) (SBDP145: SMD = 1.75, 95% CI = 1.37 ~ 2.13, P < 0.00001; SBDP150: SMD = 1.14, 95% CI = 0.75 ~ 1.52, P < 0.00001). In addition, CSF and serum SBDP145 are valuable in diagnosing TBI (AUC = 0.89, 95% CI = 0.80 ~ 0.99, P < 0.00001), and CSF SBDP145 also has diagnostic value for PFO (AUC = 0.80, 95% CI = 0.76 ~ 0.84, P < 0.00001).

CONCLUSIONS

The limited evidence supports that the SBDPs can be employed as potential biomarkers for the diagnosis and prognosis of TBI.

Neuroworsening in the Emergency Department Is a Predictor of Traumatic Brain Injury Intervention and Outcome: A TRACK-TBI Pilot Study

INTRODUCTION

Neuroworsening may be a sign of progressive brain injury and is a factor for treatment of traumatic brain injury (TBI) in intensive care settings. The implications of neuroworsening for clinical management and long-term sequelae of TBI in the emergency department (ED) require characterization.

METHODS

Adult TBI subjects from the prospective Transforming Research and Clinical Knowledge in Traumatic Brain Injury Pilot Study with ED admission and disposition Glasgow Coma Scale (GCS) scores were extracted. All patients received head computed tomography (CT) scan <24 h post-injury. Neuroworsening was defined as a decline in motor GCS at ED disposition (vs. ED admission). Clinical and CT characteristics, neurosurgical intervention, in-hospital mortality, and 3- and 6-month Glasgow Outcome Scale-Extended (GOS-E) scores were compared by neuroworsening status. Multivariable regressions were performed for neurosurgical intervention and unfavorable outcome (GOS-E ≤ 3). Multivariable odds ratios (mOR) with [95% confidence intervals] were reported.

RESULTS

In 481 subjects, 91.1% had ED admission GCS 13-15 and 3.3% had neuroworsening. All neuroworsening subjects were admitted to intensive care unit (vs. non-neuroworsening: 26.2%) and were CT-positive for structural injury (vs. 45.4%). Neuroworsening was associated with subdural (75.0%/22.2%), subarachnoid (81.3%/31.2%), and intraventricular hemorrhage (18.8%/2.2%), contusion (68.8%/20.4%), midline shift (50.0%/2.6%), cisternal compression (56.3%/5.6%), and cerebral edema (68.8%/12.3%; all p < 0.001). Neuroworsening subjects had higher likelihoods of cranial surgery (56.3%/3.5%), intracranial pressure (ICP) monitoring (62.5%/2.6%), in-hospital mortality (37.5%/0.6%), and unfavorable 3- and 6-month outcome (58.3%/4.9%; 53.8%/6.2%; all p < 0.001). On multivariable analysis, neuroworsening predicted surgery (mOR = 4.65 [1.02-21.19]), ICP monitoring (mOR = 15.48 [2.92-81.85], and unfavorable 3- and 6-month outcome (mOR = 5.36 [1.13-25.36]; mOR = 5.68 [1.18-27.35]).

CONCLUSIONS

Neuroworsening in the ED is an early indicator of TBI severity, and a predictor of neurosurgical intervention and unfavorable outcome. Clinicians must be vigilant in detecting neuroworsening, as affected patients are at increased risk for poor outcomes and may benefit from immediate therapeutic interventions.

Aging with TBI vs. Aging: 6-month temporal profiles for neuropathology and astrocyte activation converge in behaviorally relevant thalamocortical circuitry of male and female rats

Traumatic brain injury (TBI) manifests late-onset and persisting clinical symptoms with implications for sex differences and increased risk for the development of age-related neurodegenerative diseases. Few studies have evaluated chronic temporal profiles of neuronal and glial pathology that include sex as a biological variable. After experimental diffuse TBI, late-onset and persisting somatosensory hypersensitivity to whisker stimulation develops at one-month post-injury and persists to at least two months post-injury in male rats, providing an in vivo model to evaluate the temporal profile of pathology responsible for morbidity. Whisker somatosensation is dependent on signaling through the thalamocortical relays of the whisker barrel circuit made up of glutamatergic projections between the ventral posteromedial nucleus of the thalamus (VPM) and primary somatosensory barrel cortex (S1BF) with inhibitory (GABA) innervation from the thalamic reticular nucleus (TRN) to the VPM. To evaluate the temporal profiles of pathology, male and female Sprague Dawley rats ( n = 5-6/group) were subjected to sham surgery or midline fluid percussion injury (FPI). At 7-, 56-, and 168-days post-injury (DPI), brains were processed for amino-cupric silver stain and glial fibrillary acidic protein (GFAP) immunoreactivity, where pixel density of staining was quantified to determine the temporal profile of neuropathology and astrocyte activation in the VPM, S1BF, and TRN. FPI induced significant neuropathology in all brain regions at 7 DPI. At 168 DPI, neuropathology remained significantly elevated in the VPM and TRN, but returned to sham levels in the S1BF. GFAP immunoreactivity was increased as a function of FPI and DPI, with an FPI × DPI interaction in all regions and an FPI × Sex interaction in the S1BF. The interactions were driven by increased GFAP immunoreactivity in shams over time in the VPM and TRN. In the S1BF, GFAP immunoreactivity increased at 7 DPI and declined to age-matched sham levels by 168 DPI, while GFAP immunoreactivity in shams significantly increased between 7 and 168 days. The FPI × Sex interaction was driven by an overall greater level of GFAP immunoreactivity in FPI males compared to FPI females. Increased GFAP immunoreactivity was associated with an increased number of GFAP-positive soma, predominantly at 7 DPI. Overall, these findings indicate that FPI, time post-injury, sex, region, and aging with injury differentially contribute to chronic changes in neuronal pathology and astrocyte activation after diffuse brain injury. Thus, our results highlight distinct patterns of pathological alterations associated with the development and persistence of morbidity that supports chronic neuropathology, especially within the thalamus. Further, data indicate a convergence between TBI-induced and age-related pathology where further investigation may reveal a role for divergent astrocytic phenotypes associated with increased risk for neurodegenerative diseases.

Micromobility Vehicles, Obstructions, and Rider Safety Behaviors in New York City Bike Lanes

Micromobility vehicles (MMVs) have become increasingly popular, particularly in urban areas where infrastructure has improved in recent years to facilitate their use. The purpose of this study was to observe protected bike lanes in 10 zones of Manhattan, NYC to: (1) describe the MMVs in bike lanes by type, phone and helmet use; and (2) document MMV users' responses to obstructions. Approximately 1 in 4 of all riders (260/998) were wearing a helmet. Fewer than 2% were observed using a phone while moving. Fewer than 9% of Citi Bike users were wearing a helmet. In contrast, over one-third of non-Citi Bike users were wearing a helmet (228 of 670, 34.03%). This difference was determined to be significant by a chi-squared test (a = 0.05) with a p-value less than 0.0001. Of the 988 MMVs observed in this study, 398 (40.28%) were motorized and 590 (59.72%) were non-motorized. A similar proportion of users of motorized riders versus non-motorized vehicles were wearing a helmet (28.14%, 112/398 versus 24.41%, 144/590). A total of 232 riders (23.50%) encountered an obstruction in their bike lane. Of these obstructions in a bike lane, 82.33% (191/232) were a car/vehicle and 17.67% (41/232) was garbage. A large majority of riders (87.93%) reacted by riding into the traffic lane. These findings suggest that further research and local education, enforcement, and legislative efforts are needed to examine and implement best practices in the safe operation of MMVs, decreasing bike lane obstructions, promoting helmet use, and raising awareness of MMV legislation.

A Systematic Review of Testosterone Therapy in Men With Spinal Cord Injury or Traumatic Brain Injury

Spinal cord injuries (SCI) and traumatic brain injuries (TBI) increase the risk of testosterone deficiency and result in adverse changes in body composition and poor functional outcomes. The current systematic review aims to provide insights into the use of testosterone therapy for treating men with SCI and TBI. The PubMed and EMBASE databases were systematically reviewed using appropriate terms, and resulting manuscripts were screened using defined Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) criteria. The patient population included male patients with SCI or TBI. Further inclusion criteria were: a) human participants 18 years of age or older; b) manuscript published in English; c) study included an intervention with exogenous testosterone; and d) articles published in peer-reviewed journals with full text available. Two reviewers independently extracted data regarding injury type, intervention, and outcomes. Following screening for inclusion/exclusion criteria, a total of 12 primary research studies conducted over the last 30 years were included. Men with SCI were investigated in 11 articles. The combination of testosterone patches and resistance training with functional electrical stimulation (FES) for 16 weeks in men with SCI and an average baseline testosterone level above the cutoff for testosterone deficiency increased muscle mass, strength, bone quality, and basal metabolic rate while testosterone patches without exercise for 16 weeks produced no significant changes in these parameters. Testosterone patches for 12 months in men with SCI and testosterone deficiency also increased lean tissue mass (LTM) and resting energy expenditure (REE). In one study, men with TBI and testosterone deficiency receiving testosterone gel for eight weeks showed a non-statistically significant greater absolute change in functional independence measure (FIM) and grip strength compared to a placebo group. Testosterone therapy with exercise may help improve muscle mass, bone health, strength, energy expenditure, and cardiac health in men with SCI without major side effects. It is difficult to draw conclusions regarding the effects of testosterone therapy in men with TBI based on the limited available evidence. Further investigation is warranted to explore the relationship between testosterone therapy and recovery after SCI and TBI.

Traumatic Brain Injury (TBI) Detection: Past, Present, and Future

Traumatic brain injury (TBI) can produce temporary biochemical imbalance due to leaks through cell membranes or disruption of the axoplasmic flow due to the misalignment of intracellular neurofilaments. If untreated, TBI can lead to Alzheimer's, Parkinson's, or total disability. Mild TBI (mTBI) accounts for about about 90 percent of all TBI cases. The detection of TBI as soon as it happens is crucial for successful treatment management. Neuroimaging-based tests provide only a structural and functional mapping of the brain with poor temporal resolution. Such tests may not detect mTBI. On the other hand, the electroencephalogram (EEG) provides good spatial resolution and excellent temporal resolution of the brain activities beside its portability and low cost. The objective of this paper is to provide clinicians and scientists with a one-stop source of information to quickly learn about the different technologies used for TBI detection, their advantages and limitations. Our research led us to conclude that even though EEG-based TBI detection is potentially a powerful technology, it is currently not able to detect the presence of a mTBI with high confidence. The focus of the paper is to review existing approaches and provide the reason for the unsuccessful state of EEG-based detection of mTBI.

Brain architecture-based vulnerability to traumatic injury

The white matter tracts forming the intricate wiring of the brain are subject-specific; this heterogeneity can complicate studies of brain function and disease. Here we collapse tractography data from the Human Connectome Project (HCP) into structural connectivity (SC) matrices and identify groups of similarly wired brains from both sexes. To characterize the significance of these architectural groupings, we examined how similarly wired brains led to distinct groupings of neural activity dynamics estimated with Kuramoto oscillator models (KMs). We then lesioned our networks to simulate traumatic brain injury (TBI) and finally we tested whether these distinct architecture groups’ dynamics exhibited differing responses to simulated TBI. At each of these levels we found that brain structure, simulated dynamics, and injury susceptibility were all related to brain grouping. We found four primary brain architecture groupings (two male and two female), with similar architectures appearing across both sexes. Among these groupings of brain structure, two architecture types were significantly more vulnerable than the remaining two architecture types to lesions. These groups suggest that mesoscale brain architecture types exist, and these architectural differences may contribute to differential risks to TBI and clinical outcomes across the population.

Traumatic brain injuries in children during COVID-19 pandemic: a national report from northern Iran

BACKGROUND

Evidence suggests that referral cases of traumatic injuries have decreased during the COVID-19 pandemic both in childhood and in adulthood. Still we have very little evidence of referrals due to traumatic brain injury among children during the COVID-19 outbreak. The present study aimed to describe epidemiological and clinical features of pediatric traumatic brain injuries.

METHODS

This cross-sectional study was performed on all patients under 15 years with any evidence of head trauma, referring to Poursina teaching hospital, a referral center for trauma and road accidents in northern Iran. The patients' data were retrospectively collected by reviewing the hospital recorded files and the trauma-specific hospital information system.

RESULTS

Of all 543 pediatric traumatic injuries referred to our hospital during the two pointed periods, 166 had any evidence of head and neck injuries leading to an overall prevalence rate of 30.6%. In this regard, the prevalence rate of head/neck injuries was estimated to be 140 out of 436 within a pre-COVID-19 period (32.1%) and 26 out of 107 within the COVID-19 period (24.3%) indicating no significant difference between the two time periods (P = 0.243). However, assessing the rate of head/neck injuries pre-COVID-19 and COVID-19 periods according to patients' age showed a higher rate of such injuries in pre-COVID-19 as compared to COVID-19 periods in patients aged less than two years (55.6% versus 37.5%, P = 0.013) as well as aged 2 to six years (45.8% versus 30.0%, P = 0.036).

CONCLUSION

The rate of admission of children due to traumatic brain injury during the COVID-19 period does not show a significant change compared to before, and only in children under 6 years of age a decrease in referrals due to brain trauma during the COVID-19 period was observed.

A Review of Family Environment and Neurobehavioral Outcomes Following Pediatric Traumatic Brain Injury: Implications of Early Adverse Experiences, Family Stress, and Limbic Development

Pediatric traumatic brain injury (TBI) is a public health crisis, with neurobehavioral morbidity observed years after an injury associated with changes in related brain structures. A substantial literature base has established family environment as a significant predictor of neurobehavioral outcomes following pediatric TBI. The neural mechanisms linking family environment to neurobehavioral outcomes have, however, received less empiric study in this population. In contrast, limbic structural differences as well as challenges with emotional adjustment and behavioral regulation in non-TBI populations have been linked to a multitude of family environmental factors, including family stress, parenting style, and adverse childhood experiences. In this article, we systematically review the more comprehensive literature on family environment and neurobehavioral outcomes in pediatric TBI and leverage the work in both TBI and non-TBI populations to expand our understanding of the underlying neural mechanisms. Thus, we summarize the extant literature on the family environment's role in neurobehavioral sequelae in children with TBI and explore potential neural correlates by synthesizing the wealth of literature on family environment and limbic development, specifically related to the amygdala. This review underscores the critical role of environmental factors, especially those predating the injury, in modeling recovery outcomes post-TBI in childhood, and discusses clinical and research implications across pediatric populations. Given the public health crisis of pediatric TBI, along with the context of sparse available medical interventions, a broader understanding of factors contributing to outcomes is warranted to expand the range of intervention targets.

Economic impact of comorbid TBI-dementia on VA facility and non-VA facility costs, 2000-2020

OBJECTIVE

There is evidence Traumatic Brain Injury (TBI) is associated with increased risk of dementia (D). We compared VA and non-VA facility costs associated with TBI+D and each diagnosis alone, relative to neither diagnosis, annually and over time, 2000-2020.

METHODS

We estimated adjusted panel models of annual VHA costs in VA and non-VA facilities, stratified by age, and by TBI-dementia status. We also estimated cost for the TBI+D cohort by time since TBI and dementia diagnoses. All costs were 2021 inflation adjusted.

RESULTS

Veterans <65 ($30,736) and ≥65 ($15,650) with TBI+D, while veterans <65 ($3,379) and ≥65 ($4,252) with TBI-only had higher annual total VHA costs, relative to neither diagnosis. Veterans with TBI+D < 65 ($42,864) and ≥65 ($72,424) had higher costs in years≥15 after TBI diagnosis, while <65 ($36,431) and ≥65 ($37,589) had higher costs in years ≥10 after dementia diagnosis.

CONCLUSIONS

The main cost driver was inpatient non-VA facility costs. Veterans had continuously increasing inpatient care costs in non-VA facilities over time since their TBI and dementia diagnoses. Given budget constraints on the VA system, quality of care in non-VA facilities warrants comparison with VA facilities to make informed decisions regarding referrals to non-VA facilities.

From Provider to Advocate: The Complexities of Traumatic Brain Injury Prompt the Evolution of Provider Engagement

Treating a patient with traumatic brain injury requires an interdisciplinary approach because of the pervasive, profound and protean manifestations of this condition. In this review, key aspects of the medical history and review of systems will be described in order to highlight how the role of any provider must evolve to become a better patient advocate. Although this review is written from the vantage point of a vision care provider, it is hoped that patients, caregivers and providers will recognize the need for a team approach.