Long-term outcome in patients with mild traumatic brain injury: a prospective observational study

Executive function improvement in response to meta-cognitive training in chronic mTBI / PTSD

Objective

We tested Goal Management Training (GMT), which has been recommended as an executive training protocol that may improve the deficits in the complex tasks inherent in life role participation experienced by those with chronic mild traumatic brain injury and post-traumatic stress disease (mTBI/PTSD). We assessed, not only cognitive function, but also life role participation (quality of life).

Methods

We enrolled and treated 14 individuals and administered 10 GMT sessions in-person and provided the use of the Veterans Task Manager (VTM), a Smartphone App, which was designed to serve as a "practice-buddy" device to ensure translation of in-person learning to independent home and community practice of complex tasks. Pre-/post-treatment primary measure was the NIH Examiner, Unstructured Task. Secondary measures were as follows: Tower of London time to complete (cTOL), Community Reintegration of Service Members (CRIS) three subdomains [Extent of Participation; Limitations; Satisfaction of Life Role Participation (Satisfaction)]. We analyzed pre-post-treatment, t-test models to explore change, and generated descriptive statistics to inspect given individual patterns of change across measures.

Results

There was statistically significant improvement for the NIH EXAMINER Unstructured Task (p < .02; effect size = .67) and cTOL (p < .01; effect size = .52. There was a statistically significant improvement for two CRIS subdomains: Extent of Participation (p < .01; effect size = .75; Limitations (p < .05; effect size = .59). Individuals varied in their treatment response, across measures.

Conclusions and Clinical Significance

In Veterans with mTBI/PTSD in response to GMT and the VTM learning support buddy, there was significant improvement in executive cognition processes, sufficiently robust to produce significant improvement in community life role participation. The individual variations support need for precision neurorehabilitation. The positive results occurred in response to treatment advantages afforded by the content of the combined GMT and the employment of the VTM learning support buddy, with advantages including the following: manualized content of the GMT; incremental complex task difficulty; GMT structure and flexibility to incorporate individualized functional goals; and the VTM capability of ensuring translation of in-person instruction to home and community practice, solidifying newly learned executive cognitive processes. Study results support future study, including a potential randomized controlled trial, the manualized GMT and availability of the VTM to ensure future clinical deployment of treatment, as warranted.

Assessing Cognitive Behavioral Therapy for Insomnia to Improve Sleep Outcomes in Individuals With a Concussion: Protocol for a Delayed Randomized Controlled Trial

BACKGROUND

Sleep disturbances post concussion have been associated with more frequent and severe concussion symptoms and may contribute to poorer recovery. Cognitive behavioral therapy for insomnia (CBT-I) is an effective treatment for insomnia; however, it remains unclear if this treatment method is effective in improving sleep outcomes and reducing concomitant postconcussion symptoms.

OBJECTIVE

The hypotheses for this study are that (1) CBT-I will improve sleep outcomes and (2) CBT-I will improve concomitant postconcussion symptoms.

METHODS

In total, 40 individuals who are within ≥4 weeks of postconcussion injury and have insomnia symptoms will be enrolled in this randomized controlled trial. Participants will be randomized into either a group that starts a 6-week CBT-I program immediately after baseline or a waitlist control group that starts CBT-I following a 6-week waiting period. All participants will be reassessed 6, 12, and 18 weeks after baseline. Standardized assessments measuring sleep outcomes, postconcussion symptoms, and mood will be used. Linear regression and t tests will be used for statistical analyses.

RESULTS

Enrollment of 40 participants was completed July 2022, data collection will be completed in November 2022, and publication of main findings is anticipated in May 2023. It is anticipated that participants experience reduced insomnia symptoms and postconcussion symptoms following CBT-I and these improvements will be retained for at least 12 weeks. Additionally, we expect to observe a positive correlation between sleep and postconcussion symptom improvement.

CONCLUSIONS

Successful completion of this pilot study will allow for a better understanding of the treatment of insomnia and postconcussion symptoms in individuals following a concussion.

TRIAL REGISTRATION

ClinicalTrials.gov NCT04885205; https://clinicaltrials.gov/ct2/show/NCT04885205.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/38608.

"Can differences in hospitalised mild traumatic brain injury (mTBI) outcomes at 12 months be predicted?"

OBJECTIVES

To identify risk factors for poor outcome one year post-mild traumatic brain injury (mTBI).

DESIGN

This study was a prospective observational study using consecutive adult hospital admissions with mTBI.

SUBJECTS

A total of 869 consecutive mTBI patients were enrolled in this study.

METHODS

All patients were reviewed by the specialist TBI rehabilitation team at six weeks and one year following mTBI. Demographic and injury data collected included: age, gender, TBI severity and Glasgow Coma Scale (GCS). At twelve months, global outcome was assessed by the Extended Glasgow Outcome Score (GOSE) and participation restriction by the Rivermead Head Injury Follow-up Questionnaire (RHFUQ) via semi-structured interview. An ordinal regression (OR) was used to identify associated factors for poor GOSE outcome and a linear regression for a poor RHFUQ outcome.

RESULTS

In the GOSE analysis, lower GCS (p < 0.001), medical comorbidity (p = 0.027), depression (p < 0.001) and male gender (p = 0.008) were identified as risk factors for poor outcome. The RHFUQ analysis identified: lower GCS (p = 0.002), female gender (p = 0.001) and injuries from assault (p = 0.003) were variables associated with worse social functioning at one year.

CONCLUSION

mTBI is associated with a significant impact upon the physical health and psychosocial function of affected individuals. The results of this study demonstrate that differences in mTBI outcome can be identified at twelve months post-mTBI and that certain features, particularly GCS, are associated with poorer outcomes.

Randomised, double-blind, placebo-controlled study investigating Safety and efficAcy of MLC901 in post-traUmatic bRAin Injury: the SAMURAI study protocol

INTRODUCTION

Traumatic brain injury (TBI) is a leading cause of death in young adults globally and 90% of cases are mild TBI. Treatment to facilitate recovery after TBI is needed. Traditional medicine MLC901 (NeuroAiD II) with neuroprotective and neuroproliferative properties in cellular and animal models of brain injury showed TBI-associated cognitive improvement in mild or moderate TBI.

METHODS AND ANALYSIS

This is a randomised placebo-controlled trial, with 6-month treatment and 9-month follow-up, to determine the safety and efficacy of MLC901 in improving cognitive function in patients with cognitive impairment following mild TBI. This multicentre trial is conducted at the research centres of six hospitals/institutions in Russia. The primary outcome is to determine the effect of MLC901 on complex attention using the CNS Vital Signs (CNS-VS) online neurological test after 6-month treatment in patients receiving MLC901 compared with placebo. Secondary outcomes include other cognitive domains of CNS-VS and Rivermead Post Concussion Symptoms Questionnaire. The exploratory endpoints include Quality of Life after Brain Injury, Hospital Anxiety and Depression Scale and evaluation of improved neurological parameters 3 months after treatment completion. In addition, treatment compliance, concomitant therapies and adverse events will be collected. Investigators will use a secured online system for data entry.

ETHICS AND DISSEMINATION

The study has been approved by the ethic committee of Ministry of Health of the Russian Federation (No: 58074). The results of this study will be published in a peer-review journal and presented at international conferences as poster presentations.

TRIAL REGISTRATION NUMBER

NCT04861688.

Pathological Computed Tomography Features Associated With Adverse Outcomes After Mild Traumatic Brain Injury: A TRACK-TBI Study With External Validation in CENTER-TBI

Question

Are different patterns of intracranial injury on head computed tomography associated with prognosis after mild traumatic brain injury (mTBI)?

Findings

In this cohort study, subarachnoid hemorrhage, subdural hematoma, and contusion often co-occurred and were associated with both incomplete recovery and more severe impairment out to 12 months after injury, while intraventricular and/or petechial hemorrhage co-occurred and were associated with more severe impairment up to 12 months after injury; epidural hematoma was associated with incomplete recovery at some points but not with more severe impairment. Some intracranial hemorrhage patterns were more strongly associated with outcomes than previously validated demographic and clinical variables.

Meaning

In this study, different pathological features on head computed tomography carried different implications for mild traumatic brain injury prognosis to 1 year.

Importance

A head computed tomography (CT) with positive results for acute intracranial hemorrhage is the gold-standard diagnostic biomarker for acute traumatic brain injury (TBI). In moderate to severe TBI (Glasgow Coma Scale [GCS] scores 3-12), some CT features have been shown to be associated with outcomes. In mild TBI (mTBI; GCS scores 13-15), distribution and co-occurrence of pathological CT features and their prognostic importance are not well understood.

Objective

To identify pathological CT features associated with adverse outcomes after mTBI.

Design, Setting, and Participants

The longitudinal, observational Transforming Research and Clinical Knowledge in Traumatic Brain Injury (TRACK-TBI) study enrolled patients with TBI, including those 17 years and older with GCS scores of 13 to 15 who presented to emergency departments at 18 US level 1 trauma centers between February 26, 2014, and August 8, 2018, and underwent head CT imaging within 24 hours of TBI. Evaluations of CT imaging used TBI Common Data Elements. Glasgow Outcome Scale–Extended (GOSE) scores were assessed at 2 weeks and 3, 6, and 12 months postinjury. External validation of results was performed via the Collaborative European NeuroTrauma Effectiveness Research in Traumatic Brain Injury (CENTER-TBI) study. Data analyses were completed from February 2020 to February 2021.

Exposures

Acute nonpenetrating head trauma.

Main Outcomes and Measures

Frequency, co-occurrence, and clustering of CT features; incomplete recovery (GOSE scores <8 vs 8); and an unfavorable outcome (GOSE scores <5 vs ≥5) at 2 weeks and 3, 6, and 12 months.

Results

In 1935 patients with mTBI (mean [SD] age, 41.5 [17.6] years; 1286 men [66.5%]) in the TRACK-TBI cohort and 2594 patients with mTBI (mean [SD] age, 51.8 [20.3] years; 1658 men [63.9%]) in an external validation cohort, hierarchical cluster analysis identified 3 major clusters of CT features: contusion, subarachnoid hemorrhage, and/or subdural hematoma; intraventricular and/or petechial hemorrhage; and epidural hematoma. Contusion, subarachnoid hemorrhage, and/or subdural hematoma features were associated with incomplete recovery (odds ratios [ORs] for GOSE scores <8 at 1 year: TRACK-TBI, 1.80 [95% CI, 1.39-2.33]; CENTER-TBI, 2.73 [95% CI, 2.18-3.41]) and greater degrees of unfavorable outcomes (ORs for GOSE scores <5 at 1 year: TRACK-TBI, 3.23 [95% CI, 1.59-6.58]; CENTER-TBI, 1.68 [95% CI, 1.13-2.49]) out to 12 months after injury, but epidural hematoma was not. Intraventricular and/or petechial hemorrhage was associated with greater degrees of unfavorable outcomes up to 12 months after injury (eg, OR for GOSE scores <5 at 1 year in TRACK-TBI: 3.47 [95% CI, 1.66-7.26]). Some CT features were more strongly associated with outcomes than previously validated variables (eg, ORs for GOSE scores <5 at 1 year in TRACK-TBI: neuropsychiatric history, 1.43 [95% CI .98-2.10] vs contusion, subarachnoid hemorrhage, and/or subdural hematoma, 3.23 [95% CI 1.59-6.58]). Findings were externally validated in 2594 patients with mTBI enrolled in the CENTER-TBI study.

Conclusions and Relevance

In this study, pathological CT features carried different prognostic implications after mTBI to 1 year postinjury. Some patterns of injury were associated with worse outcomes than others. These results support that patients with mTBI and these CT features need TBI-specific education and systematic follow-up.

Predicting outcome following mild traumatic brain injury: protocol for the longitudinal, prospective, observational Concussion Recovery (CREST) cohort study

INTRODUCTION

Mild traumatic brain injury (mTBI) is a complex injury with heterogeneous physical, cognitive, emotional and functional outcomes. Many who sustain mTBI recover within 2 weeks of injury; however, approximately 10%-20% of individuals experience mTBI symptoms beyond this 'typical' recovery timeframe, known as persistent post-concussion symptoms (PPCS). Despite increasing interest in PPCS, uncertainty remains regarding its prevalence in community-based populations and the extent to which poor recovery may be identified using early predictive markers.

OBJECTIVE

(1) Establish a research dataset of people who have experienced mTBI and document their recovery trajectories; (2) Evaluate a broad range of novel and established prognostic factors for inclusion in a predictive model for PPCS.

METHODS AND ANALYSIS

The Concussion Recovery Study (CREST) is a prospective, longitudinal observational cohort study conducted in Perth, Western Australia. CREST is recruiting adults aged 18-65 from medical and community-based settings with acute diagnosis of mTBI. CREST will create a state-wide research dataset of mTBI cases, with data being collected in two phases. Phase I collates data on demographics, medical background, lifestyle habits, nature of injury and acute mTBI symptomatology. In Phase II, participants undergo neuropsychological evaluation, exercise tolerance and vestibular/ocular motor screening, MRI, quantitative electroencephalography and blood-based biomarker assessment. Follow-up is conducted via telephone interview at 1, 3, 6 and 12 months after injury. Primary outcome measures are presence of PPCS and quality of life, as measured by the Post-Concussion Symptom Scale and the Quality of Life after Brain Injury questionnaires, respectively. Multivariate modelling will examine the prognostic value of promising factors.

ETHICS AND DISSEMINATION

Human Research Ethics Committees of Royal Perth Hospital (#RGS0000003024), Curtin University (HRE2019-0209), Ramsay Health Care (#2009) and St John of God Health Care (#1628) have approved this study protocol. Findings will be published in peer-reviewed journals and presented at scientific conferences.

TRIAL REGISTRATION NUMBER

ACTRN12619001226190.

Magnetic Resonance Spectroscopy following Mild Traumatic Brain Injury: A Systematic Review and Meta-Analysis on the Potential to Detect Posttraumatic Neurodegeneration

INTRODUCTION

Traumatic brain injury (TBI) is the most relevant external risk factor for dementia and a major global health burden. Mild TBI (mTBI) contributes to up to 90% of all TBIs, and the classification "mild" often misrepresents the patient's burden who suffer from neuropsychiatric long-term sequelae. Magnetic resonance spectroscopy (MRS) allows in vivo detection of compromised brain metabolism although it is not routinely used after TBI.

OBJECTIVE

Thus, we performed a systematic review and meta-analysis to elucidate if MRS has the potential to identify changes in brain metabolism in adult patients after a single mTBI with a negative routine brain scan (CCT and/or MRI scan) compared to aged- and sex-matched healthy controls (HC) during the acute or subacute postinjury phase (≤90 days after mTBI).

METHODS

A comprehensive literature search was conducted from the first edition of electronic databases until January 31, 2020. Group analyses were performed per metabolite using a random-effects model.

RESULTS

Four and 2 out of 5,417 articles met the inclusion criteria for the meta-analysis and systematic review, respectively. For the meta-analysis, 50 mTBI patients and 51 HC with a mean age of 31 and 30 years, respectively, were scanned using N-acetyl-aspartate (NAA), a marker for neuronal integrity. Glutamate (Glu), a marker for disturbed brain metabolism, choline (Cho), a marker for increased cell membrane turnover, and creatine (Cr) were used in 2 out of the 4 included articles. Regions of interests were the frontal lobe, the white matter around 1 cm above the lateral ventricles, or the whole brain. NAA was decreased in patients compared to HC with an effect size (ES) of -0.49 (95% CI -1.08 to 0.09), primarily measured in the frontal lobe. Glu was increased in the white matter in 22 mTBI patients compared to 22 HC (ES 0.79; 95% CI 0.17-1.41). Cho was decreased in 31 mTBI patients compared to 31 HC (ES -0.31; 95% CI -0.81 to 0.19). Cr was contradictory and, therefore, potentially not suitable as a reference marker after mTBI.

CONCLUSIONS

MRS pinpoints changes in posttraumatic brain metabolism that correlate with cognitive dysfunction and, thus, might possibly help to detect mTBI patients at risk for unfavorable outcome or posttraumatic neurodegeneration early.

Sleep Disturbances in the Acute Stage of Concussion are Associated With Poorer Long-Term Recovery: A Systematic Review

OBJECTIVE

To examine the association between sleep during the acute stage of concussion and long-term outcomes.

LITERATURE SURVEY

Literature searches were performed 1 July 2018 to 1 August 2018 in Ovid MEDLINE, CINAHL, and Web of Science, along with hand searching for gray literature and cited references. Of the 610 search results, 359 unique references were reviewed after duplicates were removed.

METHODOLOGY

Two reviewers independently reviewed and came to consensus on which titles/abstracts met inclusion/exclusion criteria (n = 23). The 23 full-text articles were assessed independently by the same two reviewers for eligibility. Consensus was achieved, leaving four articles for quality assessment and data extraction. One person extracted relevant data from each study using a standard data-extraction table. The data extraction table was reviewed by two reviewers and consensus was achieved for completeness and accuracy. Quality appraisal was conducted to assess the risk for potential bias and quality of included articles.

SYNTHESIS

Two of the articles included children younger than 16 years old and two included a wide age range. In general, poorer sleep was associated with poorer outcomes following concussion at reassessments across any age population. In addition, poorer sleep in the acute stage of concussion was associated with poorer long-term outcomes and recovery.

CONCLUSIONS

The variability in sleep assessments used, symptoms assessed, length of time to reassessments, and comparator group included made data synthesis challenging. The use of standard valid and reliable sleep assessments is recommended. Future studies may consider if addressing sleep disturbances early following concussion will improve longer-term outcomes.

"I couldn't even do normal chores": a qualitative study of the impacts of injury for Māori

AIMS

To investigate the rehabilitation experiences of Māori who were still reporting disability 24 months after an injury resulting in hospitalisation.

METHODS

Participants had been hospitalised for an Accident Compensation Corporation (New Zealand's no-fault injury compensation insurer) entitlement claim injury between 2007 and 2009, and were experiencing disability 24 months post-injury. In-depth kanohi ki te kanohi (face-to-face) qualitative interviews with 12 participants aged between 37 and 71 years at the time of interviews were conducted. Interpretive analyses of interview transcripts, focused on the impacts of injury was conducted with the aid of NVivo software.

RESULTS

The overarching theme identified during the analysis was "Impact" with four sub-themes of: Impact on daily life; Impact on relationships, Impact on employment; and, long-term or ongoing impacts.

CONCLUSIONS

For Māori living with disability 24 months after hospitalisation for injury, adjusting to life after the injury and the rehabilitation process was challenging. Participants discussed frustration with feeling dependent on others, being bored and feeling unfulfilled after their injury, and that many aspects of their lives were impacted on and not always in the expected directions. Many reported longer lasting impacts even after rehabilitation was completed. Implications for rehabilitation programmes e.g., strengthening programmes by taking into account issues discussed by participants, recognising the long-term impacts on both those injured and their whānau (family), and further investigations required are also discussed.IMPLICATIONS FOR REHABILITATIONDisability after injury can have long term impacts for injured Māori and their relationships.Social impacts can be perceived as more debilitating than the physical impacts after injury.Experiences of employment changes and future prospects are often difficult to navigate for Māori returning to work after an injury.

Long-term mortality and quality of life after trauma: an ancillary study from the prospective multicenter trial FROG-ICU

INTRODUCTION

The long-term outcomes of intensive care unit (ICU) patients are known to be worse than those of the general population, but they are poorly known in severe trauma patients. We conducted an ancillary examination of the FROG-ICU study to identify risk factors and biomarkers associated with the poorer long-term outcomes and mortality in trauma ICU patients.

METHODS

Mortality, quality of life (QoL) and stress level scores were obtained 1 year after discharge from ICU. Blood samples were collected at ICU admission and discharge for measurement of inflammatory and cardiovascular biomarkers.

RESULTS

ICU trauma patients had a significantly lower 1-year mortality than non-trauma patients (7% vs. 23%, p < 0.001), but had worse stress levels scores (19 vs. 13, p = 0.041). No difference was found regarding physical and mental QoL scores (33 vs. 31, p = 0.19 and 30 vs. 28, p = 0.42). Patients with better QoL scores had lower tracheotomy rates (11% vs. 30%, p = 0.01). Worse stress level scores are associated with poor QoL scores and vice versa. Some study biomarkers were significantly higher in those ICU trauma patients who had worse QoL scores at 1 year after discharge.

DISCUSSION

Our study suggests that quality of life 1 year after an ICU stay is poor and is similar in both trauma and non-trauma patients, but ICU trauma patients are at greater risk of developing post-traumatic stress disorder-related symptoms. Tracheotomy and high levels of inflammatory biomarkers could be associated with impaired quality of life.

Visual Dysfunction and Associated Co-morbidities as Predictors of Mild Traumatic Brain Injury Seen Among Veterans in Non-VA Facilities: Implications for Clinical Practice

Introduction

Traumatic brain injury (TBI) and post-traumatic stress disorder are considered the signature injuries of the Iraq and Afghanistan conflicts. With the extensive use of improvised explosive devices by the enemy, the concussive effects from blast have a greater potential to cause mild TBI (mTBI) in military Service Members. These mTBI can be associated with other physical and psychological health problems, including mTBI-induced visual processing and eye movement dysfunctions. Our study assessed if any visual dysfunctions existed in those surveyed in non-Veterans Administration (VA) facilities who had suffered mTBI (concussive effect), in addition to the presence of concussion-related co-morbidities.

Materials and Methods

As part of a larger study involving veterans from different service eras, we surveyed 235 Veterans who had served during the Iraq and/or Afghanistan conflict era. Data for the study were collected using diagnostic telephone interviews of these veterans who were outpatients of the Geisinger Health System. We assess visual dysfunction in this sample and compare visual dysfunctions of those who had suffered a mTBI (concussive effect), as well as co-morbidities, with those in the cohort who had not suffered concussion effects.

Results

Of those veterans who experienced visual dysfunctions, our results reflected that the visual symptoms were significant for concussion with the subjects surveyed, even though all had experienced a mTBI event greater than five years ago. Although we did find an association with concussion and visual symptoms, the association for concussion was strongest with the finding of greater than or equal to three current TBI symptoms, therefore we found this to be the best predictor of previous concussion among the veterans.

Conclusions

Veterans from the Iraq/Afghanistan era who had suffered concussive blast effects (mTBI) can present with covert visual dysfunction as well as additional physical and psychological health problems. The primary eye care providers, especially those in a non-military/VA facility, who encounter these veterans need to be aware of the predictors of mTBI, with the aim of uncovering visual dysfunctions and other associated co-morbidities.

Influence of demographic factors and clinical status parameters on long-term neurological, psychological and vegetative outcome following traumatic brain injury

PRIMARY OBJECTIVE

We evaluated the neurologic, psychological and vegetative outcome, the health status and changes of the personal and occupational status of patients after traumatic brain injuries (TBIs). Correlations between outcome parameters and basic demographic factors and initial clinical status parameters of the patients were assessed.

RESEARCH DESIGN

Monocentric, retrospective follow-up analysis.

METHODS AND PROCEDURES

We evaluated the neurologic, psychological and vegetative outcome and health status of patients, who survived TBI with a mean follow-up time of 54 months. Glasgow Outcome Scale (GOS), Disability Rating Scale (DRS) and a questionnaire on Quality of Life were used for outcome measurement. The personal and occupational status, trauma-derived changes to that status and medical and demographic factors that have an impact on the health condition of patients after TBI were assessed.

MAIN OUTCOMES AND RESULTS

With a median GOS of 5.0 and median DRS of 3.0, our patients showed just moderate disabilities. Fifty-six per cent of the patients felt 'very good' or 'good'. Age, gender, the preclinical Glasgow Coma Scale (GCS), state of pupil reaction and surgical treatment did not seem to affect the GOS or DRS. Correlations between body mass index, age and gender and distinct neurologic, psychological and vegetative symptoms were found. The personal status did not change significantly after TBI. Changes to occupational and socioeconomic status were evident.

CONCLUSIONS

One-third of the patients are heavily affected by neurological, psychological and vegetative symptoms after surviving TBI. Some demographic factors affected this integrity.

MLC901 (NeuroAiD II™) for cognition after traumatic brain injury: a pilot randomized clinical trial

Background and purpose

Treatments to facilitate recovery after traumatic brain injury (TBI) are urgently needed. We conducted a 9‐month pilot, randomized placebo‐controlled clinical trial to examine the safety and potential effects of the herbal supplement MLC901 (NeuroAiD II™) on cognitive functioning following TBI.

Methods

Adults aged 18–65 years at 1–12 months after mild or moderate TBI were randomized to receive MLC901 (0.8 g capsules 3 times daily) or placebo for 6 months. The primary outcome was cognitive functioning as assessed by the CNS Vital Signs online neuropsychological test. Secondary outcomes included the Cognitive Failures Questionnaire, the Rivermead Post‐concussion Symptom Questionnaire (neurobehavioral sequelae), Quality of Life after Brain Injury, Hospital Anxiety and Depression Scale, Modified Fatigue Impact Scale and extended Glasgow Outcome Scale (physical disability). Assessments were completed at baseline and at 3‐, 6‐ and 9‐month follow‐up. Linear mixed‐effects models were conducted, with the primary outcome time‐point of 6 months.

Results

A total of 78 participants [mean age 37.5 ± 14.8 years, 39 (50%) female] were included in the analysis. Baseline variables were similar between groups (treatment group, n = 36; control group, n = 42). Linear mixed‐effects models controlling for time, group allocation, repeated measurements, adherence and baseline assessment scores revealed significant improvements in complex attention (P = 0.04, d = 0.6) and executive functioning (P = 0.04, d = 0.4) at 6 months in the MLC901 group compared with controls. There were no significant differences between the groups for neurobehavioral sequelae, mood, fatigue, physical disability or overall quality of life at 6 months. No serious adverse events were reported.

Conclusions

MLC901 was safe and well tolerated post‐TBI. This study provided Class I/II evidence that, for patients with mild to moderate TBI, 6 months of MLC901 improved cognitive functioning.

Neurobehavioral Characteristics of Older Veterans With Remote Traumatic Brain Injury

OBJECTIVE

While traumatic brain injury (TBI) is common across the life span, the detailed neurobehavioral characteristics of older adults with prior TBI remain unclear. Our goal was to compare the clinical profile of older independently living veterans with and without prior TBI.

SETTING

Two veterans' retirement communities.

PARTICIPANTS

Seventy-five participants with TBI and 71 without (mean age = 78 years).

DESIGN

Cross-sectional.

MAIN MEASURES

TBI history was determined by the Ohio State University TBI Questionnaire. We assessed psychiatric and medical history via interviews and chart review and conducted measures assessing functional/lifestyle, psychiatric, and cognitive outcomes. Regression analyses (adjusted for demographics, diabetes, prior depression, substance abuse, and site) were performed to compare between TBI and non-TBI participants.

RESULTS

Compared with veterans without TBI, those with TBI had greater functional impairment (adjusted P = .05), endorsed more current depressive (adjusted P = .04) and posttraumatic stress disorder symptoms (adjusted P = .01), and had higher rates of prior depression and substance abuse (both adjusted Ps < .01). While composite memory and language scores did not differ between groups, participants with TBI performed worse on tests of executive functioning/processing speed (adjusted P = .01).

CONCLUSIONS

Our results suggest that TBI may have adverse long-term neurobehavioral consequences and that TBI-exposed adults may require careful screening and follow-up.

Long-term changes of patient-reported quality of life after major trauma: The importance of the time elapsed after injury

BACKGROUND

Numerous studies have identified various risk factors for a poor health-related quality of life (HRQOL) after severe trauma. The relative importance of the time elapsed after injury, however, is unknown and results of clinical studies have been conflicting.

METHODS

A cross-sectional study was performed in two trauma centres using data from the German TraumaRegister DGU^®, which contained prospectively collected information on the type and severity of the injury, on critical care, and on outcome. To evaluate HRQOL in patients surviving more than 500days after the injury, we used a self-rating instrument, the EQ-5D which contains a visual analogue scale (EQ-VAS), and which allows the calculation of a global outcome indicator, the EQ-D5 index value. Complex statistical models were used to evaluate independent associations between the time elapsed after injury and a poor HRQOL.

RESULTS

Of 380 contacted patients, follow-up assessments could be obtained in 168 patients (44.2%) 3.6±1.6 (SD) years after the injury. There was a linear association between the time elapsed after the injury and the% of contacted patients not participating in the study (p=0.013). In participating subjects, average EQ-5D index value was 0.599±0.299, and average EQ-VAS rating 67.8±22.0. A very poor quality of life (EQ-5D index value<0.6, EQ-VAS rating≤50) could be found in 43.5% and 28.0% of the patients, respectively. After adjusting for multiple confounders, the number of days elapsed after injury showed a complex non-linear and independent association with a poor HRQOL (low EQ-5D index value: p=0.027; low EQ-VAS rating: p=0.008). Frequencies of a poor HRQOL reached their minimum about four to five years after the injury and increased thereafter.

CONCLUSIONS

There is an independent, U-shaped association between the frequency of extreme values of HRQOL and the time elapsed after injury. Time patterns of HRQOL may be sensitive to increasing rates of attrition since patients with a good outcome are less likely to respond to questionnaires. Time from injury should be incorporated into all future cross sectional studies trying to identify predictors of HRQOL.

Concussion and the autonomic nervous system: An introduction to the field and the results of a systematic review

BACKGROUND

Recent evidence suggests that autonomic nervous dysfunction may be one of many potential factors contributing to persisting post-concussion symptoms.

OBJECTIVE

This is the first systematic review to explore the impact of concussion on multiple aspects of autonomic nervous system functioning.

METHODS

The methods employed are in compliance with the American Academy of Neurology (AAN) and PRISMA standards. Embase, MEDLINE, PsychINFO, and Science Citation Index literature searches were performed using relevant indexing terms for articles published prior to the end of December 2016. Data extraction was performed by two independent groups, including study quality indicators to determine potential risk for bias according to the 4-tiered classification scheme of the AAN.

RESULTS

Thirty-six articles qualified for inclusion in the analysis. Only three studies (one Class II and two Class IV) did not identify anomalies in measures of ANS functioning in concussed populations.

CONCLUSIONS

The evidence supports the conclusion that it is likely that concussion causes autonomic nervous system anomalies. An awareness of this relationship increases our understanding of the physical impact of concussion, partially explains the overlap of concussion symptoms with other medical conditions, presents opportunities for further research, and has the potential to powerfully inform treatment decisions.

Understanding the interplay between mild traumatic brain injury and cognitive fatigue: models and treatments

Nearly 2 million traumatic brain injuries occur annually, most of which are mild (mTBI). One debilitating sequela of mTBI is cognitive fatigue: fatigue following cognitive work. Cognitive fatigue has proven difficult to quantify and study, but this is changing, allowing models to be proposed and tested. Here, we review evidence for four models of cognitive fatigue, and relate them to specific treatments following mTBI. The evidence supports two models: cognitive fatigue results from the increased work/effort required for the brain to process information after trauma-induced damage; and cognitive fatigue results from sleep disturbances. While there are no evidence-based treatments for fatigue after mTBI, some pharmacological and nonpharmacological treatments show promise for treating this debilitating problem. Future work may target the role of genetics, neuroinflammation and the microbiome and their role in complex cognitive responses such as fatigue.

Do Mild Traumatic Brain Injury Severity Sub-classification Systems Help to Identify People Who Go on to Experience Long-Term Symptoms?

Objective: To identify the systems available to sub-classify mild traumatic brain injury (TBI) and to determine their utility in predicting 1-year outcome.

Methods: A systematic review to identify mild-TBI sub-classification systems was conducted until March 2016. The identified systems were applied to a cohort ofN= 290 adults who had experienced a mild-TBI, and who had been assessed for post-concussion symptoms 1-year post injury. ANOVAs and regression models were used to determine whether each sub-classification system could distinguish between outcomes and to explore their contribution to explaining variance in post-concussion symptoms 1-year post injury.

Results: Nineteen sub-classification systems for mild-TBI met the inclusion criteria for this review. The Saal (1991) classification system significantly differentiated the experience of post-concussion symptoms in our cohort 1-year post injury (F= 2.39,p= 0.05). However, the findings did not remain significant following correction for multiple comparisons and inclusion of socio-demographic and contextual factors in the regression model.

Conclusions: Current sub-classification systems fail to explain much of the variance in post-concussion symptoms 1 year following mild-TBI. Further research is needed to identify the factors (including socio-demographic and contextual factors) to determine, who may be at risk of developing persistent post-concussion symptoms.

Functional and Structural Network Recovery after Mild Traumatic Brain Injury: A 1-Year Longitudinal Study

Brain connectivity after mild traumatic brain injury (mTBI) has not been investigated longitudinally with respect to both functional and structural networks together within the same patients, crucial to capture the multifaceted neuropathology of the injury and to comprehensively monitor the course of recovery and compensatory reorganizations at macro-level. We performed a prospective study with 49 mTBI patients at an average of 5 days and 1 year post-injury and 49 healthy controls. Neuropsychological assessments as well as resting-state functional and diffusion-weighted magnetic resonance imaging were obtained. Functional and structural connectome analyses were performed using network-based statistics. They included a cross-sectional group comparison and a longitudinal analysis with the factors group and time. The latter tracked the subnetworks altered at the early phase and, in addition, included a whole-brain group × time interaction analysis. Finally, we explored associations between the evolution of connectivity and changes in cognitive performance. The early phase of mTBI was characterized by a functional hypoconnectivity in a subnetwork with a large overlap of regions involved within the classical default mode network. In addition, structural hyperconnectivity in a subnetwork including central hub areas such as the cingulate cortex was found. The impaired functional and structural subnetworks were strongly correlated and revealed a large anatomical overlap. One year after trauma and compared to healthy controls we observed a partial normalization of both subnetworks along with a considerable compensation of functional and structural connectivity subsequent to the acute phase. Connectivity changes over time were correlated with improvements in working memory, divided attention, and verbal recall. Neuroplasticity-induced recovery or compensatory processes following mTBI differ between brain regions with respect to their time course and are not fully completed 1 year after trauma.

Long-Term Use and Perceived Benefits of Goal-Oriented Attentional Self-Regulation Training in Chronic Brain Injury

Primary Objective. To investigate the long-term use and perceived benefit(s) of strategies included in Goal-Oriented Attentional Self-Regulation (GOALS) training (Novakovic-Agopian et al., 2011) by individuals with acquired brain injury (ABI) and chronic executive dysfunction. Research Design. Longitudinal follow-up of training. Methods and Procedures. Sixteen participants with chronic ABI participated in structured telephone interviews 20 months (range 11 to 31 months) following completion of GOALS training. Participants responded to questions regarding the range of strategies they continued to utilize, perceived benefit(s) of strategy use, situations in which strategy use was found helpful, and functional changes attributed to training. Results. Nearly all participants (94%) reported continued use of at least one trained strategy in their daily lives, with 75% of participants also reporting improved functioning resulting from training. However, there was considerable variability with respect to the specific strategies individuals found helpful as well as the perceived impact of training on overall functioning. Conclusions. GOALS training shows promising long-term benefits for individuals in the chronic phase of brain injury. Identifying individual- and injury-level factors that account for variability in continued strategy use and the perceived long-term benefits of training will help with ongoing intervention development.

Traumatic Brain Injury Incidence, Clinical Overview, and Policies in the US Military Health System Since 2000

Exposure to explosive armaments during Operation Iraqi Freedom and Operation Enduring Freedom contributed to approximately 14% of the 352 612 traumatic brain injury (TBI) diagnoses in the US military between 2000 and 2016. The US Department of Defense issued guidelines in 2009 to (1) standardize TBI diagnostic criteria; (2) classify TBI according to mechanism and severity; (3) categorize TBI symptoms as somatic, psychological, or cognitive; and (4) systematize types of care given during the acute and rehabilitation stages of TBI treatment. Polytrauma and associated psychological and neurologic conditions may create barriers to optimal rehabilitation from TBI. Given the completion of recent combat operations and the transition of TBI patients into long-term care within the US Department of Veterans Affairs system, a review of the literature concerning TBI is timely. Long-term follow-up care for patients who have sustained TBI will remain a critical issue for the US military.

Post-concussion symptoms and chronic pain after mild traumatic brain injury are modulated by multiple locus effect in the BDNF gene through the expression of antisense: A pilot prospective control study

Background: Mild traumatic brain injury (mTBI) often results in post-concussion symptoms, chronic pain, and sleepiness. Genetic factors are thought to play an important role in poor prognosis.

Aims: The aims of this study are to (1) document the prevalence of pain and post-concussion symptoms in mTBI patients in acute and chronic phases (2) determine whether candidate genes predispose to post-concussive symptoms and pain.

Methods: Posttraumatic symptoms, evaluated using the Rivermead Post-Concussion Symptoms Questionnaire, and pain were assessed in 94 mTBI patients in the acute phase as well as in 22 healthy controls. Assessment was repeated in 36 patients after one year who agreed to participate in the follow-up visit. Gene polymorphisms and expression were assessed in mTBI patients and healthy controls.

Results: In the acute phase, mTBI patients with pain (69%) presented more psychological symptoms and sleepiness and were less able to return to work than those without pain. At one year, 19% of mTBI patients had persistent pain and psychological distress. Two haplotypes (H2 and H3) in the brain-derived neurotrophic factor (BDNF) gene were shown to be respectively deleterious and protective against post-concussion symptoms and pain in both acute and chronic phases. Protective haplotype H3 was associated with a decreased expression of the anti-sense of BDNF (BDNF-AS). Deleterious haplotype H2 predicted the development of chronic pain at one year, whereas H3 was protective.

Conclusions: This pilot study suggests a protective mechanism of a multilocus effect in BDNF, through BDNF-AS, against post-concussion symptoms and pain in the acute phase and possibly chronic pain at one year post-mTBI. The role of antisense RNA should be validated in larger cohorts.

Randomised, waiting list controlled trial of cognitive-behavioural therapy for persistent postconcussional symptoms after predominantly mild-moderate traumatic brain injury

BACKGROUND

Persistent postconcussional symptoms (PCS) can be a source of distress and disability following traumatic brain injury (TBI). Such symptoms have been viewed as difficult to treat but may be amenable to psychological approaches such as cognitive-behavioural therapy (CBT).

OBJECTIVES

To evaluate the effectiveness of a 12-session individualised, formulation-based CBT programme.

METHOD

Two-centre randomised waiting list controlled trial with 46 adults with persistent PCS after predominantly mild-to-moderate TBI (52% with post-traumatic amnesia (PTA)≤24 hours), but including some with severe TBIs (20% with PTA>7 days).

RESULTS

Improvements associated with CBT were found on the primary outcome measures relating to quality of life (using the Quality of Life Assessment Schedule and the Brain Injury Community Rehabilitation Outcome Scale). Treatment effects after covarying for treatment duration were also found for PCS and several secondary outcomes, including measures of anxiety and fatigue (but not depression or post-traumatic stress disorder (PTSD)). Improvements were more apparent for those completing CBT sessions over a shorter period of time, but were unrelated to medicolegal status, injury severity or length of time since injury.

CONCLUSIONS

This study suggests that CBT can improve quality of life for adults with persistent PCS and potentially reduce symptoms for some, in the context of outpatient brain injury rehabilitation services.

TRIAL REGISTRATION NUMBER

ISRCTN49540320.

Trajectories and associated factors of quality of life, global outcome, and post-concussion symptoms in the first year following mild traumatic brain injury

PURPOSE

To investigate the associated factors and change trajectories of quality of life (QoL), global outcome, and post-concussion symptoms (PCS) over the first year following mild traumatic brain injury (mTBI).

METHODS

This was a prospective longitudinal study of 100 participants with mTBI from neurosurgical outpatient departments in Chiayi County District Hospitals in Taiwan. The checklist of post-concussion syndromes (CPCS) was used to assess PCS at enrollment and at 1, 3, and 12 months after mTBI; the glasgow outcome scale extended (GOSE), the quality of life after brain injured (QOLIBRI), Chinese version, and the Short Form 36 Health Survey (SF-36), Taiwan version, were used to assess mTBI global outcome and QoL at 1, 3, and 12 months after mTBI.

RESULTS

Latent class growth models (LCGMs) indicated the change trajectories of QOLIBRI, PCS SF-36, MCS SF-36, GOSE, and PCS. Classes of trajectory were associated with age ≥40 years, unemployment at 1 month after injury, and educational level ≤12 years. Univariate analysis revealed that employment status at 1 month post-injury was correlated with the trajectories of QOLIBRI, PCS SF-36, MCS SF-36, and GOSE, but not PCS.

CONCLUSIONS

Employment status was the most crucial associated factor for QoL in individuals with mTBI at the 1-year follow-up. Future studies should explore the benefits of employment on QoL of individuals with mTBI.

Quality of life after mild to moderate trauma

INTRODUCTION

To evaluate potential reduction in health-related quality of life (HRQOL) after a mild to moderate trauma.

MATERIALS AND METHODS

Follow-up study of a cohort of 153 trauma patients admitted to the High Dependency Unit of the Emergency Department of the University-Hospital of Florence from July 2008 to February 2012. After 6 months from the event, a telephone interview using the Physical (PCS) and Mental (MCS) Health Composite Score (SF12) was conducted. Patients reported their HRQOL both at present and before trauma. Scores ≥ 50 represent no disability; 40-49, mild disability; 30-39, moderate disability; and below 30, severe disability.

RESULTS

Before the event 143 (93%) subjects reported a normal PCS and MCS. After the events, a significantly lower proportion of patients maintained a normal PCS and MCS values (52 and 68%, all p<0.01). One, two, three and four PCS items worsened in 14%, 15%, 18% and 38% of the study population, while one, two, three or four MCS dimensions worsened in 12%, 19%, 19% and 24%. We identified 109 subjects (N+), which showed normal PCS and MCS values before trauma, in the absence of any pre-existing medical condition. After the event, we observed a significant PCS (before: 54, standard deviation, SD 6; after 43, SD 11, p<0.0001) and MCS (before: 55, SD 7; after 47, SD 11, p<0.0001) worsening among N+ subjects. Distribution across the four disability categories was 52, 24, 17 and 6% for MCS score and 38, 25, 27 and 11% for PCS score: overall 8 (7%) patients reported a moderate disability and 5 (5%) reported a severe disability in both dimensions. Compared with subjects with preserved values, patients with an abnormal (<39) HRQOL were older, showed a higher prevalence of female gender and pre-existing medical conditions and a worst Sequential Organ Failure Assessment score. An advanced age (OR 1.033, 95% CI 1.010-1.057, p=0.005) and a higher SOFA T1 score (OR 1.500, 95% CI 1.027-2.190, p=0.036) were independently associated with a worsening PCS.

CONCLUSIONS

After a mild trauma, we evidenced a relevant reduction in HRQOL; an advanced age and a higher degree of organ dysfunction were independently associated with HRQOL deterioration.

Cerebral hemodynamic changes of mild traumatic brain injury at the acute stage

Mild traumatic brain injury (mTBI) is a significant public health care burden in the United States. However, we lack a detailed understanding of the pathophysiology following mTBI and its relation to symptoms and recovery. With advanced magnetic resonance imaging (MRI), we can investigate brain perfusion and oxygenation in regions known to be implicated in symptoms, including cortical gray matter and subcortical structures. In this study, we assessed 14 mTBI patients and 18 controls with susceptibility weighted imaging and mapping (SWIM) for blood oxygenation quantification. In addition to SWIM, 7 patients and 12 controls had cerebral perfusion measured with arterial spin labeling (ASL). We found increases in regional cerebral blood flow (CBF) in the left striatum, and in frontal and occipital lobes in patients as compared to controls (p = 0.01, 0.03, 0.03 respectively). We also found decreases in venous susceptibility, indicating increases in venous oxygenation, in the left thalamostriate vein and right basal vein of Rosenthal (p = 0.04 in both). mTBI patients had significantly lower delayed recall scores on the standardized assessment of concussion, but neither susceptibility nor CBF measures were found to correlate with symptoms as assessed by neuropsychological testing. The increased CBF combined with increased venous oxygenation suggests an increase in cerebral blood flow that exceeds the oxygen demand of the tissue, in contrast to the regional hypoxia seen in more severe TBI. This may represent a neuroprotective response following mTBI, which warrants further investigation.

Chronic visual dysfunction after blast-induced mild traumatic brain injury

The purpose of this study was to investigate the long-term visual dysfunction in patients after blast-induced mild traumatic brain injury (mbTBI) using a retrospective case series of 31 patients with mbTBI (>12 mo prior) without eye injuries. Time since mbTBI was 50.5 +/- 19.8 mo. Age at the time of injury was 30.0 +/- 8.3 yr. Mean corrected visual acuity was 20/20. Of the patients, 71% (n = 22) experienced loss of consciousness; 68% (n = 15) of patients in this subgroup were dismounted during the blast injury. Overall, 68% (n = 21) of patients had visual complaints. The most common complaints were photophobia (55%) and difficulty with reading (32%). Of all patients, 25% were diagnosed with convergence insufficiency and 23% had accommodative insufficiency. Patients with more than one mbTBI had a higher rate of visual complaints (87.5%). Asymptomatic patients had a significantly longer time (62.5 +/- 6.2 mo) since the mbTBI than symptomatic patients (42.0 +/- 16.4 mo, p < 0.004). Long-term visual dysfunction after mbTBI is common even years after injury despite excellent distance visual acuity and is more frequent if more than one incidence of mbTBI occurred. We recommend obtaining a careful medical history, evaluation of symptoms, and binocular vision assessment during routine eye examinations in this prepresbyopic patient population.

Neurologically-related sequelae associated with mild traumatic brain injury

OBJECTIVE

Mild traumatic brain injury (mTBI) accounts for more than 75% of traumatic brain injuries every year. This study examines the temporal association between non-blast mTBI and the onset of neurologic sequelae to illuminate risks of post-concussive syndrome, epilepsy and chronic pain.

METHODS

A large historical prospective study was conducted utilizing electronically-recorded demographic, medical and military-specific data for over half a million active duty US Air Force Airmen. This study utilized diagnostic codes to identify mTBI exposures, two control groups and three post-mTBI time periods. Adjusted hazard ratios (HRs) were calculated using Cox proportional hazards modelling.

RESULTS

HRs were higher when mTBI exposed Airmen were compared with the full cohort and lower when compared with the other injured group. When compared to the other injured group, mTBI was positively associated with epilepsy/recurrent seizure outcomes, post-concussive syndrome and pain disorders. HRs tended to be highest within the first 30 days and decreased over time.

CONCLUSIONS

Findings support that mTBI may have a prolonged neurological impact. Findings are also likely generalizable to young adult populations with exposure to non-blast related mTBI, including civilians, as those included in this study were young adults with a high prevalence of recreational/sports and motor vehicle injuries.

Delayed neurological deterioration after mild head injury: cause, temporal course, and outcomes

BACKGROUND

Mild head injury (MHI) complicated by an intracranial hemorrhage (ICH) is a common cause of hospital admission after head trauma. Most patients are treated nonoperatively, remain neurologically stable, and are discharged uneventfully. However, a small percentage of patients suffer delayed neurological deterioration (DND). Little is known about the characteristics of DND after an MHI complicated by ICH.

OBJECTIVE

To identify the cause, temporal course, and outcomes of patients who deteriorated neurologically after presenting with MHI and ICH.

METHODS

A retrospective review was performed of all adult patients presenting over 54 consecutive months with MHI and ICH. Patients who were treated nonoperatively after initial head computed tomography and had a subsequent DND (Glasgow Coma Scale score decrease ≥2) were identified. Demographics, neurological status, clinical course, radiographic findings, and outcome data were collected.

RESULTS

Over 54 months, 757 patients with MHI plus ICH were admitted for observation; of these, 31 (4.1%) experienced DND. Eighty-seven percent of patients deteriorated within 24 hours after admission. Twenty-one patients (68%) deteriorated as a result of progressive intracranial hemorrhage, and 10 patients (32%) deteriorated as a result of medical causes. Seven patients (23%) died. Variables significantly associated with mortality included age > 60 years, coagulopathy, and change in Marshall computed tomography classification.

CONCLUSION

The incidence of delayed neurological deterioration after MHI with ICH is low and usually occurs within 24 hours after admission. It results in significant morbidity and mortality if it is the result of progressive intracranial hemorrhage. Further research is needed to identify risk factors that can allow early detection and improve outcomes in these patients.

Physical and psychological long-term outcome after traumatic brain injury in children and adult patients

Background

Several studies have indicated that younger age is associated with worse recovery after pediatric traumatic brain injury (TBI) compared to elder children. In order to verify this association between long-term outcome after moderate to severe TBI and patient’s age, direct comparison between different pediatric age groups as well as an adult population was performed.

Methods

This investigation represents a retrospective cohort study at a level I trauma center including patients with moderate to severe, isolated TBI with a minimum follow-up of 10 years. According to their age at time of injury, patients were divided in pre-school (0–7 years), school (8–17 years) and adult (18–65 years) patients. Physical examination and standardized questionnaire on physical and psychological aspects (Glasgow Outcome Scale, Barthel Index, Impact of Event Scale, Hospital Anxiety and Depression Scale, short form 12) were performed.

Results

135 traumatized patients were included. Physical and psychological long-term outcome was associated with injury severity but not with patients’ age at time of injury. Outcome recovery measured by Glasgow Outcome Scale was demonstrated with best results for pre-school aged children (p = 0.009). According to the Hospital Anxiety and Depression Scale an increased incidence of anxiety (p = 0.010) and depression (p = 0.026) was evaluated in older patients.

Conclusion

Long-term outcome perceptions after moderate to severe TBI presented in this study question current views of deteriorated recovery for the immature brain. The sustained TBI impact seemed not to reduce the child’s ability to overcome the suffered impairment measured by questionnaire based psychological, physical and health related outcome scores. These results distinguish the relevance of rehabilitation and family support in the long term.

Quality of life in severely injured patients depends on psychosocial factors rather than on severity or type of injury

BACKGROUND

Former studies have demonstrated that health-related quality of life is decreased in severely injured patients. However, in those studies patients were asked about their functioning and not about their (dis)contentment concerning their functioning. Little is known about how severely injured patients experience their quality of life (QOL). The objective of this cross-sectional study was to measure this subjective QOL of severely injured patients after their rehabilitation phase and to examine which accident- and patient-related factors affect the QOL of these patients.

METHODS

Patients of 18 years or older with an injury severity score (ISS) above 15 were included 15-53 months after their accident. Comorbidity before the accident, accident and sociodemographic characteristics, and QOL were obtained from the trauma registry and questionnaires. The WHOQOL-BREF was used to measure QOL. A reference group of the Dutch general population was used for comparison.

RESULTS

The participation rate was 61% (n=173). Compared with the reference data, severely injured patients experienced a significantly worse QOL in all domains except social relations. The QOL scores were significantly decreased in all domains for patients with intracranial injury in combination with other injuries. Patients with a severe intracranial injury (AIS>3) only reported significantly impaired QOL in the general and physical domains. Patients who resumed working or lived with others had significantly higher scores in all domains of QOL than patients who did not work anymore or were living alone. Significantly lower QOL scores were obtained from patients with comorbidity before the accident and from patients with longer durations of intensive care unit (ICU) treatment or hospitalisation. Gender, accident characteristics and time since the accident did not appear to be important for experienced QOL.

CONCLUSIONS

The experience of impaired QOL appears to depend on living alone, inability to return to work and pre-accidental comorbidity rather than on the injured body area or the severity of the injury. Duration of hospital or ICU stay is important to subsequent QOL, even if ISS or body region is not.

Subjective impact of traumatic brain injury on long-term outcome at a minimum of 10 years after trauma- first results of a survey on 368 patients from a single academic trauma center in Germany

Background

Traumatic Brain Injury (TBI) may lead to significant impairments in personal, social and professional life. However, knowledge of the influence on long-term outcome after TBI is sparse. We therefore aimed to investigate the subjective effects of TBI on long-term outcome at a minimum of 10 years after trauma in one of the largest study populations in Germany.

Methods

The current investigation represents a retrospective cohort study at a level I trauma center including physical examination or standardized questionnaires of patients with mild, moderate or severe isolated TBI with a minimum follow-up of 10 years. We investigated the subjective physical, psychological and social outcome evaluating the Glasgow Outcome Scale, short-form 12, and social as well as vocational living circumstances.

Results

368 patients aged 0 to 88 years were included. Patients with severe TBI were younger compared to patients with moderate or mild TBI (p < 0.05). Patients with severe TBI lived more often as single after the trauma impact. A significantly worse outcome was associated with higher severity of TBI resulting in an increased incidence of mental disability. A professional decline was analyzed in case of severe TBI resulting in significant loss of salary.

Conclusions

The severity of TBI significantly influenced the subjective social and living conditions. Subjective mental and physical outcome as well as professional life depended on the severity of TBI 10 years after the injury.

Does additional head trauma affect the long-term outcome after upper extremity trauma in multiple traumatized patients: is there an additional effect of traumatic brain injury?

BACKGROUND

Musculoskeletal injuries are common in patients with multiple trauma resulting in pain, functional deficits, and disability. Traumatic brain injuries (TBIs) are common in severely injured patients potentially resulting in neurological impairment and permanent disability that would add to that from the musculoskeletal injuries. However, it is unclear to what degree the combination affects impairment.

QUESTIONS/PURPOSES

We therefore asked whether added upper extremity injuries or TBI worsened the functional, psychological, and vocational status in multiple trauma patients.

METHODS

We retrospectively reviewed 281 patients with multiple trauma: 229 with upper extremity injuries but without TBI (Group I), 32 with concomitant upper extremity injuries and TBI (Group II), and 20 with TBI but no upper extremity injuries (Group III). We assessed patients with the Glasgow Outcome Score (GOS), Hannover Score for Polytrauma Outcome, SF-12 (Physical Component Summary Score and Mental Component Summary Score), medical aid requirements, need of psychological support, and vocational living circumstances. The minimum followup was 10 years (median, 17.5 years; range, 10-28 years).

RESULTS

Additional TBI in multiple trauma patients led to reduced function (GOS: Group I: 4.9 ± 0.2, Group II: 4.5 ± 0.7, Group III: 4.5 ± 0.8) resulting in vocational restrictions (job change: Group I: 74%, Group II: 91%, Group III: 90%). The combination of upper extremity and TBIs did not result in worse long-term scores compared with TBI alone.

CONCLUSIONS

Rehabilitation and social reintegration in multiple trauma patients with TBI requires particular emphasis to minimize disability and vocational isolation. Musculoskeletal injuries should not be neglected to ensure the maximum extremity function given the impaired cognitive functions after TBI.

What is the incidence of intracranial bleeding in patients with mild traumatic brain injury? A retrospective study in 3088 Canadian CT head rule patients

Objective. Only limited data exists in terms of the incidence of intracranial bleeding (ICB) in patients with mild traumatic brain injury (MTBI). Methods. We retrospectively identified 3088 patients (mean age 41 range (7–99) years) presenting with isolated MTBI and GCS 14-15 at our Emergency Department who had undergone cranial CT (CCT) between 2002 and 2011. Indication for CCT was according to the “Canadian CT head rules.” Patients with ICB were either submitted for neurosurgical treatment or kept under surveillance for at least 24 hours. Pearson's correlation coefficient was used to correlate the incidence of ICB with age, gender, or intake of coumarins, platelet aggregation inhibitors, or heparins. Results. 149 patients (4.8%) had ICB on CCT. No patient with ICB died or deteriorated neurologically. The incidence of ICB increased with age and intake of anticoagulants without clinically relevant correlation (R = 0.11; P < 0.001; R = −0.06; P < 0.001). Conclusion. Our data show an incidence of 4.8% for ICB after MTBI. However, neurological deterioration after MTBI seems to be rare, and the need for neurosurgical intervention is only required in selected cases. The general need for CCT in patients after MTBI is therefore questionable, and clinical surveillance may be sufficient when CCT is not available.

Managing behavioral health needs of veterans with traumatic brain injury (TBI) in primary care

Traumatic brain injury (TBI) is a frequent occurrence in the United States, and has been given particular attention in the veteran population. Recent accounts have estimated TBI incidence rates as high as 20 % among US veterans who served in Afghanistan or Iraq, and many of these veterans experience a host of co-morbid concerns, including psychiatric complaints (such as depression and post-traumatic stress disorder), sleep disturbance, and substance abuse which may warrant referral to behavioral health specialists working in primary care settings. This paper reviews many common behavioral health concerns co-morbid with TBI, and suggests areas in which behavioral health specialists may assess, intervene, and help to facilitate holistic patient care beyond the acute phase of injury. The primary focus is on sequelae common to mild and moderate TBI which may more readily present in primary care clinics.

Magnetic resonance imaging improves 3-month outcome prediction in mild traumatic brain injury

OBJECTIVE

To determine the clinical relevance, if any, of traumatic intracranial findings on early head computed tomography (CT) and brain magnetic resonance imaging (MRI) to 3-month outcome in mild traumatic brain injury (MTBI).

METHODS

One hundred thirty-five MTBI patients evaluated for acute head injury in emergency departments of 3 LEVEL I trauma centers were enrolled prospectively. In addition to admission head CT, early brain MRI was performed 12 ± 3.9 days after injury. Univariate and multivariate logistic regression were used to assess for demographic, clinical, socioeconomic, CT, and MRI features that were predictive of Extended Glasgow Outcome Scale (GOS-E) at 3 months postinjury.

RESULTS

Twenty-seven percent of MTBI patients with normal admission head CT had abnormal early brain MRI. CT evidence of subarachnoid hemorrhage was associated with a multivariate odds ratio of 3.5 (p = 0.01) for poorer 3-month outcome, after adjusting for demographic, clinical, and socioeconomic factors. One or more brain contusions on MRI, and ≥4 foci of hemorrhagic axonal injury on MRI, were each independently associated with poorer 3-month outcome, with multivariate odds ratios of 4.5 (p = 0.01) and 3.2 (p = 0.03), respectively, after adjusting for head CT findings and demographic, clinical, and socioeconomic factors.

INTERPRETATION

In this prospective multicenter observational study, the clinical relevance of abnormal findings on early brain imaging after MTBI is demonstrated. The addition of early CT and MRI markers to a prognostic model based on previously known demographic, clinical, and socioeconomic predictors resulted in a >2-fold increase in the explained variance in 3-month GOS-E.

Improving outcomes in the early phases after major trauma

PURPOSE OF REVIEW

The scope of this review is to describe what is known about injury outcomes and the principles by which they can be improved by acute phase interventions. Assessing which outcomes matter to trauma patients is important both for the evaluation of existing and novel acute interventions and to assess the delivery of care within trauma systems' performance improvement frameworks.

RECENT FINDINGS

Trauma care is moving away from the straightforward assessment of simple endpoints such as mortality or amputation. These have limited applicability and may not truly demonstrate the effectiveness of some acute interventions. Other intermediate or long-term measures are more patient-centred but are harder to measure, collect and interpret. Acute interventions improve outcomes through a combination of early definitive care concurrent with techniques to maintain homeostasis and preserve cells and tissues. These interventions need to be delivered within a regional systems framework. Trauma systems improve outcomes by reducing randomness and error from trauma care pathways.

SUMMARY

Improving outcomes in the acute phase of trauma care requires the timely delivery of complex interventions with an organized trauma system. Research is needed both in developing novel interventions and in developing and validating patient-centred and surrogate outcome tools.

Incidence of traumatic brain injury across the full disease spectrum: a population-based medical record review study

BACKGROUND

Extremely few objective estimates of traumatic brain injury incidence include all ages, both sexes, all injury mechanisms, and the full spectrum from very mild to fatal events.

METHODS

We used unique Rochester Epidemiology Project medical records-linkage resources, including highly sensitive and specific diagnostic coding, to identify all Olmsted County, MN, residents with diagnoses suggestive of traumatic brain injury regardless of age, setting, insurance, or injury mechanism. Provider-linked medical records for a 16% random sample were reviewed for confirmation as definite, probable, possible (symptomatic), or no traumatic brain injury. We estimated incidence per 100,000 person-years for 1987-2000 and compared these record-review rates with rates obtained using Centers for Disease Control and Prevention (CDC) data-systems approach. For the latter, we identified all Olmsted County residents with any CDC-specified diagnosis codes recorded on hospital/emergency department administrative claims or death certificates during 1987-2000.

RESULTS

Of sampled individuals, 1257 met record-review criteria for incident traumatic brain injury; 56% were ages 16-64 years, 56% were male, and 53% were symptomatic. Mechanism, sex, and diagnostic certainty differed by age. The incidence rate per 100,000 person-years was 558 (95% confidence interval = 528-590) versus 341 (331-350) using the CDC data-system approach. The CDC approach captured only 40% of record-review cases. Seventy-four percent of missing cases presented to the hospital/emergency department; none had CDC-specified codes assigned on hospital/emergency department administrative claims or death certificates; and 66% were symptomatic.

CONCLUSIONS

Capture of symptomatic traumatic brain injuries requires a wider range of diagnosis codes, plus sampling strategies to avoid high rates of false-positive events.