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Nishat E, Scratch SE, Ameis SH, Wheeler AL. Disrupted Maturation of White Matter Microstructure After Concussion Is Associated With Internalizing Behavior Scores in Female Children. Biol Psychiatry 2024:S0006-3223(24)00031-3. [PMID: 38237797 DOI: 10.1016/j.biopsych.2024.01.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/13/2023] [Revised: 12/08/2023] [Accepted: 01/08/2024] [Indexed: 03/09/2024]
Abstract
BACKGROUND Some children who experience concussions, particularly females, develop long-lasting emotional and behavioral problems. Establishing the potential contribution of preexisting behavioral problems and disrupted white matter maturation has been challenging due to a lack of preinjury data. METHODS From the Adolescent Brain Cognitive Development cohort, 239 (90 female) children age 12.1 ± 0.6 years who experienced a concussion after study entry at 10.0 ± 0.6 years were compared to 6438 (3245 female) children without head injuries who were age 9.9 ± 0.6 years at baseline and 12.0 ± 0.6 years at follow-up. The Child Behavior Checklist was used to assess internalizing and externalizing behavior at study entry and follow-up. In the children with magnetic resonance imaging data available (concussion n = 134, comparison n = 3520), deep and superficial white matter was characterized by neurite density from restriction spectrum image modeling of diffusion magnetic resonance imaging. Longitudinal ComBat harmonization removed scanner effects. Linear regressions modeled 1) behavior problems at follow-up controlling for baseline behavior, 2) impact of concussion on white matter maturation, and 3) contribution of deviations in white matter maturation to postconcussion behavior problems. RESULTS Only female children with concussion had higher internalizing behavior problem scores. The youngest children with concussion showed less change in superficial white matter neurite density over 2 years than children with no concussion. In females with concussion, less change in superficial white matter neurite density was correlated with increased internalizing behavior problem scores. CONCLUSIONS Concussions in female children are associated with emotional problems beyond preinjury levels. Injury to superficial white matter may contribute to persistent internalizing behavior problems in females.
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Affiliation(s)
- Eman Nishat
- Department of Physiology, Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada; Neurosciences and Mental Health, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Shannon E Scratch
- Department of Paediatrics, Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada; Rehabilitation Sciences Institute, Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada; Bloorview Research Institute, Holland Bloorview Kids Rehabilitation Hospital, Toronto, Ontario, Canada
| | - Stephanie H Ameis
- Department of Psychiatry, Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada; Cundill Centre for Child and Youth Depression, Margaret and Wallace McCain Centre for Child, Youth and Family Mental Health, Campbell Family Mental Health Research Institute, Centre for Addiction and Mental Health, Toronto, Ontario, Canada
| | - Anne L Wheeler
- Department of Physiology, Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada; Neurosciences and Mental Health, The Hospital for Sick Children, Toronto, Ontario, Canada.
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Miller SM, Valovich McLeod TC, Zaslow TL, Wilson JC, Master CL, Snedden TR, Halstead ME, Grady MF, Fazekas ML, Santana JA, Coel RA, Howell DR. Utility of a Clinical Prediction Tool for Persisting Postconcussive Symptoms in a Multicenter Sample of Youth Athletes With Concussion: The Sport Concussion Outcomes in Pediatrics (SCOPE) Study. Am J Sports Med 2023; 51:3546-3553. [PMID: 37794642 DOI: 10.1177/03635465231201610] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/06/2023]
Abstract
BACKGROUND A validated clinical risk tool has been developed to identify pediatric and adolescent patients at risk of developing persisting symptoms after concussion, but has not been prospectively investigated within a sample of athletes seen after concussion by primary care sports medicine physicians and/or athletic trainers. PURPOSE To determine whether a validated clinical risk prediction tool for persistent postconcussive symptoms (PPCSs) predicted which patients would develop PPCSs when obtained within 14 days of concussion among a multicenter sample of adolescent athletes. STUDY DESIGN Cohort study; Level of evidence, 2. METHODS Pediatric and adolescent patients (8-18 years of age) from 7 pediatric medical centers and 6 secondary school athletic training facilities who were diagnosed with a concussion and presented ≤14 days after concussion were enrolled as part of the Sport Concussion Outcomes in Pediatrics (SCOPE) study during their initial visit and were followed until symptom resolution. Clinical risk scores (Predicting and Preventing Post-concussive Problems in Pediatrics [5P]) and total symptom severity were obtained using the Post-Concussion Symptom Inventory at the initial visit (mean, 4.9 ± 2.9 days after concussion). Participants were then compared based on symptom resolution time: PPCS group (≥28 days to symptom resolution) and no-PPCS group (<28 days). The authors assessed the odds of developing PPCSs based on the 5P risk score using a binary logistic regression model and the utility of the clinical risk prediction tool to identify total time to symptom resolution using a Cox proportional hazards model. RESULTS A total of 184 participants enrolled, underwent initial evaluation, and were followed until symptom resolution (mean age, 15.2 ± 2.1 years; 35% female). The mean time to symptom resolution across the entire sample was 17.6 ± 3.7 days; 16% (n = 30) of participants developed PPCS. Those in the PPCS group had significantly greater mean initial total 5P risk scores than those in the no-PPCS group (7.9 ± 1.7 vs 5.9 ± 2.3, respectively; P < .001). After adjustment for initial symptom severity, time to assessment, and assessment setting, a higher initial total 5P risk score was associated with a significantly greater odds of developing PPCSs (adjusted odds ratio, 1.49; 95% CI, 1.07-2.08; P = .019). Furthermore, a higher 5P risk score was significantly associated with longer total symptom resolution time (hazard ratio, 0.80; 95% CI, 0.74-0.88; P < .001). CONCLUSION In a multicenter sample of youth athletes seen in different outpatient health care settings, the 5P risk score accurately predicted which athletes may be at risk for developing PPCSs.
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Affiliation(s)
- Shane M Miller
- Scottish Rite for Children and UT Southwestern Medical Center, Dallas, Texas, USA
| | | | - Tracy L Zaslow
- Cedars Sinai Kerlan Jobe Institute, Los Angeles, California, USA
| | - Julie C Wilson
- Children's Hospital Colorado and University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Christina L Master
- Children's Hospital of Philadelphia and Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Traci R Snedden
- University of Wisconsin-Madison School of Nursing, Madison, Wisconsin, USA
| | - Mark E Halstead
- St Louis Children's Hospital and Washington University School of Medicine, St Louis, Missouri, USA
| | - Matthew F Grady
- Children's Hospital of Philadelphia and Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | | | - Jonathan A Santana
- Children's Hospital Los Angeles and Keck School of Medicine of USC, Los Angeles, California, USA
| | - Rachel A Coel
- Kapi'olani Medical Center for Women and Children, University of Hawai'i John A. Burns School of Medicine, Honolulu, Hawaii, USA
| | - David R Howell
- Children's Hospital Colorado and University of Colorado School of Medicine, Aurora, Colorado, USA
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Cook NE, Kissinger-Knox A, Iverson IA, Liu BC, Gaudet CE, Norman MA, Iverson GL. Social Determinants of Health and Health Equity in the Diagnosis and Management of Pediatric Mild Traumatic Brain Injury: A Content Analysis of Research Underlying Clinical Guidelines. J Neurotrauma 2023; 40:1977-1989. [PMID: 37071186 PMCID: PMC10541940 DOI: 10.1089/neu.2023.0021] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/19/2023] Open
Abstract
We conducted a content analysis of the literature underlying the Centers for Disease Control and Prevention (CDC) Guideline on the Diagnosis and Management of Mild Traumatic Brain Injury Among Children (i.e., the "Guideline") to determine the extent to which social determinants of health (SDoH) were examined or addressed. The systematic review forming the basis for the Guideline included 37 studies addressing diagnosis, prognosis, and treatment/rehabilitation. We examined those studies to identify SDoH domains derived from the U.S. Department of Health and Human Services' Healthy People 2020 and 2030 websites. No study explicitly mentioned "social determinants of health," by name, and few studies addressed SDoH domains as a primary focus (ranging from 0% to 27% of studies across SDoH domains). The most frequently represented SDoH domains, described in an inferential or a descriptive manner, were Education Access and Quality (29.7% of studies), Social and Community Context (27.0% of studies), and Economic Stability (21.6% of studies). Health Care Access (13.5% of studies) was less well represented and no studies (0%) examined Neighborhood and Built Environment. In terms of the CDC clinical questions, SDoH were only examined as predictors of outcome (prognosis) and no studies examined SDoH in relation to diagnosis or treatment/rehabilitation. The Guideline includes some commentary on health literacy and socioeconomic status. Overall, social determinants of health are largely unrepresented as important or meaningful variables influencing the Guideline on the Diagnosis and Management of Mild Traumatic Brain Injury Among Children, or in the studies that informed the Guideline.
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Affiliation(s)
- Nathan E. Cook
- Department of Physical Medicine and Rehabilitation, Harvard Medical School, Boston, Massachusetts, USA
- MassGeneral Hospital for Children Sports Concussion Program, Waltham, Massachusetts, USA
- Department of Physical Medicine and Rehabilitation, Spaulding Rehabilitation Hospital, Charlestown, Massachusetts, USA
| | - Alicia Kissinger-Knox
- Department of Physical Medicine and Rehabilitation, Harvard Medical School, Boston, Massachusetts, USA
- Department of Physical Medicine and Rehabilitation, Spaulding Rehabilitation Hospital, Charlestown, Massachusetts, USA
| | - Ila A. Iverson
- Department of Psychology, University of British Columbia, Vancouver, British Columbia, Canada
| | - Brian C. Liu
- MassGeneral Hospital for Children Sports Concussion Program, Waltham, Massachusetts, USA
- Department of Physical Medicine and Rehabilitation, Spaulding Rehabilitation Hospital, Charlestown, Massachusetts, USA
| | - Charles E. Gaudet
- Department of Physical Medicine and Rehabilitation, Harvard Medical School, Boston, Massachusetts, USA
- MassGeneral Hospital for Children Sports Concussion Program, Waltham, Massachusetts, USA
- Department of Physical Medicine and Rehabilitation, Spaulding Rehabilitation Hospital, Charlestown, Massachusetts, USA
| | - Marc A. Norman
- Department of Psychiatry, UC San Diego School of Medicine, San Diego, California, USA
| | - Grant L. Iverson
- Department of Physical Medicine and Rehabilitation, Harvard Medical School, Boston, Massachusetts, USA
- MassGeneral Hospital for Children Sports Concussion Program, Waltham, Massachusetts, USA
- Department of Physical Medicine and Rehabilitation, Spaulding Rehabilitation Hospital, Charlestown, Massachusetts, USA
- Department of Physical Medicine and Rehabilitation, Shoen Adams Research Institute at Spaulding Rehabilitation, Charlestown, Massachusetts, USA
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Aderman MJ, Brett BL, Ross JD, Malvasi SR, McGinty G, Jackson JC, Estevez CA, Brodeur RM, Svoboda SJ, McCrea MA, Broglio SP, McAllister TW, Pasquina PF, Cameron KL, Roach MH. Association Between Symptom Cluster Endorsement at Initiation of a Graduated Return-to-Activity Protocol and Time to Return to Unrestricted Activity After Concussion in United States Service Academy Cadets. Am J Sports Med 2023; 51:2996-3007. [PMID: 37551673 DOI: 10.1177/03635465231189211] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/09/2023]
Abstract
BACKGROUND The endorsement of symptoms upon initiation of a graduated return-to-activity (GRTA) protocol has been associated with prolonged protocols. It is unclear whether there are specific symptom clusters affecting protocol durations. PURPOSE To describe the endorsement of specific concussion symptom clusters at GRTA protocol initiation and examine the association between symptom cluster endorsement and GRTA protocol duration. STUDY DESIGN Cohort study; Level of evidence, 2. METHODS This study was conducted among cadets enrolled at 3 US service academies. Participants completed an evaluation upon GRTA protocol initiation. Participants endorsing symptoms were binarized based on 6 symptom clusters (cognitive, emotional, insomnia, physical, sensitivity, and ungrouped). The primary outcome of interest was GRTA protocol duration based on symptom cluster endorsement severity. Prevalence rates were calculated to describe symptom cluster endorsement. Kaplan-Meier survival estimates and univariate and multivariable Cox proportional hazards regression models were calculated for all 6 symptom clusters to estimate GRTA protocol duration while controlling for significant covariates. RESULTS Data from 961 concussed participants were analyzed. Of these, 636 participants were asymptomatic upon GRTA protocol initiation. Among the 325 symptomatic participants, the physical symptom cluster (80%) was most endorsed, followed by the cognitive (29%), insomnia (23%), ungrouped (19%), sensitivity (15%), and emotional (9%) clusters. Univariate results revealed a significant association between endorsing cognitive (hazard ratio [HR], 0.79; p = .001), physical (HR, 0.84; p < .001), insomnia (HR, 0.83; p = .013), sensitivity (HR, 0.70; p < .001), and ungrouped (HR, 0.75; p = .005) symptom clusters and GRTA protocol duration. Endorsing physical (HR, 0.84; p < .001) and sensitivity (HR, 0.81; p = .036) clusters maintained a significant association with GRTA protocol duration in the multivariable models. CONCLUSION Participants endorsing physical or sensitivity symptom clusters displayed GRTA protocols prolonged by 16% to 19% compared with participants not endorsing that respective cluster after controlling for significant covariates.
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Affiliation(s)
- Michael J Aderman
- Keller Army Hospital, West Point, New York, USA
- Investigation performed at Keller Army Hospital, West Point, New York, USA
| | - Benjamin L Brett
- Medical College of Wisconsin, Milwaukee, Wisconsin, USA
- Investigation performed at Keller Army Hospital, West Point, New York, USA
| | - Jeremy D Ross
- Investigation performed at Keller Army Hospital, West Point, New York, USA
| | - Steven R Malvasi
- Keller Army Hospital, West Point, New York, USA
- Investigation performed at Keller Army Hospital, West Point, New York, USA
| | - Gerald McGinty
- Investigation performed at Keller Army Hospital, West Point, New York, USA
| | - Jonathan C Jackson
- United States Air Force Academy, Colorado Springs, Colorado, USA
- Investigation performed at Keller Army Hospital, West Point, New York, USA
| | - Carlos A Estevez
- Investigation performed at Keller Army Hospital, West Point, New York, USA
| | - Rachel M Brodeur
- United States Coast Guard Academy, New London, Connecticut, USA
- Investigation performed at Keller Army Hospital, West Point, New York, USA
| | - Steven J Svoboda
- MedStar Health, Washington, DC, USA
- Investigation performed at Keller Army Hospital, West Point, New York, USA
| | - Michael A McCrea
- Medical College of Wisconsin, Milwaukee, Wisconsin, USA
- Investigation performed at Keller Army Hospital, West Point, New York, USA
| | - Steven P Broglio
- University of Michigan Concussion Center, Ann Arbor, Michigan, USA
- Investigation performed at Keller Army Hospital, West Point, New York, USA
| | - Thomas W McAllister
- Indiana University School of Medicine, Indianapolis, Indiana, USA
- Investigation performed at Keller Army Hospital, West Point, New York, USA
| | - Paul F Pasquina
- Walter Reed National Military Medical Center, Bethesda, Maryland, USA
- Investigation performed at Keller Army Hospital, West Point, New York, USA
| | - Kenneth L Cameron
- Keller Army Hospital, West Point, New York, USA
- Investigation performed at Keller Army Hospital, West Point, New York, USA
| | - Megan H Roach
- Extremity Trauma and Amputation Center of Excellence, Defense Health Agency, Falls Church, Virginia, USA; Department of Clinical Investigations, Womack Army Medical Center, Fort Liberty, North Carolina, USA
- Investigation performed at Keller Army Hospital, West Point, New York, USA
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5
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Ijaz S, Scott L, Dawson S, Wilson R, Jackson J, Birnie K, Redaniel MT, Savović J, Wright I, Lyttle MD, Mytton J. Factors related to adverse long-term outcomes after mild traumatic brain injury in children: a scoping review. Arch Dis Child 2023; 108:492-497. [PMID: 37001968 DOI: 10.1136/archdischild-2022-325202] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/04/2022] [Accepted: 03/16/2023] [Indexed: 05/20/2023]
Abstract
OBJECTIVE To identify demographic, premorbid and injury-related factors, or biomarkers associated with long-term (≥3 months) adverse outcomes in children after mild traumatic brain injury (mTBI). DESIGN Scoping review of literature. PATIENTS Children and adolescents with mTBI. RISK FACTORS Any demographic, premorbid and injury-related factors, or biomarkers were included. We excluded genetic and treatment-related factors. MAIN OUTCOME MEASURES Postconcussion syndrome (PCS), recovery. RESULTS Seventy-three publications were included, reporting 12 long-term adverse outcomes, including PCS in 12 studies and recovery in 29 studies. Additional outcomes studied were symptom scores/severity (n=22), quality of life (n=9) and cognitive function (n=9). Forty-nine risk factors were identified across studies. Risk factors most often assessed were sex (n=28), followed by age (n=23), injury mechanism = (n=22) and prior mTBI (n=18). The influence of these and other risk factors on outcomes of mTBI were inconsistent across the reviewed literature. CONCLUSIONS The most researched risk factors are sex, age and mechanism of injury, but their effects have been estimated inconsistently and did not show a clear pattern. The most studied outcomes are recovery patterns and symptom severity. However, these may not be the most important outcomes for clinicians and patients. Future primary studies in this area should focus on patient-important outcomes. Population-based prospective studies are needed that address prespecified hypotheses on the relationship of risk factors with given outcomes to enable reliable prediction of long-term adverse outcomes for childhood mTBI.
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Affiliation(s)
- Sharea Ijaz
- NIHR ARC West, Population Health Sciences, University of Bristol, Bristol, UK
| | - Lauren Scott
- NIHR ARC West, Population Health Sciences, University of Bristol, Bristol, UK
| | - Sarah Dawson
- NIHR ARC West, Population Health Sciences, University of Bristol, Bristol, UK
| | - Rebecca Wilson
- NIHR ARC West, Population Health Sciences, University of Bristol, Bristol, UK
| | - Joni Jackson
- NIHR ARC West, Population Health Sciences, University of Bristol, Bristol, UK
| | - Kate Birnie
- Population Health Sciences, University of Bristol, Bristol, UK
| | | | - Jelena Savović
- NIHR ARC West, Population Health Sciences, University of Bristol, Bristol, UK
| | - Ingram Wright
- School of Psychological Science, University of Bristol, Bristol, UK
| | - Mark D Lyttle
- Emergency Department, Bristol Royal Hospital for Children, Bristol, UK
- Research in Emergency Care Avon Collaborative Hub (REACH), University of the West of England, Bristol, Avon, UK
| | - Julie Mytton
- School of Health and Social Wellbeing, University of the West of England, Bristol, UK
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von Steinbuechel N, Hahm S, Muehlan H, Arango-Lasprilla JC, Bockhop F, Covic A, Schmidt S, Steyerberg EW, Maas AIR, Menon D, Andelic N, Zeldovich M. Impact of Sociodemographic, Premorbid, and Injury-Related Factors on Patient-Reported Outcome Trajectories after Traumatic Brain Injury (TBI). J Clin Med 2023; 12:jcm12062246. [PMID: 36983247 PMCID: PMC10052290 DOI: 10.3390/jcm12062246] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2023] [Revised: 03/08/2023] [Accepted: 03/11/2023] [Indexed: 03/15/2023] Open
Abstract
Traumatic brain injury (TBI) remains one of the leading causes of death and disability worldwide. To better understand its impact on various outcome domains, this study pursues the following: (1) longitudinal outcome assessments at three, six, and twelve months post-injury; (2) an evaluation of sociodemographic, premorbid, and injury-related factors, and functional recovery contributing to worsening or improving outcomes after TBI. Using patient-reported outcome measures, recuperation trends after TBI were identified by applying Multivariate Latent Class Mixed Models (MLCMM). Instruments were grouped into TBI-specific and generic health-related quality of life (HRQoL; QOLIBRI-OS, SF-12v2), and psychological and post-concussion symptoms (GAD-7, PHQ-9, PCL-5, RPQ). Multinomial logistic regressions were carried out to identify contributing factors. For both outcome sets, the four-class solution provided the best match between goodness of fit indices and meaningful clinical interpretability. Both models revealed similar trajectory classes: stable good health status (HRQoL: n = 1944; symptoms: n = 1963), persistent health impairments (HRQoL: n = 442; symptoms: n = 179), improving health status (HRQoL: n = 83; symptoms: n = 243), and deteriorating health status (HRQoL: n = 86; symptoms: n = 170). Compared to individuals with stable good health status, the other groups were more likely to have a lower functional recovery status at three months after TBI (i.e., the GOSE), psychological problems, and a lower educational attainment. Outcome trajectories after TBI show clearly distinguishable patterns which are reproducible across different measures. Individuals characterized by persistent health impairments and deterioration require special attention and long-term clinical monitoring and therapy.
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Affiliation(s)
- Nicole von Steinbuechel
- Institute of Medical Psychology and Medical Sociology, University Medical Center Goettingen, Waldweg 37A, 37073 Goettingen, Germany
- Correspondence:
| | - Stefanie Hahm
- Department Health & Prevention, Institute of Psychology, University of Greifswald, Robert-Blum-Str. 13, 17489 Greifswald, Germany
| | - Holger Muehlan
- Department Health & Prevention, Institute of Psychology, University of Greifswald, Robert-Blum-Str. 13, 17489 Greifswald, Germany
| | - Juan Carlos Arango-Lasprilla
- Departments of Psychology and Physical Medicine and Rehabilitation, Virginia Commonwealth University, 907 Floyd Ave., Richmond, VA 23284, USA
| | - Fabian Bockhop
- Institute of Medical Psychology and Medical Sociology, University Medical Center Goettingen, Waldweg 37A, 37073 Goettingen, Germany
| | - Amra Covic
- Institute of Medical Psychology and Medical Sociology, University Medical Center Goettingen, Waldweg 37A, 37073 Goettingen, Germany
| | - Silke Schmidt
- Department Health & Prevention, Institute of Psychology, University of Greifswald, Robert-Blum-Str. 13, 17489 Greifswald, Germany
| | - Ewout W. Steyerberg
- Department of Biomedical Data Sciences, Leiden University Medical Center, 2333 RC Leiden, The Netherlands
| | - Andrew I. R. Maas
- Department of Neurosurgery, Antwerp University Hospital and University of Antwerp, 2650 Edegem, Belgium
| | - David Menon
- Division of Anaesthesia, University of Cambridge/Addenbrooke’s Hospital, Box 157, Cambridge CB2 0QQ, UK
| | - Nada Andelic
- Department of Physical Medicine and Rehabilitation, Oslo University Hospital, 0450 Oslo, Norway
- Institute of Health and Society, Research Centre for Habilitation and Rehabilitation Models, Faculty of Medicine, Univeristy of Oslo, 0373 Oslo, Norway
| | - Marina Zeldovich
- Institute of Medical Psychology and Medical Sociology, University Medical Center Goettingen, Waldweg 37A, 37073 Goettingen, Germany
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Thamjamrassri T, Watanitanon A, Moore A, Chesnut RM, Vavilala MS, Lele AV. A Pilot Prospective Observational Study of Cerebral Autoregulation and 12-Month Outcomes in Children With Complex Mild Traumatic Brain Injury: The Argument for Sufficiency Conditions Affecting TBI Outcomes. J Neurosurg Anesthesiol 2022; 34:384-391. [PMID: 34009858 PMCID: PMC8563492 DOI: 10.1097/ana.0000000000000775] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2021] [Accepted: 03/25/2021] [Indexed: 11/25/2022]
Abstract
BACKGROUND The relationship between cerebral autoregulation and outcomes in pediatric complex mild traumatic brain injury (TBI) is unknown, and explored in this study. METHODS We conducted a prospective observational study of patients aged 0 to 18 years hospitalized with complex mild TBI (admission Glasgow Coma Scale score 13 to 15 with either abnormal computerized tomogram of the head or history of loss of consciousness). Cerebral autoregulation was tested using transcranial Doppler ultrasonography, and impaired autoregulation defined as autoregulation index<0.4. We collected Glasgow Outcome Scale Extended-Pediatrics score and health-related quality of life data at 3, 6, and 12 months after discharge. RESULTS Twenty-four patients aged 1.8 to 16.6 years (58.3% male) with complete 12-month outcome data were included in the analysis. Median admission Glasgow Coma Scale score was 15 (range: 13 to 15), median injury severity score was 12 (range: 4 to 29) and 23 patients (96%) had isolated TBI. Overall, 10 (41.7%) patients had impaired cerebral autoregulation. Complete recovery was observed in 6 of 21 (28.6%) children at 3 months, in 4 of 16 (25%) children at 6 months, and in 8 of 24 (33.3%) children at 12 months. There was no difference in median (interquartile range) Glasgow Outcome Scale Extended-Pediatrics score (2 [2.3] vs. 2 [interquartile range 1.3]) or health-related quality of life scores (91.5 [21.1] vs. 90.8 [21.6]) at 12 months between those with intact and impaired autoregulation, respectively. Age-adjusted hypotension occurred in 2/24 (8.3%) patients. CONCLUSION Two-thirds of children with complex mild TBI experienced incomplete functional recovery at 1 year. The co-occurrence of hypotension and cerebral autoregulation may be a sufficiency condition needed to affect TBI outcomes.
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Affiliation(s)
| | | | - Anne Moore
- Department of Neurological Surgery, University of Washington, Harborview Medical Center
| | - Randall M. Chesnut
- Department of Neurological Surgery, University of Washington, Harborview Medical Center
- Orthopedics and Sport Medicine, Seattle, WA
| | - Monica S. Vavilala
- Harborview Injury Prevention and Research Center
- Department of Anesthesiology and Pain Medicine, University of Washington, Seattle
| | - Abhijit V. Lele
- Harborview Injury Prevention and Research Center
- Department of Anesthesiology and Pain Medicine, University of Washington, Seattle
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8
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Aderman MJ, Brett BL, Malvasi SR, McGinty G, Jackson JC, Svoboda SJ, McCrea M, Broglio SP, McAllister TW, Pasquina PF, Cameron KL, Houston MN. Association Between Symptom Burden at Initiation of a Graduated Return to Activity Protocol and Time to Return to Unrestricted Activity After Concussion in Service Academy Cadets. Am J Sports Med 2022; 50:823-833. [PMID: 35006034 DOI: 10.1177/03635465211067551] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Current consensus and position statements recommend that concussed patients be asymptomatic upon the initiation of the graduated return to activity (RTA) protocol. However, a significant number of concussed patients are beginning their RTA protocols while endorsing symptoms. PURPOSE To characterize symptom endorsement at the beginning of the RTA protocol and examine the association between symptom endorsement and RTA protocol duration in service academy cadets. STUDY DESIGN Cohort study; Level of evidence, 2. METHODS A prospective cohort study was conducted with cadets at 3 US service academies. Postconcussion symptom inventories were recorded upon the initiation of an RTA protocol. The Sport Concussion Assessment Tool Symptom Inventory was used to classify participants into 3 groups (0 symptoms, 1 symptom, and ≥2 symptoms) upon the initiation of the RTA protocol. The primary outcome of interest was RTA protocol duration. Kaplan-Meier survival estimates were calculated to estimate RTA protocol duration by symptom endorsement, sex, varsity status, academic break, and time to graduated RTA initiation. Univariate and multivariable Cox proportional hazards models were used to estimate the association between symptom endorsement at the initiation of the RTA protocol and RTA protocol duration (α < .05). RESULTS Data were analyzed from 966 concussed cadets (36% women). Headache (42%) and faintness/dizziness (44%) were the most commonly endorsed symptoms on the Sport Concussion Assessment Tool-Third Edition and the Brief Symptom Inventory-18, respectively. Univariate results revealed a significant association between endorsing ≥2 symptoms and RTA protocol duration. In the multivariable model, endorsing ≥2 symptoms maintained a statistically significant association with RTA protocol duration. Significant associations were observed between RTA protocol duration and nonvarsity status (27% longer), women (15% longer), academic breaks (70% longer), and time to the initiation of the RTA protocol (1.1% longer daily incremental increase) after controlling for covariates. CONCLUSION Symptom endorsement at the initiation of an RTA protocol was associated with RTA protocol duration. Cadets who had returned to preinjury baseline symptom burden or improved from baseline symptom burden and endorsed ≥2 symptoms at the initiation of the RTA protocol took longer to RTA.
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Affiliation(s)
| | | | | | - Gerald McGinty
- United States Air Force Academy, Colorado Springs, Colorado, USA
| | | | | | | | - Steven P Broglio
- Michigan Concussion Center, University of Michigan, Ann Arbor, Michigan, USA
| | | | - Paul F Pasquina
- Uniformed Services University of the Health Sciences, Bethesda, Maryland, USA
| | - Kenneth L Cameron
- Keller Army Hospital, West Point, New York, USA.,Uniformed Services University of the Health Sciences, Bethesda, Maryland, USA
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9
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Moyron RB, Vallejos PA, Fuller RN, Dean N, Wall NR. Neuroimaging and advanced research techniques may lead to improved outcomes in military members suffering from traumatic brain injury. Trauma Surg Acute Care Open 2021; 6:e000608. [PMID: 33490604 PMCID: PMC7797256 DOI: 10.1136/tsaco-2020-000608] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2020] [Revised: 12/07/2020] [Accepted: 12/22/2020] [Indexed: 12/17/2022] Open
Abstract
Recent military conflicts in Iraq and Afghanistan have resulted in the significant increase in blast-related traumatic brain injury (TBI), leading to increased Department of Defense interest in its potential long-term effects ranging from the mildest head injuries termed subconcussive trauma to the most debilitating termed chronic traumatic encephalopathy (CTE). Most patients with mild TBI will recover quickly while others report persistent symptoms called postconcussive syndrome. Repeated concussive and subconcussive head injuries result in neurodegenerative conditions that may hinder the injured for years. Fundamental questions about the nature of these injuries and recovery remain unanswered. Clinically, patients with CTE present with either affective changes or cognitive impairment. Genetically, there have been no clear risk factors identified. The discovery that microglia of the cerebral cortex discharged small extracellular vesicles in the injured and adjacent regions to a TBI may soon shed light on the immediate impact injury mechanisms. The combination of neuroimaging and advanced research techniques may, one day, fill critical knowledge gaps and lead to significant TBI research and treatment advancements.
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Affiliation(s)
- Ron B Moyron
- Department of Basic Sciences, Loma Linda University, Loma Linda, California, USA
| | - Paul A Vallejos
- Department of Basic Sciences, Loma Linda University, Loma Linda, California, USA
| | - Ryan N Fuller
- Department of Basic Sciences, Loma Linda University, Loma Linda, California, USA
| | - Natasha Dean
- Department of Biology, La Sierra University, Riverside, California, USA
| | - Nathan R Wall
- Department of Basic Sciences, Loma Linda University, Loma Linda, California, USA
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Callahan CE, Moore RD, Kay JJ, Colwell A, Register-Mihalik JK, Vesia M, Broglio SP. Postconcussion Depressive Symptoms and Clinical Assessment Associations in Adolescents. TRANSLATIONAL JOURNAL OF THE AMERICAN COLLEGE OF SPORTS MEDICINE 2021. [DOI: 10.1249/tjx.0000000000000159] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
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Interaction between Age, Sex, and Mental Health Status as Precipitating Factors for Symptom Presentation in Concussed Individuals. JOURNAL OF SPORTS MEDICINE 2020; 2019:9207903. [PMID: 31976333 PMCID: PMC6955124 DOI: 10.1155/2019/9207903] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/21/2019] [Revised: 12/12/2019] [Accepted: 12/13/2019] [Indexed: 11/17/2022]
Abstract
Concussions are among the most common neurological conditions, with emergency departments and sports injury clinics seeing hundreds of patients each year. The consideration of risk factors such as age, sex, and comorbid conditions are very important when looking at individual physiological and psychological outcomes after a concussion. The purpose of this study was to look at four comorbid conditions (depression, anxiety, behavioural disorder, or learning disability) and identify any interactions with age and sex in symptom presentation after suffering a concussion. A total of 4,865 participants from the CCMI (Complete Concussion Management Inc.) dataset were used with 1,577 self-identified with a diagnosis of anxiety, depression, a behavioural disorder, or a learning disability. Fixed-factor analyses of variance were used with age and sex as fixed, grouping factors and symptom total and severity as dependent measures. For the individuals who did not have one of the 4 mental health conditions (3,288 control participants), symptom total and symptom severity increased with age (p < 0.05), and females showed more symptoms and a higher symptom severity than males across all ages (p < 0.05). A diagnosis of anxiety or depression exacerbated total symptoms and symptom severity from 25–50% above control levels in the 19 and under age groups, while depression or anxiety exacerbated total symptoms and severity by 10–15% in males more than females over 20. A diagnosis of a behavioural disorder or a learning disability exacerbated symptom severity by approximately 50% above control levels in 13–19–year-old females and in males of 30 years and older. This study highlights how the presence of a mental health condition may alter concussion symptom presentation dependent on age and sex. The identification of risk factors and how they may interact can be of great value to health care providers who manage concussion symptoms and recovery.
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