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

Critical Care in the Austere Environment

Practice of critical care in austere settings involves navigating rapidly evolving environments, where physical resources, provider availability, and healthcare capacity are constrained. Austere Critical Care focuses on maintaining the highest standard of care possible for patients while also identifying resource limitations, responding to patient surges, and adhering to proper triage practices at the austere site. This includes transferring the patient when able and necessary. This article describes the current practice of critical care medicine in the austere environment, using recent natural disasters, pandemics, and conflicts as case studies.

Level of Evidence of Telehealth Rehabilitation and Behavioral Health Services for Traumatic Brain Injury: A Scoping Review

Traumatic brain injury (TBI) can result in significant impairments in functioning associated with partial or permanent disabilities. Examining the evidence for domain-specific telehealth interventions is necessary to guide the development of effective clinical and research programs for this population. The present scoping review characterizes the level of evidence across a range of TBI-related disabilities and impairments. A literature search was performed across comprehensive databases using search terms related to TBI, rehabilitation, telehealth, and outcome. A total of 19 publications from 17 studies met inclusion criteria. Articles focused on telehealth interventions to improve global, cognitive, emotional, and physical functioning post-TBI. Levels of evidence ranged from 1 to 4 across domains, with predominantly experimental designs (level 1). Outcomes demonstrating improvement or benefit from telehealth treatments were reported across all functional domains (50-80% of studies). Results highlight the potential of telehealth interventions across the span of comprehensive interdisciplinary rehabilitation care. Expanded research is needed on remote treatment options for physical symptoms, for subgroups within TBI populations (i.e., mild TBI, military populations), as well as on remote and hybrid comprehensive rehabilitation programs.

Non-pharmacological interventions for sleep disruptions and fatigue after traumatic brain injury: a scoping review

OBJECTIVE

The aim of this study was to conduct a scoping review to determine the nature, variety, and volume of empirical evidence on nonpharmacological interventions for sleep disturbances with potential implications for fatigue in adults sustaining a traumatic brain injury (TBI).

METHODS

A systematic literature search was conducted across four databases to identify primary studies testing a single non-pharmacological intervention or a combination of non-pharmacological interventions for sleep disturbances and fatigue in community-dwelling adults with TBI.

RESULTS

Sixteen studies were reviewed addressing six non-pharmacological interventions for sleep disruptions and fatigue after TBI including light therapy, cognitive-behavioral therapy, warm footbath application, shiatsu, and sleep hygiene protocol. Non-pharmacological interventions involving light or cognitive-behavioral therapy were reported in 75% of the studies. Actigraphy-based estimation of total sleep time and subjective level of fatigue were frequent outcomes.

CONCLUSION

While this scoping review has utility in describing existing non-pharmacological approaches to manage sleep and fatigue after TBI, the findings suggest that interventions are often developed without considering TBI individuals' source of motivation and the need for support in self-administration. Future studies may achieve greater sustainability by considering the evolving needs of TBI patients and their families and the drivers and barriers that might influence non-pharmacological intervention use at home.

Traumatic brain injury and occupational risk of low-level blast exposure on adverse career outcomes: an examination of administrative and medical separations from Service (2005-2015)

Introduction

Although traumatic brain injury (TBI) has been linked with adverse long-term health, less research has examined whether TBI is linked with non-clinical outcomes including involuntary job loss. Symptoms associated with TBI may influence one's ability to maintain gainful employment including employment in the U.S. military. That influence may impact military service members with exposure to repetitive low-level blast (LLB). Understanding the association between TBI and involuntary job loss outcomes among military populations is particularly important as it may be associated with differences in eligibility for post-service benefits. The purpose of the present research was to determine whether (1) TBI and related conditions are associated with involuntary job loss (i.e., medical and administrative separations from service) among military personnel, and (2) occupational risk of LLB is associated with involuntary job loss in both the presence and absence of clinical diagnoses of TBI and related conditions.

Method

This research leveraged population-level data from the Career History Archival Medical and Personnel System for enlisted personnel who served on active duty between 2005-2015. Risk of LLB exposure was categorized using military occupational specialty as a proxy. Medical diagnoses were identified using ICD-9 codes. Separations for medical and administrative reasons were identified.

Results

Risk for administrative separation differed across medical diagnoses of interest, but those who worked in high-risk occupations were more likely to be administratively separated than those working in low-risk occupations. Risk for medical separation was associated with occupational risk of LLB and each of the diagnoses of interest, though significant interactions suggested that the effects of certain diagnoses of interest (e.g., concussion, cognitive problems, postconcussive syndrome, migraines) on medical separations was greater among those working in high-risk occupations.

Discussion

Taken together, the present research suggests that TBI and associated medical conditions, as well as occupational risk of LLB, are associated with long-term involuntary job loss for medical reasons. This study is the first to demonstrate involuntary military job loss outcomes associated with TBI, mental health conditions, and conditions associated with blast exposure using both inpatient and outpatient population-level data and may have important implications for civilian employment and post-service benefits.

Optimization of a translational murine model of closed-head traumatic brain injury

Traumatic brain injury (TBI) from closed-head trauma is a leading cause of disability, with limited effective interventions. Many TBI models impact brain parenchyma directly, and are limited by the fact that these forces do not recapitulate clinically relevant closed head injury. However, applying clinically relevant injury mechanics to the intact skull may lead to variability and as a result, preclinical modeling TBI remains a challenge. Current models often do not explore sex differences in TBI, which is critically important for translation to clinical practice. We systematically investigated sources of variability in a murine model of closed-head TBI and developed a framework to reduce variability across severity and sex. We manipulated pressure, dwell time, and displacement to determine effects on motor coordination, spatial learning, and neuronal damage in 10-week-old male and female mice. Increasing pressure beyond 70 psi had a ceiling effect on cellular and behavioral outcomes, while manipulating dwell time only affected behavioral performance. Increasing displacement precisely graded injury severity in both sexes across all outcomes. Physical signs of trauma occurred more frequently at higher displacements. Stratifying severity based on day-1 rotarod performance retained histological relationships and separated both sexes into injury severity cohorts with distinct patterns of behavioral recovery. Utilizing this stratification strategy, within-group rotarod variability over 6 days post-injury was reduced by 50%. These results have important implications for translational research in TBI and provide a framework for using this clinically relevant translational injury model in both male and female mice.

Traumatic Brain Injury and Subsequent Risk of Brain Cancer in US Veterans of the Iraq and Afghanistan Wars

Importance

While brain cancer is rare, it has a very poor prognosis and few established risk factors. To date, epidemiologic work examining the potential association of traumatic brain injury (TBI) with the subsequent risk of brain cancer is conflicting. Further data may be useful.

Objective

To examine whether a history of TBI exposure is associated with the subsequent development of brain cancer.

Design, Setting, and Participants

A retrospective cohort study was conducted from October 1, 2004, to September 20, 2019, and data analysis was performed between January 1 and June 26, 2023. The median follow-up for the cohort was 7.2 (IQR, 4.1-10.1) years. Veterans Affairs (VA) and Department of Defense (DoD) administrative data on 1 919 740 veterans from the Long-Term Impact of Military-Relevant Brain Injury Consortium-Chronic Effects of Neurotrauma Consortium were included.

Exposure

The main exposure of interest was TBI severity (categorized as mild, moderate or severe [moderate/severe], and penetrating).

Main Outcomes and Measures

The outcome of interest was the development of brain cancer based on International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) or International Statistical Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM) diagnostic codes in either the DoD/VA medical records or from the National Death Index.

Results

After 611 107 exclusions (predominately for no encounter during the study period), a cohort including 1 919 740 veterans was included, most of whom were male (80.25%) and non-Hispanic White (63.11%). Median age at index date was 31 (IQR, 25-42) years. The cohort included 449 880 individuals with TBI (mild, 385 848; moderate/severe, 46 859; and penetrating, 17 173). Brain cancer occurred in 318 individuals without TBI (0.02%), 80 with mild TBI (0.02%), 17 with moderate/severe TBI (0.04%), and 10 or fewer with penetrating TBI (≤0.06%). After adjustment, moderate/severe TBI (adjusted hazard ratio [AHR], 1.90; 95% CI, 1.16-3.12) and penetrating TBI (AHR, 3.33; 95% CI, 1.71-6.49), but not mild TBI (AHR, 1.14; 95% CI, 0.88-1.47), were associated with the subsequent development of brain cancer.

Conclusions and Relevance

In this cohort study of veterans of the Iraq and Afghanistan wars, moderate/severe TBI and penetrating TBI, but not mild TBI, were associated with the subsequent development of brain cancer.

Exploring the relationship between sleep apnea and vestibular symptoms following traumatic brain injury

BACKGROUND

Traumatic brain injury (TBI) is a complex health problem in military veterans and service members (V/SM) that often involves comorbid vestibular impairment. Sleep apnea is another comorbidity that may exacerbate, and/or be exacerbated by, vestibular dysfunction.

OBJECTIVE

To examine the relationship between sleep apnea and vestibular symptoms in V/SM diagnosed with TBI of any severity.

DESIGN

Multicenter cohort study; cross-sectional sample.

SETTING

In-patient TBI rehabilitation units within five Veterans Affairs (VA) Polytrauma Rehabilitation Centers.

PARTICIPANTS

V/SM with a diagnosis of TBI (N = 630) enrolled in the VA TBI Model Systems study.

INTERVENTION

Not applicable.

METHODS

A multivariable regression model was used to evaluate the association between sleep apnea and vestibular symptom severity while controlling for relevant covariates, for example, posttraumatic stress disorder (PTSD).

MAIN OUTCOME MEASURES

Lifetime history of sleep apnea was determined via best source reporting. Vestibular disturbances were measured with the 3-item Vestibular subscale of the Neurobehavioral Symptom Inventory (NSI).

RESULTS

One third (30.6%) of the sample had a self-reported sleep apnea diagnosis. Initial analysis showed that participants who had sleep apnea had more severe vestibular symptoms (M = 3.84, SD = 2.86) than those without sleep apnea (M = 2.88, SD = 2.67, p < .001). However, when the data was analyzed via a multiple regression model, sleep apnea no longer reached the threshold of significance as a factor associated with vestibular symptoms. PTSD severity was shown to be significantly associated with vestibular symptoms within this sample (p < .001).

CONCLUSION

Analysis of these data revealed a relationship between sleep apnea and vestibular symptoms in V/SM with TBI. The significance of this relationship was affected when PTSD symptoms were factored into a multivariable regression model. However, given that the mechanisms and directionality of these relationships are not yet well understood, we assert that in terms of clinical relevance, providers should emphasize screening for each of the three studied comorbidities (sleep apnea, vestibular symptoms, and PTSD).

In her own words: a phenomenological analysis of stories told by female service members and veterans after traumatic brain injury

PURPOSE

Given the majority of Service Members and Veterans (SMV) who have sustained a traumatic brain injury (TBI) are male, the female experience with TBI has not been captured in the general understanding of TBI. To improve understanding of the experience of female SMV after TBI utilizing a qualitative phenomenological approach on stories as told by female SMV.

MATERIALS AND METHODS

Ten female SMV participated in storytelling workshops and created video stories documenting their personal experience with TBI. Workshops were hosted by the VA Palo Alto Health Care System Polytrauma System of Care (VAPAHCS PSC). A grounded thematic analysis was conducted on the video stories.

RESULTS

Three common content themes emerged from all the stories: (1) negative psychological and emotional impacts of TBI, (2) acceptance and healing process associated with recovery, and (3) military contexts. Negative psychological and emotional impacts included intrapersonal impacts such as negative emotions, suicidal ideation, and dealing with cognitive and physical challenges, and interpersonal impacts in relationships and loss of independence. Notably, all the stories acknowledged an acceptance and healing process, characterized by several subthemes including motivational factors, TBI education, spirituality, and advocacy work. Lastly, each story mentioned military context, highlighting the unique experience within this population.

CONCLUSIONS

This phenomenological examination adds evidence-based understanding to the experience after TBI among female SMV. Each story uncovered nuanced and multifaceted issues that women experience in their TBI recovery. Our findings provide context to guide future intervention on the care, support, and TBI recovery for the female SMV population.

Consciousness Recovery in Traumatic Brain Injury: A Systematic Review Comparing Modafinil and Amantadine

OBJECTIVES

Acute traumatic brain injury is one of the most common causes of death and disability. Reduction in the level of consciousness is a significant complication that can impact morbidity. Glasgow Coma Scale (GCS) is the most widely used method of assessing the level of consciousness. Neurostimulants such as amantadine and modafinil are common pharmacologic agents that increase GCS in patients with brain trauma. This study aimed to compare the effectiveness of these 2 drugs.

METHODS

This systematic review obtained articles from Google Scholar, PubMed, Scopus, Embase, and MEDLINE databases. Extensive searches were conducted separately by 4 individuals in 3 stages. Ultimately, 16 clinical trials, cohort studies, case reports, and case series articles were obtained after reading the title, abstract, and full text and considering the exclusion criteria. The data of the final article were entered into the analysis table. This study was registered with PROSPERO (registration number CRD42022334409) and conducted in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines.

RESULTS

Amantadine seems to be associated with a higher overall response rate. In contrast, modafinil is associated with the most remarkable change in GCS score during treatment. However, the number of clinical trials with high quality and sample size has not been satisfactory to compare the effectiveness of these 2 drugs and their potential side effects.

CONCLUSIONS

The authors recommend additional double-blind clinical trials are needed to be conducted with a larger sample size, comparing amantadine with modafinil to delineate the efficacy and adverse effects, both short and long term.

Systemic inflammation induced from remote extremity trauma is a critical driver of secondary brain injury

Blast exposure, commonly experienced by military personnel, can cause devastating life-threatening polysystem trauma. Despite considerable research efforts, the impact of the systemic inflammatory response after major trauma on secondary brain injury-inflammation is largely unknown. The aim of this study was to identify markers underlying the susceptibility and early onset of neuroinflammation in three rat trauma models: (1) blast overpressure exposure (BOP), (2) complex extremity trauma (CET) involving femur fracture, crush injury, tourniquet-induced ischemia, and transfemoral amputation through the fracture site, and (3) BOP+CET. Six hours post-injury, intact brains were harvested and dissected to obtain biopsies from the prefrontal cortex, striatum, neocortex, hippocampus, amygdala, thalamus, hypothalamus, and cerebellum. Custom low-density microarray datasets were used to identify, interpret and visualize genes significant (p < 0.05 for differential expression [DEGs]; 86 neuroinflammation-associated) using a custom python-based computer program, principal component analysis, heatmaps and volcano plots. Gene set and pathway enrichment analyses of the DEGs was performed using R and STRING for protein-protein interaction (PPI) to identify and explore key genes and signaling networks. Transcript profiles were similar across all regions in naïve brains with similar expression levels involving neurotransmission and transcription functions and undetectable to low-levels of inflammation-related mediators. Trauma-induced neuroinflammation across all anatomical brain regions correlated with injury severity (BOP+CET > CET > BOP). The most pronounced differences in neuroinflammatory-neurodegenerative gene regulation were between blast-associated trauma (BOP, BOP+CET) and CET. Following BOP, there were few DEGs detected amongst all 8 brain regions, most were related to cytokines/chemokines and chemokine receptors, where PPI analysis revealed Il1b as a potential central hub gene. In contrast, CET led to a more excessive and diverse pro-neuroinflammatory reaction in which Il6 was identified as the central hub gene. Analysis of the of the BOP+CET dataset, revealed a more global heightened response (Cxcr2, Il1b, and Il6) as well as the expression of additional functional regulatory networks/hub genes (Ccl2, Ccl3, and Ccl4) which are known to play a critical role in the rapid recruitment and activation of immune cells via chemokine/cytokine signaling. These findings provide a foundation for discerning pathophysiological consequences of acute extremity injury and systemic inflammation following various forms of trauma in the brain.

Military-related mild traumatic brain injury: clinical characteristics, advanced neuroimaging, and molecular mechanisms

Mild traumatic brain injury (mTBI) is a significant health burden among military service members. Although mTBI was once considered relatively benign compared to more severe TBIs, a growing body of evidence has demonstrated the devastating neurological consequences of mTBI, including chronic post-concussion symptoms and deficits in cognition, memory, sleep, vision, and hearing. The discovery of reliable biomarkers for mTBI has been challenging due to under-reporting and heterogeneity of military-related mTBI, unpredictability of pathological changes, and delay of post-injury clinical evaluations. Moreover, compared to more severe TBI, mTBI is especially difficult to diagnose due to the lack of overt clinical neuroimaging findings. Yet, advanced neuroimaging techniques using magnetic resonance imaging (MRI) hold promise in detecting microstructural aberrations following mTBI. Using different pulse sequences, MRI enables the evaluation of different tissue characteristics without risks associated with ionizing radiation inherent to other imaging modalities, such as X-ray-based studies or computerized tomography (CT). Accordingly, considering the high morbidity of mTBI in military populations, debilitating post-injury symptoms, and lack of robust neuroimaging biomarkers, this review (1) summarizes the nature and mechanisms of mTBI in military settings, (2) describes clinical characteristics of military-related mTBI and associated comorbidities, such as post-traumatic stress disorder (PTSD), (3) highlights advanced neuroimaging techniques used to study mTBI and the molecular mechanisms that can be inferred, and (4) discusses emerging frontiers in advanced neuroimaging for mTBI. We encourage multi-modal approaches combining neuropsychiatric, blood-based, and genetic data as well as the discovery and employment of new imaging techniques with big data analytics that enable accurate detection of post-injury pathologic aberrations related to tissue microstructure, glymphatic function, and neurodegeneration. Ultimately, this review provides a foundational overview of military-related mTBI and advanced neuroimaging techniques that merit further study for mTBI diagnosis, prognosis, and treatment monitoring.

An Examination of Racial/Ethnic Differences on the Neurobehavioral Symptom Inventory Among Veterans Completing the Comprehensive Traumatic Brain Injury Evaluation: A Veterans Affairs Million Veteran Program Study

OBJECTIVE

The purpose of this study was to explore racial/ethnic differences in neurobehavioral symptom reporting and symptom validity testing among military veterans with a history of traumatic brain injury (TBI).

METHOD

Participants of this observational cross-sectional study (N = 9,646) were post-deployed Iraq-/Afghanistan-era veterans enrolled in the VA's Million Veteran Program with a clinician-confirmed history of TBI on the Comprehensive TBI Evaluation (CTBIE). Racial/ethnic groups included White, Black, Hispanic, Asian, Multiracial, Another Race, American Indian or Alaska Native, and Native Hawaiian or Other Pacific Islander. Dependent variables included neurobehavioral symptom domains and symptom validity assessed via the Neurobehavioral Symptom Inventory (NSI) and Validity-10, respectively.

RESULTS

Chi-square analyses showed significant racial/ethnic group differences for vestibular, somatic/sensory, and affective symptoms as well as for all Validity-10 cutoff scores examined (≥33, ≥27, ≥26, >22, ≥22, ≥13, and ≥7). Follow-up analyses compared all racial/ethnic groups to one another, adjusting for sociodemographic- and injury-related characteristics. These analyses revealed that the affective symptom domain and the Validity-10 cutoff of ≥13 revealed the greatest number of racial/ethnic differences.

CONCLUSIONS

Results showed significant racial/ethnic group differences on neurobehavioral symptom domains and symptom validity testing among veterans who completed the CTBIE. An enhanced understanding of how symptoms vary by race/ethnicity is vital so that clinical care can be appropriately tailored to the unique needs of all veterans. Results highlight the importance of establishing measurement invariance of the NSI across race/ethnicity and underscore the need for ongoing research to determine the most appropriate Validity-10 cutoff score(s) to use across racially/ethnically diverse veterans.

Behavioral and Psychiatric Symptoms in Patients with Severe Traumatic Brain Injury: A Comprehensive Overview

Traumatic brain injury (TBI) is defined as an altered brain structure or function produced by an external force. Adults surviving moderate and severe TBI often experience long-lasting neuropsychological and neuropsychiatric disorders (NPS). NPS can occur as primary psychiatric complications or could be an exacerbation of pre-existing compensated conditions. It has been shown that changes in behavior following moderate to severe TBI have a prevalence rate of 25-88%, depending on the methodology used by the different studies. Most of current literature has found that cognitive behavioral and emotional deficit following TBI occurs within the first six months whereas after 1-2 years the condition becomes stable. Identifying the risk factors for poor outcome is the first step to reduce the sequelae. Patients with TBI have an adjusted relative risk of developing any NPS several-fold higher than in the general population after six months of moderate-severe TBI. All NPS features of an individual's life, including social, working, and familiar relationships, may be affected by the injury, with negative consequences on quality of life. This overview aims to investigate the most frequent psychiatric, behavioral, and emotional symptoms in patients suffering from TBI as to improve the clinical practice and tailor a more specific rehabilitation training.

Blast-Induced Neurotrauma Results in Spatially Distinct Gray Matter Alteration Alongside Hormonal Alteration: A Preliminary Investigation

Blast-induced neurotrauma (BINT) frequently occurs during military training and deployment and has been linked to long-term neuropsychological and neurocognitive changes, and changes in brain structure. As military personnel experience frequent exposures to stress, BINT may negatively influence stress coping abilities. This study aimed to determine the effects of BINT on gray matter volume and hormonal alteration. Participants were Canadian Armed Forces personnel and veterans with a history of BINT (n = 12), and first responder controls (n = 8), recruited due to their characteristic occupational stress professions. Whole saliva was collected via passive drool on the morning of testing and analyzed for testosterone (pg/mL), cortisol (μg/dL), and testosterone/cortisol (T/C) ratio. Voxel-based morphometry was performed to compare gray matter (GM) volume, alongside measurement of cortical thickness and subcortical volumes. Saliva analyses revealed distinct alterations following BINT, with significantly elevated testosterone and T/C ratio. Widespread and largely symmetric loci of reduced GM were found specific to BINT, particularly in the temporal gyrus, precuneus, and thalamus. These findings suggest that BINT affects hypothalamic-pituitary-adrenal and -gonadal axis function, and causes anatomically-specific GM loss, which were not observed in a comparator group with similar occupational stressors. These findings support BINT as a unique injury with distinct structural and endocrine consequences.

Deployment-related concussion and long-term health-related quality of life among US military personnel

PURPOSE

To examine the relationship between deployment-related concussion and long-term health-related quality of life (HRQoL) among injured US military personnel.

METHODS

The study sample included 810 service members with deployment-related injuries between 2008 and 2012 who responded to a web-based longitudinal health survey. Participants were categorized into three injury groups: concussion with loss of consciousness (LOC; n = 247), concussion without LOC (n = 317), or no concussion (n = 246). HRQoL was measured using the 36-Item Short Form Health Survey physical and mental component summary (PCS and MCS) scores. Current post-traumatic stress disorder (PTSD) and depression symptoms were examined. Multivariable linear regression models assessed the effects of concussion on PCS and MCS scores, while controlling for covariates.

RESULTS

A lower PCS score was observed in participants with concussion with LOC (B =  - 2.65, p = 0.003) compared with those with no history of concussion. Symptoms of PTSD (PCS: B =  - 4.84, p < 0.001; MCS: B =  - 10.53, p < 0.001) and depression (PCS: B =  - 2.85, p < 0.001; MCS: B =  - 10.24, p < 0.001) were the strongest statistically significant predictors of lower HRQoL.

CONCLUSION

Concussion with LOC was significantly associated with lower HRQoL in the physical domain. These findings affirm that concussion management should integrate physical and psychological care to improve long-term HRQoL and warrant a more detailed examination of causal and mediating mechanisms. Future research should continue to incorporate patient-reported outcomes and long-term follow-up of military service members to further define the lifelong impact of deployment-related concussion.

Co-administration of Nanowired Oxiracetam and Neprilysin with Monoclonal Antibodies to Amyloid Beta Peptide and p-Tau Thwarted Exacerbation of Brain Pathology in Concussive Head Injury at Hot Environment

Environmental temperature adversely affects the outcome of concussive head injury (CHI)-induced brain pathology. Studies from our laboratory showed that animals reared at either cold environment or at hot environment exacerbate brain pathology following CHI. Our previous experiments showed that nanowired delivery of oxiracetam significantly attenuated CHI-induced brain pathology and associated neurovascular changes. Military personnel are the most susceptible to CHI caused by explosion, blasts, missile or blunt head trauma leading to lifetime functional and cognitive impairments affecting the quality of life. Severe CHI leads to instant death and/or lifetime paralysis. Military personnel engaged in combat operations are often subjected to extreme high or low environmental temperature zones across the globe. Thus, further exploration of novel therapeutic agents at cold or hot ambient temperatures following CHI are the need of the hour. CHI is also a major risk factor for developing Alzheimer's disease by enhancing amyloid beta peptide deposits in the brain. In this review, effect of hot environment on CHI-induced brain pathology is discussed. In addition, whether nanodelivery of oxiracetam together with neprilysin and monoclonal antibodies (mAb) to amyloid beta peptide and p-tau could lead to superior neuroprotection in CHI is explored. Our results show that co-administration of oxiracetam with neprilysin and mAb to AβP and p-tau significantly induced superior neuroprotection following CHI in hot environment, not reported earlier.

Implementation of telehealth and hybrid service delivery of interdisciplinary rehabilitation for military populations with traumatic brain injury

BACKGROUND

The COVID-19 pandemic necessitated the implementation of telehealth and hybrid service delivery models and provided an opportunity to study the impact of this care model in military populations with history of traumatic brain injury (TBI).

OBJECTIVE

To present telehealth service utilization rates across rehabilitation specialties, treatment outcome indicators, and patient satisfaction outcomes from a retrospective clinical sample.

METHODS

The study sample consists of 34 patients who underwent telehealth/hybrid Intensive Outpatient Programming (IOP) at a major rehabilitation hospital. Retrospective chart review and clinical data extraction were performed. A historical cohort receiving in-person care was used as a comparison group. Statistical analyses included partial correlations, mixed method analysis of variance (ANOVA), and independent sample t-tests.

RESULTS

Medical, behavioral health, physical, occupational, and speech-language therapy providers exhibited similar rates of telehealth service delivery (35 to 41% of all sessions). No significant association was found between percent telehealth sessions and the global treatment outcome indicator. Comparison of treatment effects across cohorts revealed similar benefits of IOP. No between-group differences were noted in satisfaction ratings.

CONCLUSION

The comparable treatment-related gains and reports of positive patient experience support the use of a telehealth and hybrid delivery model for military service members and veterans with TBI.

Nanoparticle-based drug delivery for the treatment of traumatic brain injury

INTRODUCTION

Traumatic brain injuries (TBIs) impact the breadth of society and remain without any approved pharmacological treatments. Despite successful Phase II clinical trials, the failure of many Phase III clinical trials may be explained by insufficient drug targeting and retention, preventing the proper attainment of an observable dosage threshold. To address this challenge, nanoparticles can be functionalized to protect pharmacological payloads, improve targeted drug delivery to sites of injury, and can be combined with supportive scaffolding to improve secondary outcomes.

AREAS COVERED

This review briefly covers the pathophysiology of TBIs and their subtypes, the current pre-clinical and clinical management strategies, explores the common models of focal, diffuse, and mixed traumatic brain injury employed in experimental animals, and surveys the existing literature on nanoparticles developed to treat TBIs.

EXPERT OPINION

Nanoparticles are well suited to improve secondary outcomes as their multifunctionality and customizability enhance their potential for efficient targeted delivery, payload protection, increased brain penetration, low off-target toxicity, and biocompatibility in both acute and chronic timescales.

A Qualitative Exploration of the Use of Service Dogs in Veterans with Post Traumatic Stress Disorder and Traumatic Brain Injury

Objective

This qualitative research was conducted to add to the body of knowledge that supports the benefits of service dogs (SDs), as a tertiary treatment modality, to veterans with post-traumatic stress disorder (PTSD) and/or traumatic brain injury (TBI).

Methods

This grounded theory research design utilized open-ended, semi-structured interviews with veterans (n = 10) who were using SDs as a treatment modality for PTSD and/or TBI. Transcripts were analyzed using NVivo qualitative software until data saturation was achieved.

Results

Results from the data analysis identified 4 major themes with concurrent subthemes. The most prominent themes were functional status, impact of a SD, recognition of symptoms of PTSD and/or TBI by the SD, and barriers and challenges to the acquisition of a SD. Participants reported that the SD increased socialization and was a positive adjunct to treatment modalities for PTSD and/or TBI.

Conclusions

Our study highlights the benefits of using a SD as a tertiary treatment for PTSD and/or TBI in veterans. Veterans in our study articulated the benefits of using a SD as a tertiary treatment option, and the need to make this a standard treatment option for all veterans who suffer from PTSD and/or TBI.

Association Between Traumatic Brain Injury and Subsequent Cardiovascular Disease Among Post-9/11-Era Veterans

Question

What is the association of a traumatic brain injury (TBI) with the subsequent risk of cardiovascular disease in veterans of the recent conflicts in Iraq and Afghanistan?

Findings

In this cohort study of 1 559 928 participants, TBI was associated with the development of a composite end point for cardiovascular disease (coronary artery disease, stroke, and peripheral artery disease). TBI was also associated with the individual components of this composite end point.

Meaning

Traumatic brain injury is a potentially novel risk factor for cardiovascular disease in veterans.

Importance

Traumatic brain injury (TBI) was common among US service members deployed to Iraq and Afghanistan. Although there is some evidence to suggest that TBI increases the risk of cardiovascular disease (CVD), prior reports were predominantly limited to cerebrovascular outcomes. The potential association of TBI with CVD has not been comprehensively examined in post-9/11–era veterans.

Objective

To determine the association between TBI and subsequent CVD in post-9/11–era veterans.

Design, Setting, and Participants

This was a retrospective cohort study conducted from October 1, 1999, to September 30, 2016. Participants were followed up until December 31, 2018. Included in the study were administrative data from the US Department of Veterans Affairs and the Department of Defense from the Long-term Impact of Military-Relevant Brain Injury Consortium–Chronic Effects of Neurotrauma Consortium. Participants were excluded if dates did not overlap with the study period. Data analysis was conducted between November 22, 2021, and June 28, 2022.

Exposures

History of TBI as measured by diagnosis in health care records.

Main Outcomes and Measures

Composite end point of CVD: coronary artery disease, stroke, peripheral artery disease, and cardiovascular death.

Results

Of the 2 530 875 veterans from the consortium, after exclusions, a total of 1 559 928 veterans were included in the analysis. A total of 301 169 veterans (19.3%; median [IQR] age, 27 [23-34] years; 265 217 male participants [88.1]) with a TBI history and 1 258 759 veterans (80.7%; median [IQR] age, 29 [24-39] years; 1 012 159 male participants [80.4%]) without a TBI history were included for analysis. Participants were predominately young (1 058 054 [67.8%] <35 years at index date) and male (1 277 376 [81.9%]). Compared with participants without a history of TBI, diagnoses of mild TBI (hazard ratio [HR], 1.62; 95% CI, 1.58-1.66; P < .001), moderate to severe TBI (HR, 2.63; 95% CI, 2.51-2.76; P < .001), and penetrating TBI (HR, 4.60; 95% CI, 4.26-4.96; P < .001) were associated with CVD in adjusted models. In analyses of secondary outcomes, all severities of TBI were associated with the individual components of the composite outcome except penetrating TBI and CVD death.

Conclusions and Relevance

Results of this cohort study suggest that US veterans with a TBI history were more likely to develop CVD compared with veterans without a TBI history. Given the relatively young age of the cohort, these results suggest that there may be an increased burden of CVD as these veterans age and develop other CVD risk factors. Future studies are needed to determine if the increased risk associated with TBI is modifiable.

Assessing the Clinical Utility of a Wearable Device for Physiological Monitoring of Heart Rate Variability in Military Service Members with Traumatic Brain Injury

Introduction: Autonomic dysfunction has been implicated as a consequence of traumatic brain injury (TBI). Heart rate variability (HRV) may be a viable measure of autonomic dysfunction that could enhance rehabilitative interventions for individuals with TBI. This pilot study sought to assess the feasibility and validity of using the Zeriscope™ platform system in a real-world clinical setting to measure HRV in active-duty service members with TBI who were participating in an intensive outpatient program. Methods: Twenty-five service members with a history of mild, moderate, or severe TBI were recruited from a military treatment facility. A baseline assessment was conducted in the cardiology clinic where point validity data were obtained by comparing a 5-min recording of a standard 12-lead electrocardiogram (ECG) output against the Zeriscope platform data. Results: Compared with the ECG device, the Zeriscope device had a concordance coefficient (rc) of 0.16, falling below the standard deemed to represent acceptable accuracy in HR measurement (i.e., 0.80). Follow-up analyses excluding outliers did not significantly improve the concordance coefficient to an acceptable standard for the total participant sample. System Usability Survey responses showed that participants rated the Zeriscope system as easy to use and something that most people would learn to use quickly. Conclusions: This study demonstrated promise in ambulatory HRV measurement in a representative military TBI sample. Future research should include further refinement of such ambulatory devices to meet the specifications required for use in a military active-duty TBI population.

Military traumatic brain injury: a challenge straddling neurology and psychiatry

Military psychiatry, a new subcategory of psychiatry, has become an invaluable, intangible effect of the war. In this review, we begin by examining related military research, summarizing the related epidemiological data, neuropathology, and the research achievements of diagnosis and treatment technology, and discussing its comorbidity and sequelae. To date, advances in neuroimaging and molecular biology have greatly boosted the studies on military traumatic brain injury (TBI). In particular, in terms of pathophysiological mechanisms, several preclinical studies have identified abnormal protein accumulation, blood-brain barrier damage, and brain metabolism abnormalities involved in the development of TBI. As an important concept in the field of psychiatry, TBI is based on organic injury, which is largely different from many other mental disorders. Therefore, military TBI is both neuropathic and psychopathic, and is an emerging challenge at the intersection of neurology and psychiatry.

Repetitive Transcranial Magnetic Stimulation as a Treatment for Veterans with Cognitive Impairment and Multiple Comorbidities

BACKGROUND

Despite decades of research efforts, current treatments for Alzheimer's disease (AD) are of limited effectiveness and do not halt the progression of the disease and associated cognitive decline. Studies have shown that repetitive transcranial magnetic stimulation (rTMS) may improve cognition.

OBJECTIVE

We conducted a pilot study to investigate the effect of rTMS on cognitive function in Veterans with numerous medical comorbidities.

METHODS

Participants underwent 20 sessions, over the course of approximately 4 weeks, of 10 Hz rTMS at the left dorsolateral prefrontal cortex with intensity of 120% resting motor threshold. Outcome measures including memory, language, verbal fluency, and executive functions were acquired at baseline, end of treatment, and 4 months after the last rTMS session. Twenty-six Veterans completed the study (13 in the active rTMS group, 13 in the sham rTMS group).

RESULTS

The study protocol was well-tolerated. Active, compared to sham, rTMS showed improved auditory-verbal memory at the end of treatment and at 4-month follow-up. However, the active rTMS group demonstrated a trend in decreased semantic verbal fluency at the end of treatment and at 4-month follow up.

CONCLUSION

These preliminary results show rTMS is safe in general in this elderly Veteran population with multiple co-morbidities. Patients in the sham group showed an expected, slight decline in the California Verbal Learning Test scores over the course of the study, whereas the active treatment group showed a slight improvement at the 4-month post-treatment follow up. These effects need to be confirmed by studies of larger sample sizes.

Creative Forces programming with military families: Art therapy, dance/movement therapy, and music therapy brief vignettes

LAY SUMMARY

Creative arts therapists (art therapists, dance/movement therapists, and music therapists) administer assessments and interventions that support the holistic well-being of military families affected by traumatic brain injury (TBI) and posttraumatic stress disorder (PTSD). Through participation in the Creative Forces: United States National Endowment for the Arts Military Healing Arts Network, military families discovered strengths, inspired connections, and improved understanding of their relationships. Creative arts therapies (CATs) motivated engagement, which ultimately boosted family resilience. CATs are an integral part of interdisciplinary care to address behavioural and rehabilitative conditions of military families impacted by TBI and PTSD. Future research should examine the efficacy of creative arts therapies in improving resilience in military families.

Utilizing the BAT-LQ to assess TBI incidence in a college student population

OBJECTIVE

Although the annual number of traumatic brain injuries (TBIs) reported in the US exceeds two million, data suggests that this is an underestimate. The goal of this study was to understand lifetime TBI incidence among a sample of college students. Additionally, this study examined whether a single yes/no question regarding TBI history was sufficient to gather accurate information about TBI incidence in college students.

DESIGN

Participants were asked a single TBI question and administered the BAT-LQ.

MAIN MEASURES

The BAT-LQ is a screening tool designed to assess for probable lifetime TBIs.

RESULTS

Data from 121 participants were analyzed for this study. On the single-question, 24.8% of participants reported experiencing a TBI. However, upon further prompting, 76.8% of all participants reported experiencing a blow to the head accompanied by at least one diagnostic symptom of a TBI, suggesting a probable TBI based on best-practice diagnosis guidelines.

CONCLUSION

The results of this study suggest that increased education about TBI is warranted to ensure that individuals receive care for probable TBIs, as many individuals likely lack knowledge about what constitutes a TBI diagnosis. Additionally, the results suggest that a single question may not be sufficient to capture true lifetime TBI incidence.

Methamphetamine exacerbates pathophysiology of traumatic brain injury at high altitude. Neuroprotective effects of nanodelivery of a potent antioxidant compound H-290/51

Military personnel are often exposed to high altitude (HA, ca. 4500-5000m) for combat operations associated with neurological dysfunctions. HA is a severe stressful situation and people frequently use methamphetamine (METH) or other psychostimulants to cope stress. Since military personnel are prone to different kinds of traumatic brain injury (TBI), in this review we discuss possible effects of METH on concussive head injury (CHI) at HA based on our own observations. METH exposure at HA exacerbates pathophysiology of CHI as compared to normobaric laboratory environment comparable to sea level. Increased blood-brain barrier (BBB) breakdown, edema formation and reductions in the cerebral blood flow (CBF) following CHI were exacerbated by METH intoxication at HA. Damage to cerebral microvasculature and expression of beta catenin was also exacerbated following CHI in METH treated group at HA. TiO2-nanowired delivery of H-290/51 (150mg/kg, i.p.), a potent chain-breaking antioxidant significantly enhanced CBF and reduced BBB breakdown, edema formation, beta catenin expression and brain pathology in METH exposed rats after CHI at HA. These observations are the first to point out that METH exposure in CHI exacerbated brain pathology at HA and this appears to be related with greater production of oxidative stress induced brain pathology, not reported earlier.

Mental Health Service Utilization among Adults with Head Injury with Loss of Consciousness: Implications for Social Work

The purpose of this study was to identify factors associated with mental health service utilization among adults with head injury with loss of consciousness (LOC) using Andersen's model of health. This secondary data analysis used the 2011-2014 National Health and Nutrition Examination Survey with data collected from 7,399 adults. Binary logistic regression was conducted to determine odds associated with predisposing, enabling, and needs factors on head injury with LOC and mental health service utilization. A total of  948 (12.8 percent) adults 40 years and older self-reported head injury with LOC. Head injury with LOC was higher among men and people with lower income, illicit drug use history, and moderate to severe depression. Mental health service utilization for people with head injury with LOC was lower among older-age adults and those with no health insurance. However, utilization was higher among adults with military service, history of drug use, and moderate to severe depression. Social workers in health care settings play critical roles serving adults with traumatic brain injury (TBI) through mental health and substance use disorder treatment and bridging gaps in service access. Social workers should recognize the complex needs of clients with TBI and factors affecting mental health service use.

The Impact of Combat Ocular Trauma and Traumatic Brain Injury on Vision- and Health-Related Quality of Life Among U.S. Military Casualties

PURPOSE

The purpose of this study was to assess visual and health-related quality of life (QOL) among U.S. military service members who sustained combat ocular trauma (COT) with or without associated traumatic brain injury (TBI).

METHODS

This was a single-center, prospective observational study of U.S. service members (n = 88) with COT who were treated at Walter Reed National Military Medical Center. Participants completed the National Eye Institute Visual Function Questionnaire (VFQ-25) at enrollment and at follow-up (>1 year) and supplemental surveys: Neurobehavioral Symptom Inventory, the Medical Outcomes 36-item Short Form Survey (SF-36), and Mayo-Portland Adaptability Inventory.

RESULTS

Initial and follow-up VFQ-25 showed a statistically significant increase in median scores for near activities (initial: 75.0, follow-up 83.3; P = .004) and peripheral vision (initial: 50.0, follow-up: 75.0; P = .009) and in composite scores (initial: 79.5, follow-up: 79.8; P = .022). Comparing those who did (n = 78) and did not (n = 8) have a TBI history, there were no significant differences in median change in VFQ-25 composite scores (with TBI: 2.3 vs. no TBI: 10.7; P = .179). Participants with a TBI history had a significantly lower median SF-36 General Health score (with TBI: 67.5 vs. no TBI: 92.5; P = .009).

CONCLUSIONS

Vision-related QOL of COT patients is generally good in the long term. However, those with both COT and a history of TBI conditions showed significantly worse functioning in several domains than those without TBI. As TBI is a common finding in COT, this association is an important factor impacting this population's overall clinical presentation and daily functions.

A Comparison of Cognitive Processing Therapy and Seeking Safety for the Treatment of Posttraumatic Stress Disorder in Veterans

To compare the outcomes of Seeking Safety (SS) and cognitive processing therapy (CPT) in veterans with PTSD in a specialty clinic of an urban VA medical center. Retrospective chart review of electronic medical records was conducted for 420 veterans with PTSD who received treatment with either CPT (n = 227) or SS (n = 193) in group setting. 1) treatment completion rate, 2) self-reported PTSD symptom severity measured by PTSD checklist (PCL), and 3) additional mental health services received within 12 months after treatment. Data were analyzed for the 160 who had both a pre and post PCL documented in their charts. The final analysis sample included n = 94 for CPT and n = 66 for SS veterans with a mean age of 49.71[SD = 14] years, 24 women [15%]; mean baseline PCL score was 68.41 [9]. Significantly more veterans completed SS treatment (SS, 59 [89%] than CPT, 47 [50%] (p = <.001). However, PCL score decreases were significantly greater for patients who completed CPT treatment than those in SS (treatment x time interaction, 9.60 vs.4.98, respectively; difference, 4.62; t₈₄ = 2.16; p = .02). The patients who received SS used significantly more mental health services of the PTSD clinical team than patients who completed CPT treatment (p = .01). The results of this study demonstrate the need for alternative approaches where dually diagnosed patients would not be delayed in their receipt of trauma-focused care - i.e., where treatment is initiated concurrently rather than sequentially to substance abuse treatment.

An Observation of Application of Structural Brain Injury Devices for Traumatic Brain Injury Evaluation in Austere Military Prehospital Settings

INTRODUCTION

Military units lack the ability to quickly, objectively, and accurately assess individuals that have suffered a closed head injury for structural brain injury and functional brain impairments in forward settings, where neurological assessment equipment and expertise may be lacking. With acute traumatic brain injury patients, detached medical providers are often faced with a decision to wait and observe or medically evacuate, both of which have cascading consequences. Structural brain injury assessment devices, when employed in forward environments, have the potential to reduce the risk of undiagnosed and/or mismanaged traumatic brain injuries given their high negative predictive value and suggested increased specificity compared to common subjective clinical decision rules. These handheld devices are portable and have an ease of use, from combat medic to physician, allowing for use in austere environments, safely keeping soldiers with their teams when able and suggesting further evaluation via computed tomography (CT) scan when warranted.

METHODS

Data collected on 13 encounters at 5 locations were retrospectively analyzed using descriptive statistics.

RESULTS

A total number of 13 examinations were performed using the BrainScope One device during the 9-month deployment. The Structural Injury Classification was negative for 11 of the patients. Two of the 11 patients underwent head CT scans, which confirmed the absence of intracranial hemorrhage. Of the two positive Structural Injury Classification exams, one was CT negative and no CT was performed for the other based on clinical judgment.

CONCLUSION

The data from this study suggest that structural brain injury devices may provide value by ruling out serious brain injury pathology while limiting excessive medical evacuations from austere settings, where neurological assessment equipment and expertise may be lacking, reducing unnecessary head CT scans.

Neuropsychological, Neurocognitive, Vestibular, and Neuroimaging Correlates of Exposure to Repetitive Low-Level Blast Waves: Evidence From Four Nonoverlapping Samples of Canadian Breachers

INTRODUCTION

We assessed the utility of a battery of neuropsychological, neurocognitive, physiological (balance, ataxia, postural tremor), and neuroimaging measures for studying the effects of blast waves in breachers-a population repeatedly exposed to low-level blast during military training and operations.

MATERIALS AND METHODS

Data were collected from four nonoverlapping samples, in the course of similarly structured 4-day breacher training exercises in successive years involving a combination of indoor and outdoor blast events. In all cases, self-report and neuropsychological measures were administered once at baseline (i.e., 1 day before the start of training). In years 1-2, neurocognitive and physiological measures were administered daily before and after training. In years 3-4, neurocognitive data were collected once at baseline. In Year 4, we introduced 3 modifications to our design. First, in addition to breachers, we also collected data from sex-and age-matched military controls at the same time points. Second, we assessed balance, ataxia, and postural tremor immediately following blast exposure "in the field," enabling us to quantify its acute effects. Third, structural magnetic resonance imaging (MRI) scans were acquired before and after the 4-day training exercise to explore differences between breachers and controls at baseline, as well as possible training-related changes using voxel-based morphometry. These design modifications were made to enable us to test additional hypotheses in the context of the same training exercise.

RESULTS

At baseline, scores on the "Rivermead Post Concussion Symptoms Questionnaire," "RAND SF-36" (physical functioning, role limitation due to physical health, social functioning, energy/fatigue, general health), and "Short Musculoskeletal Function Questionnaire" distinguished breachers from controls. Also at baseline, the MRI data revealed that there was greater regional gray matter volume in controls compared to breachers in the right superior frontal gyrus. Balance, ataxia, and postural tremor did not exhibit sensitivity to the acute effects of blast in the field, nor did neurocognitive measures to its cumulative or daily effects.

CONCLUSION

Our exploratory results suggest that self-report neuropsychological measures and structural MRI hold promise as sensitive measures for quantifying the long-term, cumulative effects of blast exposure in breachers. We discuss the limitations of our study and the need for prospective longitudinal data for drawing causal inferences regarding the impact of blast exposure on breachers' health and performance.

Cross-sectional study of major procedure codes among hospitalized patients with traumatic brain injury by level of injury severity in the 2004 to 2014 Nationwide Inpatient Sample

Despite its public health significance, TBI management across US healthcare institutions and patient characteristics with an emphasis on utilization and outcomes of TBI-specific procedures have not been evaluated at the national level.We aimed to characterize top 10 procedure codes among hospitalized adults with TBI as primary diagnosis by injury severity.A Cross-sectional study was conducted using 546, 548 hospitalization records from the 2004 to 2014 Nationwide Inpatient Sample were analyzed.Data elements of interest included injury, patient, hospital characteristics, procedures, in-hospital death and length of stay.Ten top procedure codes were "Closure of skin and subcutaneous tissue of other sites", "Insertion of endotracheal tube", "Continuous invasive mechanical ventilation for less than 96 consecutive hours", "Venous catheterization (not elsewhere classified)", "Continuous invasive mechanical ventilation for 96 consecutive hours or more", "Transfusion of packed cells", "Incision of cerebral meninges", "Serum transfusion (not elsewhere classified)", "Temporary tracheostomy", and "Arterial catherization". Prevalence rates ranged between 3.1% and 15.5%, with variations according to injury severity and over time. Whereas "Closure of skin and subcutaneous tissue of other sites" was associated with fewer in-hospital deaths and shorter hospitalizations, "Temporary tracheostomy" was associated with fewer in-hospital deaths among moderate-to-severe TBI patients, and "Continuous invasive mechanical ventilation for less than 96 consecutive hours" was associated with shorter hospitalizations among severe TBI patients. Other procedures were associated with worse outcomes.Nationwide, the most frequently reported hospitalization procedure codes among TBI patients aimed at homeostatic stabilization and differed in prevalence, trends, and outcomes according to injury severity.

Military TBI—What civilian primary care providers should know

In June 2019, the Department of Veterans Affairs (VA) launched the VA Mission Act, which expanded veterans’ health-care access to the private sector. Since civilian primary care providers may see more veterans in their practice, it will be important to understand the unique experiences, comorbidities, and culture of this population in order to provide optimal care. Military service members (SMs) are at an increased risk for traumatic brain injury (TBI), and comorbidities, such as post traumatic stress disorder (PTSD), increasing the likelihood of prolonged symptoms. Military training and repetitive low-level blast exposure may cause symptoms similar to TBI or increase long-term negative effects in SMs. Military culture often has a strong influence in this population. Those who serve in the military identify with military values and have a strong team mentality, which places emphasis on the mission above all else, not accepting defeat, and not ever leaving a fellow SM behind. These values can impact the way a SM/veteran seeks care and/or communicates with his or her health-care provider. Taking a detailed history to understand how these factors apply, as well as screening for mental health comorbidities, are recommended. Understanding the military cultural influences can assist in promoting a stronger therapeutic alliance and encourage more open communication. Ultimately, it is the trusting and respectful relationship between the SM/veteran and the provider that will determine the most effective treatment and result in the most effective resolution of TBI and comorbid symptoms.

Blast in Context: The Neuropsychological and Neurocognitive Effects of Long-Term Occupational Exposure to Repeated Low-Level Explosives on Canadian Armed Forces' Breaching Instructors and Range Staff

Currently, there is strong interest within the military to better understand the effects of long-term occupational exposure to repeated low-level blast on health and performance. To gain traction on the chronic sequelae of blast, we focused on breaching—a tactical technique for gaining entry into closed/blocked spaces by placing explosives and maintaining a calculated safe distance from the detonation. Using a cross-sectional design, we compared the neuropsychological and neurocognitive profiles of breaching instructors and range staff to sex- and age-matched Canadian Armed Forces (CAF) controls. Univariate tests demonstrated that breaching was associated with greater post-concussive symptoms (Rivermead Post Concussion Symptoms Questionnaire) and lower levels of energy (RAND SF-36). In addition, breaching instructors and range staff were slower on a test that requires moving and thinking simultaneously (i.e., cognitive-motor integration). Next, using a multivariate approach, we explored the impact of other possible sources of injury, including concussion and prior war-zone deployment on the same outcomes. Concussion history was associated with higher post-concussive scores and musculoskeletal problems, whereas deployment was associated with higher post-concussive scores, but lower energy and greater PTSD symptomatology (using PCL-5). Our results indicate that although breaching, concussion, and deployment were similarly correlated with greater post-concussive symptoms, concussion history appears to be uniquely associated with altered musculoskeletal function, whereas deployment history appears to be uniquely associated with lower energy and risk of PTSD. We argue that the broader injury context must, therefore, be considered when studying the impact of repetitive low-level explosives on health and performance in military members.

Development of a Practice Tool for Primary Care Providers: Medication Management of Posttraumatic Stress Disorder in Veterans with Mild Traumatic Brain Injury

Posttraumatic stress disorder (PTSD) and comorbid mild traumatic brain injury (mTBI) are highly prevalent in veterans who served in Iraq [Operation Iraqi Freedom/Operation New Dawn] and Afghanistan [Operation Enduring Freedom]. Complicated psychotropic medications are used for treatment of PTSD and comorbid mTBI symptoms lead to polypharmacy related complications. Primary care providers (PCPs) working in Community Based Outpatient Clinics (CBOCs) are usually burdened with the responsibility of managing this complicated medication regimen or relevant side effects. The PCPs do not feel equipped to provide this complicated psychopharmacological management. Thus, there is a need for a comprehensive yet concise tool for the medication management of PTSD in veterans with comorbid mTBI. (1) To conduct focus groups of interdisciplinary team of experts and other stake holders to assess need, (2) To carefully review current VA/Department of Defense practice guideline to identify content, (3) To develop an evidence based, user friendly, and concise pocket guide for the PCP's. Content was identified by review of current guidelines and available literature and was finalized after input from stakeholders, multidisciplinary team of experts, and review of qualitative data from focus groups/interviews of clinicians working in remote CBOCs. The pocket tool was formatted and designed by multimedia service. A pocket guide in the form of a bi-fold, 4″ × 5.5″ laminated card was developed. One thousand hard copies were distributed in the local VA medical center. This product is available online for download at the South-Central Mental Illness Research, Education, and Clinical Center website ( https://www.mirecc.va.gov/VISN16/ptsd-and-mtbi-pocket-card.asp ). This pocket card provides PCPs an easy to carry and user-friendly clinical decision-making tool to effectively treat veterans with PTSD and comorbid mTBI.

The Prehospital Evaluation and Care of Moderate/Severe TBI in the Austere Environment

Increased resource constraints secondary to a smaller medical footprint, prolonged evacuation times, or overwhelming casualty volumes all increase the challenges of effective management of traumatic brain injury (TBI) in the austere environment. Prehospital providers are responsible for the battlefield recognition and initial management of TBI. As such, targeted education is critical to efficient injury recognition, promoting both provider readiness and improved patient outcomes. When austere conditions limit or prevent definitive treatment, a comprehensive understanding of TBI pathophysiology can help inform acute care and enhance prevention of secondary brain injury. Field deployable, noninvasive TBI assessment and monitoring devices are urgently needed and are currently undergoing clinical evaluation. Evidence shows that the assessment, monitoring, and treatment in the first few hours and days after injury should focus on the preservation of cerebral perfusion and oxygenation. For cases where medical management is inadequate (eg, evidence of an enlarging intracranial hematoma), guidelines have been developed for the performance of cranial surgery by nonneurosurgeons. TBI management in the austere environment will continue to be a challenge, but research focused on improving evidence-based monitoring and therapeutic interventions can help to mitigate some of these challenges and improve patient outcomes.

Characteristics and Impact of U.S. Military Blast-Related Mild Traumatic Brain Injury: A Systematic Review

As a result of armed conflict, head trauma from exposure to blasts is an increasing critical health issue, particularly among military service members. Whilst numerous studies examined the burden of blast-related brain injuries on service members', few systematic reviews have been published. This work provides a comprehensive summary of the evidence on blast-related mild traumatic brain injury (mTBI) burden in active U.S. military service members and inactive Veterans, describing characteristics and outcomes. Records published up to April 2017 were identified through a search of PubMed, Web of Science, Scopus, Ovid MEDLINE, and Cochrane Library. Records-based and original research reporting on U.S. military service members and Veterans with mild blast TBI were included. Data on subject characteristics, exposure, diagnostic criterion, and outcomes were extracted from included studies using a standardized extraction form and were presented narratively. Of the 2,290 references identified by the search, 106 studies with a total of 37,515 participants met inclusion criteria for blast-related mTBI. All but nine studies were based out of military or Veteran medical facilities. Unsurprisingly, men were over-represented (75–100%). The criteria used to define blast-related mTBI were consistent; however, the methodology used to ascertain whether individuals met those criteria for diagnosis were inconsistent. The diagnosis, most prevalent among the Army, heavily relied on self-reported histories. Commonly reported adverse outcomes included hearing disturbances and headaches. The most frequently associated comorbidities were post-traumatic stress disorder, depression, anxiety, sleep disorders, attention disorders, and cognitive disorders. The primary objective of this review was to provide a summary of descriptive data on blast-related mTBI in a U.S. military population. Low standardization of the methods for reaching diagnosis and problems in the study reporting emphasize the importance to collect high-quality data to fill knowledge gaps pertaining to blast-related mTBI.

Effect of an in-home, family-inclusive rehabilitation programme on depressive symptoms in veterans with traumatic brain injury and its mediation by activity engagement

Background/Aims

Depression, the most common psychiatric sequela of traumatic brain injury in both civilians and veterans, produces serious and wide-ranging problems. Although medication and cognitive behavioural therapy are the most common treatments, some rehabilitation approaches designed to enhance functioning and/or community reintegration may decrease depression by facilitating active engagement in life – the key component of some depression therapies. The present secondary analysis of a community reintegration-focused rehabilitation programme for veterans with traumatic brain injury posed two questions: Did the programme affect depressive symptoms? If so, was this effect mediated by engagement in activities?

Methods

A secondary analysis was undertaken of an intervention study of 83 former members of the United States Armed Forces (veterans) with traumatic brain injury, who were interviewed in their homes. Depressive symptoms were assessed using the short-form Centre for Epidemiological Studies-Depression Scale, activity engagement using an 8-item subscale derived from the Community Reintegration of Injured Service Members Scale, and physical and emotional functioning using the SF-36V. Sociodemographic, medical and military characteristics were elicited during the first interview, and medical and military characteristics were identified through a medical chart review.

Results

Depressive symptoms significantly decreased among the veterans in the treatment group. That effect was mediated by activity engagement. Thus, the intervention's impact on depressive symptoms was attributable to the increased activity that it produced.

Conclusions

Research on rehabilitation that enhances engagement in activities should examine its possible benefits for improving mood.

Quetiapine augmentation of prolonged exposure therapy in veterans with PTSD and a history of mild traumatic brain injury: design and methodology of a pilot study

BACKGROUND

Selective serotonergic reuptake inhibitors (SSRIs) are first-line pharmacologic treatments for patients with posttraumatic stress disorder (PTSD), but must be given over extended period of time before the onset of action. The use of SSRIs in PTSD patients with mild traumatic brain injury (mTBI) is problematic since SSRIs could exacerbate post-concussion syndrome (PCS) symptoms. VA/DOD guidelines identify trauma-focused psychotherapy as the best evidence-based treatment for PTSD, but overall effectiveness is limited by reduced levels of patient engagement and retention. A previous study from this research group suggested that quetiapine monotherapy, but not risperidone or valproate, could increase engagement in trauma-focused psychotherapy.

METHODS

We report the study protocol of a pilot study funded under the South-Central Mental Illness Research, Education, and Clinical Center pilot study program from the U.S. Department of Veterans Affairs. This randomized, open-label study was designed to evaluate the feasibility of completing a randomized trial of quetiapine vs. treatment as usual to promote patient engagement in PTSD patients with a history of mTBI.

DISCUSSION

We expect that the success of this ongoing study should provide us with the preliminary data necessary to design a full-scale randomized trial. Positive efficacy results in a full- scale trial should inform new VA guidelines for clinical practice by showing that quetiapine-related improvements in patient engagement and retention may be the most effective approach to assure that VA resources achieve the best possible outcome for veterans.

TRIAL REGISTRATION

NCT04280965 .

Sex as a Biological Variable in Preclinical Modeling of Blast-Related Traumatic Brain Injury

Approaches to furthering our understanding of the bioeffects, behavioral changes, and treatment options following exposure to blast are a worldwide priority. Of particular need is a more concerted effort to employ animal models to determine possible sex differences, which have been reported in the clinical literature. In this review, clinical and preclinical reports concerning blast injury effects are summarized in relation to sex as a biological variable (SABV). The review outlines approaches that explore the pertinent role of sex chromosomes and gonadal steroids for delineating sex as a biological independent variable. Next, underlying biological factors that need exploration for blast effects in light of SABV are outlined, including pituitary, autonomic, vascular, and inflammation factors that all have evidence as having important SABV relevance. A major second consideration for the study of SABV and preclinical blast effects is the notable lack of consistent model design—a wide range of devices have been employed with questionable relevance to real-life scenarios—as well as poor standardization for reporting of blast parameters. Hence, the review also provides current views regarding optimal design of shock tubes for approaching the problem of primary blast effects and sex differences and outlines a plan for the regularization of reporting. Standardization and clear description of blast parameters will provide greater comparability across models, as well as unify consensus for important sex difference bioeffects.

Factors Associated With Delayed Concussion Reporting by United States Service Academy Cadets

CONTEXT

Approximately half of individuals who sustain a concussion do not immediately report their injuries. Motivators for not reporting include thinking the suspected concussion was not a serious injury and wanting to continue participating in activity. Additionally, military personnel have concerns about how concussions may affect their careers. However, delayed reporting can prolong neurobehavioral recovery. Understanding the frequency of delayed reporting and contributing factors will aid in identifying individuals who may be more likely to delay reporting.

OBJECTIVE

To describe the frequency of delayed concussion reporting by service academy cadets and determine if sex, injury setting, sport level, or medical history is capable of predicting delayed reporting.

DESIGN

Cohort study.

SETTING

Service academies.

PATIENTS OR OTHER PARTICIPANTS

A total of 316 patients with concussions were observed from January 2014 to August 2016.

MAIN OUTCOME MEASURE(S)

All cadets completed an annual concussion baseline collection of demographic, medical history, and sports participation information. Delayed concussion reporting served as the outcome variable. Predictor variables were sex, injury setting, and sport level, as well as concussion, headache, and learning disorder history. Frequencies were calculated to describe the proportion of participants who delayed reporting. Univariable and multivariable logistic regression models were used to assess if the predictor variables were associated with delayed concussion reporting. Odds ratios (ORs) and 95% confidence intervals were calculated for all variables included in the final model.

RESULTS

Of the patients with concussion, 51% were classified as delayed reporting. In univariable models, females (OR = 1.70) and National Collegiate Athletic Association cadet-athletes (OR = 1.98) were more likely to delay reporting than males and intramural cadet-athletes, respectively. The multivariable model yielded similar findings.

CONCLUSIONS

Roughly half of the cadets who sustained a concussion failed to immediately report their injury. Specifically, our data suggested that female cadets, cadets injured outside of competition, and highly competitive cadet-athletes were almost twice as likely to delay reporting as others.

Polytrauma Is Associated with Increased Three- and Six-Month Disability after Traumatic Brain Injury: A TRACK-TBI Pilot Study

Polytrauma and traumatic brain injury (TBI) frequently co-occur and outcomes are routinely measured by the Glasgow Outcome Scale-Extended (GOSE). Polytrauma may confound GOSE measurement of TBI-specific outcomes. Adult patients with TBI from the prospective Transforming Research and Clinical Knowledge in Traumatic Brain Injury Pilot (TRACK-TBI Pilot) study had presented to a Level 1 trauma center after injury, received head computed tomography (CT) within 24 h, and completed the GOSE at 3 months and 6 months post-injury. Polytrauma was defined as an Abbreviated Injury Score (AIS) ≥3 in any extracranial region.

Univariate regressions were performed using known GOSE clinical cutoffs. Multi-variable regressions were performed for the 3- and 6-month GOSE, controlling for known demographic and injury predictors. Of 361 subjects (age 44.9 ± 18.9 years, 69.8% male), 69 (19.1%) suffered polytrauma. By Glasgow Coma Scale (GCS) assessment, 80.1% had mild, 5.8% moderate, and 14.1% severe TBI. On univariate logistic regression, polytrauma was associated with increased odds of moderate disability or worse (GOSE ≤6; 3 month odds ratio [OR] = 2.57 [95% confidence interval (CI): 1.50-4.41; 6 month OR = 1.70 [95% CI: 1.01-2.88]) and death/severe disability (GOSE ≤4; 3 month OR = 3.80 [95% CI: 2.03-7.11]; 6 month OR = 3.33 [95% CI: 1.71-6.46]). Compared with patients with isolated TBI, more polytrauma patients experienced a decline in GOSE from 3 to 6 months (37.7 vs. 24.7%), and fewer improved (11.6 vs. 22.6%). Polytrauma was associated with greater univariate ordinal odds for poorer GOSE (3 month OR = 2.79 [95% CI: 1.73-4.49]; 6 month OR = 1.73 [95% CI: 1.07-2.79]), which was conserved on multi-variable ordinal regression (3 month OR = 3.05 [95% CI: 1.76-5.26]; 6 month OR = 2.04 [95% CI: 1.18-3.42]). Patients with TBI with polytrauma are at greater risk for 3- and 6-month disability compared with those with isolated TBI. Methodological improvements in assessing TBI-specific disability, versus disability attributable to all systemic injuries, will generate better TBI outcomes assessment tools.

Two latent classes of diagnostic and treatment procedures among traumatic brain injury inpatients

To characterize latent classes of diagnostic and/or treatment procedures among hospitalized U.S. adults, 18-64 years, with primary diagnosis of TBI from 2004-2014 Nationwide Inpatient Samples, latent class analysis (LCA) was applied to 10 procedure groups and differences between latent classes on injury, patient, hospital and healthcare utilization outcome characteristics were modeled using multivariable regression. Using 266,586 eligible records, LCA resulted in two classes of hospitalizations, namely, class I (n = 217,988) (mostly non-surgical) and class II (n = 48,598) (mostly surgical). Whereas orthopedic procedures were equally likely among latent classes, skin-related, physical medicine and rehabilitation procedures as well as behavioral health procedures were more likely among class I, and other types of procedures were more likely among class II. Class II patients were more likely to have moderate-to-severe TBI, to be admitted on weekends, to urban, medium-to-large hospitals in Midwestern, Southern or Western regions, and less likely to be > 30 years, female or non-White. Class II patients were also less likely to be discharged home and necessitated longer hospital stays and greater hospitalization charges. Surgery appears to distinguish two classes of hospitalized patients with TBI with divergent healthcare needs, informing the planning of healthcare services in this target population.

Enhancing Access to Psychiatric Care for Posttraumatic Stress Disorder in Veterans with Mild Traumatic Brain Injury through Integrated Services

(i) To describe an integrated model of psychiatric care for the treatment of posttraumatic stress disorder (PTSD) in veterans with mild traumatic brain injury (mTBI). (ii) To evaluate access to and engagement in psychiatric care among veterans with comorbid PTSD and mTBI after implementation of an Integrated Care (IC) model compared to the previous Usual Care (UC). 100 randomly selected charts, 50 from each of UC and IC were reviewed in this non-concurrent case- control study. Polytrauma Network Site (PNS), an outpatient rehabilitation clinic, for veterans who suffered from brain and other traumatic injuries at an urban VA Polytrauma Rehabilitation Center. Veterans receiving treatment for mTBI symptoms by the rehabilitation team were referred for medication management for PTSD to UC and IC. Co-located access to psychiatric care for medication management as part of the interdisciplinary team with the goal of expediting rehabilitation and functional recovery. Number of consults for psychiatric care for medication management scheduled and completed within 30 days, and number of veterans offered, initiating, and completing evidence-based psychotherapies for PTSD in UC compared to IC. After implementation of IC there were significant improvements in timely completion of consults and patient engagement with a psychiatrist. There also were improvements in number of referrals, initiation, and completion of evidence-based psychotherapies for the treatment of PTSD. IC within the PNS shows promise as an effective care model for increasing access and engagement in care for veterans with comorbid PTSD/mTBI. Future research is needed to examine the utility of this model in other sites.

Characteristics of traumatic brain injury during Operation Enduring Freedom–Afghanistan: a retrospective case series

Traumatic brain injury (TBI) is a significant cause of morbidity and mortality, especially among members of the armed services. Injuries sustained in the battlefield are subject to different mechanisms than those sustained in civilian life, particularly blast and high-velocity injury. Due to the unique nature of these injuries and the challenges associated with battlefield medicine, surgical interventions play a key role in acute management of TBI. However, the burden of chronic disease posed by TBI is poorly understood and difficult to investigate, especially in the military setting. The authors report the case logs of a United States Navy neurosurgeon, detailing the acute management and outcomes of 156 patients sustaining TBI between November 2010 and May 2011 during the war in Afghanistan. By demographics, more than half of the patients treated were local nationals. By mechanism of injury, blunt trauma (40.4%) and explosive injury (37.2%) were the most common contributors to TBI. Decompressive craniectomies (24.0%) and clot evacuations (14.7%) were the procedures most commonly performed. Nearly one-quarter of patients were transferred to receive further care, yet only 3 patients were referred for rehabilitative services. Furthermore, the data suggest that patients sustaining comorbid injuries in addition to TBI may be predisposed to worse outcomes. Improvements in documentation of military patients may improve knowledge of TBI and further identify potential variables or treatments that may affect prognosis. The increased survivability from TBI also highlights the need for additional research expenditure in the field of neurorehabilitation specifically.