Traumatic brain injury in older adults: epidemiology, outcomes, and future implications

Traumatic brain injury in patients aged ≥65 years versus patients aged ≥80 years: a multicenter prospective study of mortality and medical resource utilization

Objective

This study aimed to determine whether there is a difference in mortality and medical resource utilization between geriatric (aged ≥65 years) and super-geriatric patients (aged ≥80 years) with traumatic brain injury (TBI).

Methods

We obtained comprehensive data (demographics, injury characteristics, injury severities, and outcomes) of geriatric and super-geriatric TBI patients from an emergency department-based injury surveillance system database from 2011 to 2016. Multivariate logistic regression analysis was performed to compare the mortality and nonroutine discharge (NRDC) status between both groups.

Results

Among 442,533 TBI patients, 48,624 were older than 65 years. A total of 48,446 patients (37,140 geriatric and 11,306 super-geriatric) without exclusion criteria were included in the final analysis. Both overall in-hospital mortality (adjusted odds ratio, 1.88; 95% confidence interval [CI], 1.28 to 2.74; P=0.001) and NRDC (adjusted odds ratio, 1.35; 95% CI, 1.07 to 1.71; P=0.011) were significantly higher in the super-geriatric group. In the stratified analysis, there were no significant differences in NRDC rate for all stratifications of treatment timing (emergency department vs. ward admission), but mortality remained to be significant for all stratifications.

Conclusion

Super-geriatric TBI patients showed a significantly higher risk-adjusted overall mortality and more inadequate medical resource utilization than did geriatric TBI patients. However, super-geriatric patients were more likely to undergo NRDC after admission; thus, further research about age-related health inequalities is needed in the treatment of super-geriatric patients.

A Population-Based Study of Pre-Existing Health Conditions in Traumatic Brain Injury

Health factors impacting both the occurrence of, and recovery from traumatic brain injury (TBI) vary in complexity, and present genuine challenges to researchers and healthcare professionals seeking to characterize injury consequences and determine prognosis. However, attempts to clarify causal links between injury characteristics and clinical outcomes (including mortality) often compel researchers to exclude pre-existing health conditions (PECs) in their samples, including psychiatric history, medication usage, and other comorbid conditions. In this pre-registered population-based study (total starting n = 939,123 patients), we examined trends in PEC incidence over 22 years in the state of Pennsylvania (1997-2019) in individuals sustaining TBI (n = 169,452) and individuals with orthopedic injury (n = 87,637). The goal was to determine how PECs interact with age and injury severity to influence short-term outcomes. A further goal was to determine whether number of PECs, or specific PEC clusters contributed to worse outcomes within the TBI cohort, compared with orthopedic injury alone. Primary findings indicate that PECs significantly influenced mortality within the TBI cohort; patients having four or more PECs were associated with approximately a two times greater likelihood of dying in acute care (odds ratio [OR] 1.9). Additionally, cluster analyses revealed four distinct PEC clusters that are age and TBI severity dependent. Overall, the likelihood of zero PECs hovers at ∼25%, which is critical to consider in TBI outcomes work and could potentially contribute to the challenges facing intervention science with regard to reproducibility of findings.

Long-Term Trends in the Epidemiology of Major Traumatic Brain Injury

Traumatic brain injury (TBI) is a leading cause of death and disability among adults. Falls and motor vehicle collisions (MVCs) are the most common causes of TBI hospitalizations in Canada. The purpose of this study was to determine whether, at the provincial level, there have been significant changes in the injury rate and causes of major TBI. This was a retrospective cohort study of all patients in Nova Scotia who presented with major TBI (Abbreviated Injury Scale Head score ≥ 3) between 2002 and 2018. Prospectively entered data were collected from the Nova Scotia Trauma Registry. Annual injury rates were calculated based on 100,000 population (all ages) using population estimates from Statistics Canada. Linear regression was performed to analyze annual trends of major TBI within the province. There were 5590 major TBI patients in Nova Scotia during the 16-year study period. The overall annual rate of major TBI was 37 per 100,000 population. There was a 39% increase in the rate of major TBI over the study period (r =  - 0.72, R2 = 0.51, p < 0.002). Patients had a mean age of 51 ± 25 years; 72% were male. The proportion of TBIs in males decreased significantly from 76% in 2002 to 69% in 2017 (p < 0.001). Mechanisms of injury were predominantly falls (45%) and MVCs (29%); the proportion of violent injuries was 11.5%. The rate of fall-related TBIs more than doubled between 2002 and 2017, increasing from 9.1 to 20.5 injuries per 100,000 (p < 0.001). Our findings demonstrate an increasing incidence of major TBI over a 16-year period with a greater than two-fold increase in the rate of fall-related TBI. These results are important for targeting TBI prevention efforts in reducing falls, especially in older adults.

Scoping Review of Clinical Practice Guidelines for Fall Risk Screening and Assessment in Older Adults across the Care Continuum

Given the rising numbers of older adults in Canada experiencing falls, evidence-based identification of fall risks and plans for prevention across the continuum of care is a significant priority for health care providers. A scoping review was conducted to synthesize published international clinical practice guidelines (CPGs) and recommendations for fall risk screening and assessment in older adults (defined as 65 years of age and older). Of the 22 CPGs, 6 pertained to multiple settings, 9 pertained to community-dwelling older adults only, 2 each pertained to acute care and long-term care settings only, and 3 did not specify setting. Two criteria, prior fall history and gait and balance abnormalities, were applied either independently or sequentially in 19 CPG fall risk screening algorithms. Fall risk assessment components were more varied across CPGs but commonly included: detailed fall history; detailed evaluation of gait, balance, and/or mobility; medication review; vision; and environmental hazards assessment. Despite these similarities, more work is needed to streamline assessment approaches for heterogeneous and complex older adult populations across the care continuum. Support is also needed for sustainable implementation of CPGs in order to improve health outcomes.

Geriatric Trauma

Geriatric trauma patients will continue to increase in prevalence as the population ages, and many specific considerations need to be made to provide appropriate care to these patients. This article outlines common presentations of trauma in geriatric patients, with consideration to baseline physiologic function and patterns of injury that may be more prevalent in geriatric populations. Additionally, the article explores specific evidence-based management practices, the significance of trauma team and geriatrician involvement, and disposition decisions.

Acute cognitive impairment after traumatic brain injury predicts the occurrence of brain atrophy patterns similar to those observed in Alzheimer's disease

Traumatic brain injuries (TBIs) are often followed by persistent structural brain alterations and by cognitive sequalae, including memory deficits, reduced neural processing speed, impaired social function, and decision-making difficulties. Although mild TBI (mTBI) is a risk factor for Alzheimer's disease (AD), the extent to which these conditions share patterns of macroscale neurodegeneration has not been quantified. Comparing such patterns can not only reveal how the neurodegenerative trajectories of TBI and AD are similar, but may also identify brain atrophy features which can be leveraged to prognosticate AD risk after TBI. The primary aim of this study is to systematically map how TBI affects white matter (WM) and gray matter (GM) properties in AD-analogous patterns. Our findings identify substantial similarities in the regional macroscale neurodegeneration patterns associated with mTBI and AD. In cerebral GM, such similarities are most extensive in brain areas involved in memory and executive function, such as the temporal poles and orbitofrontal cortices, respectively. Our results indicate that the spatial pattern of cerebral WM degradation observed in AD is broadly similar to the pattern of diffuse axonal injury observed in TBI, which frequently affects WM structures like the fornix, corpus callosum, and corona radiata. Using machine learning, we find that the severity of AD-like brain changes observed during the chronic stage of mTBI can be accurately prognosticated based on acute assessments of post-traumatic mild cognitive impairment. These findings suggest that acute post-traumatic cognitive impairment predicts the magnitude of AD-like brain atrophy, which is itself associated with AD risk.

Event-related potentials of episodic encoding after traumatic brain injury in older adults

Episodic memory and attention impairments are frequently observed following a traumatic brain injury (TBI). Older adults are more affected than young adults after a TBI, partly because of the age-related neural and memory changes. Neural mechanisms underlying episodic memory deficits in older adults with chronic TBI remain to be investigated. The current study aimed to investigate the impact of TBI in older adults on the neural mechanisms of episodic encoding. Event-related potentials were recorded while 13 participants with mild-to-severe TBI and 14 matched controls were performing an episodic memory task in which the level of organizational strategy was manipulated through three encoding conditions. Participants were explicitly instructed to memorize words without any semantic relationship (Unrelated condition), words semantically related without any given strategies (Spontaneous condition) and words semantically related with provided category labels and organizational strategy (Guided condition). Behavioral performances indicated that older individuals with a TBI were impaired compared to matched controls whatever the condition. The electrophysiological findings showed a reduction of the P200 and LPC components amplitude in the TBI group relative to control group. Moreover, control participants without any neurological history showed a right frontal sustained activity only in the Spontaneous condition, whereas a right frontal asymmetry was observed in participants with chronic TBI whatever the encoding conditions. This was mainly the result of negative left frontal activity. These findings evidence neural dysfunctions underlying attentional and associative processes involved in memory strategies after a TBI sustained at an older age that are consistent with executive functions impairments.

Does cognitive decline occur decades after moderate to severe traumatic brain injury? A prospective controlled study

This prospective controlled study examined long-term trajectories of neuropsychological performance in individuals with traumatic brain injury (TBI) compared to healthy controls, and the impact of IQ, age at injury, time since injury, and injury severity on change over time. Fifty-three individuals with moderate to severe TBI (60.37% male; M = 59.77 yrs, SD = 14.03), and 26 controls (46.15% male; M = 63.96 yrs, SD = 14.42) were studied prospectively (M = 12.72 yrs between assessments). Participants completed measures of premorbid IQ (Weschler Test of Adult Reading), processing speed (Digit Symbol Coding Test), working memory (Digit Span Backwards), memory (Rey Auditory Verbal Learning Test) and executive function (Trail Making Test Part B; Hayling Errors), at a mean of 10.62 yrs (Initial) and 23.91 yrs (Follow-Up) post injury. Individuals with TBI did not show a significantly greater decline in neuropsychological performance over time compared with demographically similar controls. There was no association between change over time with IQ, time since injury or injury severity. Being older at injury had a greater adverse impact on executive function at follow-up. In this small sample, a single moderate to severe TBI was not associated with ongoing cognitive decline up to three decades post injury. Changes in cognitive function were similar between the groups and likely reflect healthy aging.

Differential neuropathology and functional outcome after equivalent traumatic brain injury in aged versus young adult mice

The CDC estimate that nearly 3 million Americans sustain a traumatic brain injury (TBI) each year. Even when medical comorbidities are accounted for, age is an independent risk factor for poor outcome after TBI. Nonetheless, few studies have examined the pathophysiology of age-linked biologic outcomes in TBI. We hypothesized that aged mice would demonstrate more severe neuropathology and greater functional deficits as compared to young adult mice after equivalent traumatic brain injuries. Young adult (14-week-old) and aged (80-week-old) C57BL/6 male mice underwent an open-head controlled cortical impact to induce TBI or a sham injury. At 30-days post-injury groups underwent behavioral phenotyping, magnetic resonance imaging, and histologic analyses. Contrary to our hypothesis, young adult TBI mice exhibited more severe neuropathology and greater loss of white matter connectivity as compared to aged mice after TBI. These findings correlated to differential functional outcomes in anxiety response, learning, and memory between young adult and aged mice after TBI. Although the mechanisms underlying this age-effect remain unclear, attenuated signs of secondary brain injury in aged TBI mice point towards different inflammatory and repair processes between age groups. These data suggest that age may need to be an a priori consideration in future clinical trial design.

Echocardiogram Utilization Patterns and Association With Mortality Following Severe Traumatic Brain Injury

BACKGROUND

Severe traumatic brain injury (TBI) can result in left ventricular dysfunction, which can lead to hypotension and secondary brain injuries. Although echocardiography is often used to examine cardiovascular function in multiple clinical settings, its use and association with outcomes following severe TBI are not known. To address this gap, we used the National Trauma Data Bank (NTDB) to describe utilization patterns of echocardiography and examine its association with mortality following severe TBI.

METHODS

A retrospective cohort study was conducted using a large administrative trauma registry maintained by the NTDB from 2007 to 2014. Patients >18 years with isolated severe TBI, and without concurrent severe polytrauma, were included in the study. We examined echocardiogram utilization patterns (including overall utilization, factors associated with utilization, and variation in utilization) and the association of echocardiography utilization with hospital mortality, using multivariable logistic regression models.

RESULTS

Among 47,808 patients, echocardiogram was utilized as part of clinical care in 2548 patients (5.3%). Clinical factors including vascular comorbidities and hemodynamic instability were associated with increased use of echocardiograms. Nearly half (46.0%, 95% confidence interval [CI], 40.3%-51.7%) of the variation in echocardiogram utilization was explained at the individual hospital level, above and beyond patient and injury factors. Exposure to an echocardiogram was associated with decreased odds of in-hospital mortality following severe TBI (adjusted odds ratio [OR] = 0.77; 95% CI, 0.69-0.87; P < .001).

CONCLUSIONS

Echocardiogram utilization following severe TBI is relatively low, with wide variation in use at the hospital level. The association with decreased in-hospital mortality suggests that the information derived from echocardiography may be relevant to improving patient outcomes but will require confirmation in further prospective studies.

Traumatic Brain Injury Related Hospitalizations: Factors Associated with In-hospital Mortality among Elderly Patients Hospitalized with a TBI

Background: This study aims to describe TBI-related hospitalizations for the whole population and identify factors associated with in-hospital mortality among elderly (≥65 years) patients hospitalized with TBI in Texas.Methods: Using Texas Hospital Discharge Data from 2012 to 2014, TBI-related hospitalizations were identified using International Classification of Diseases - Ninth Revision - Clinical Modification (ICD-9-CM) codes. Rates for age and gender were estimated using U.S. Census data. Univariate and multivariate analyses were used to identify factors associated with in-hospital mortality among those aged at least 65 years.Results: There were 51,419 TBI-related hospitalizations from 2012 to 2014 in Texas. Falls were the leading cause of TBI-related hospitalizations 6235 (36.64%), 6595 (38.40%), and 5412 (37.59%) for 2012, 2013, and 2014, respectively. Males had higher rates of hospitalizations while rates were highest for those above 80 years of age. Compared to Whites, Hispanics had 1.18 higher adjusted odds of in-hospital mortality [OR = 1.18: 95% CI (1.01-1.40)]. Similarly, adjusted odds of in-hospital mortality were higher among males [OR = 1.55: 95% CI (1.36-1.77)].Conclusion: This study provided evidence of demographic disparities in the burden and outcome of TBI in Texas, findings could serve as a foundation for targeted TBI prevention interventions.

Impact of chronic medical conditions on mortality in geriatric trauma, 10-year analysis of a single centre in Turkey

BACKGROUND

The healthy and active lifestyle adopted by the elderly as a result of improvements in the standards of living may lead to an increase in the risk of injury. Comorbidities increase the risk of posttraumatic complications and mortality. The aim of this study was to investigate the impact of chronic medical conditions (CMCs) on the risk of mortality in geriatric trauma patients.

METHODS

All geriatric trauma patients admitted to emergency department over a 10-year period were retrospectively analysed. Patients were stratified by baseline characteristics, injury severity score (ISS), presence of CMCs, and in-hospital mortality. Multivariate logistic regression was used to determine variables significantly associated with in-hospital mortality.

RESULTS

9455 patients included in the study. The median age was 74 (10) years and 57% of them were female. The presence of ≥1 CMC and ≥2 CMCs increased the risk of mortality 5.64 and 2.38 times respectively in mild traumas and 2.67 and 2.59 times respectively in moderate traumas. Age, ISS and penetrating traumas had a significant impact on the risk of mortality in all ISS groups. In severe traumas, only renal disease had an impact on the risk of mortality (OR = 2.58, 95%CI = 1.03-6.43, p = 0.042). All other CMCs, ≥1 CMC, and ≥2 CMCs had no impact on the risk of mortality.

CONCLUSION

The presence of CMCs in elderly patients with mild and moderate injuries increases the risk of mortality. Such patients should be diagnosed and treated more quickly and aggressively during the prehospital process and in the hospital.

A population-based study of head injury, cognitive function and pathological markers

Objective

To assess associations between head injury (HI) with loss of consciousness (LOC), ageing and markers of later‐life cerebral pathology; and to explore whether those effects may help explain subtle cognitive deficits in dementia‐free individuals.

Methods

Participants (n = 502, age = 69–71) from the 1946 British Birth Cohort underwent cognitive testing (subtests of Preclinical Alzheimer Cognitive Composite), ¹⁸F‐florbetapir Aβ‐PET and MR imaging. Measures include Aβ‐PET status, brain, hippocampal and white matter hyperintensity (WMH) volumes, normal appearing white matter (NAWM) microstructure, Alzheimer’s disease (AD)‐related cortical thickness, and serum neurofilament light chain (NFL). LOC HI metrics include HI occurring: (i) >15 years prior to the scan (ii) anytime up to age 71.

Results

Compared to those with no evidence of an LOC HI, only those reporting an LOC HI>15 years prior (16%, n = 80) performed worse on cognitive tests at age 69–71, taking into account premorbid cognition, particularly on the digit‐symbol substitution test (DSST). Smaller brain volume (BV) and adverse NAWM microstructural integrity explained 30% and 16% of the relationship between HI and DSST, respectively. We found no evidence that LOC HI was associated with Aβ load, hippocampal volume, WMH volume, AD‐related cortical thickness or NFL (all p > 0.01).

Interpretation

Having a LOC HI aged 50’s and younger was linked with lower later‐life cognitive function at age ~70 than expected. This may reflect a damaging but small impact of HI; explained in part by smaller BV and different microstructure pathways but not via pathology related to AD (amyloid, hippocampal volume, AD cortical thickness) or ongoing neurodegeneration (serum NFL).

Age- and Severity-Related In-Hospital Mortality Trends and Risks of Severe Traumatic Brain Injury in Japan: A Nationwide 10-Year Retrospective Study

Traumatic brain injury (TBI) is the major cause of mortality and morbidity in severely-injured patients worldwide. This retrospective nationwide study aimed to evaluate the age- and severity-related in-hospital mortality trends and mortality risks of patients with severe TBI from 2009 to 2018 to establish effective injury prevention measures. We retrieved information from the Japan Trauma Data Bank dataset between 2009 and 2018. The inclusion criteria for this study were patients with severe TBI defined as those with an Injury Severity Score ≥ 16 and TBI. In total, 31,953 patients with severe TBI (32.6%) were included. There were significant age-related differences in characteristics, mortality trend, and mortality risk in patients with severe TBI. The in-hospital mortality trend of all patients with severe TBI significantly decreased but did not improve for patients aged ≤ 5 years and with a Glasgow Coma Scale (GCS) score between 3 and 8. Severe TBI, age ≥ 65 years, fall from height, GCS score 3-8, and urgent blood transfusion need were associated with a higher mortality risk, and mortality risk did not decrease after 2013. Physicians should consider specific strategies when treating patients with any of these risk factors to reduce severe TBI mortality.

Characteristics of Older Adult First-Time Sex Offenders: Insights From the Missouri Registry

OBJECTIVE

To explore the characteristics of older adult first-time sex offenders (who offended for the first time at the age of 65 years or above).

DESIGN

The authors retrieved and analyzed data from the publicly available Missouri sex offender registry database up to December 2018 and the Missouri public case management system website.

PARTICIPANTS

Registered older (≥65 years) sex offenders in the state of Missouri, United States.

MEASUREMENTS

Sociodemographic characteristics of the offender, offense type(s), offense, and conviction dates; age and sex of the victim(s); and case disposition information (whether the trial was waived or not and what were the sentences imposed).

RESULTS

One hundred and ninety-four older adult sex offenders all males were identified, of which 172 were first-time offenders. The majority were white; the median age of offense was 68.6 years old. One hundred and thirty-nine (80.8%) first-time offenders were convicted strictly of non-pornography offenses, with prepubescent girls the predominant victim pool. The most prevalent charge in this subgroup was Child Molestation, First Degree (36.5%). Twenty-eight (16.3%) offenders were convicted strictly of pornography offenses, the most prevalent one being Possession of Child Pornography (96.6%). The recidivism rate among first-time offenders was close to 1%.

CONCLUSION

A substantial proportion of older registered sex offenders are first-time sex offenders and most of them have underage victims. Although the offense and recidivism rates seem to be low, future longitudinal studies should focus on the predictors of sexual offending in the older population, in order to design targeted preventive measures, risk assessment, and treatment options.

Traumatic Brain Injury in the Elderly: Clinical Features, Prognostic Factors, and Outcomes of 133 Consecutive Surgical Patients

Objective

With the aging of the global population, an increase in the proportion of elderly patients presenting with traumatic brain injury (TBI) is expected. This population presents several distinctive characteristics that impact management and outcome of TBI, such as comorbidities, frailty, and preinjury use of medications - specially antiplatelets and anticoagulants. The purpose of this study was to assess the general characteristics and prognostic factors of elderly patients with TBI that were surgically managed at a single institution.

Methods

The authors performed a retrospective review of all elderly patients (age ≥ 65 years) with a history of TBI that underwent cranial neurosurgical procedures at their institution, between 2015 and 2019. Clinical characteristics, laboratory tests, and radiological scans, as well as surgeries, performed, outcome, and prognostic factors were analyzed, comprising 133 consecutive cases overall.

Results

The mean age of patients was 76.6 ± 7.3 years, ranging from 65 years to 97 years. There was a predominance of males (71.4%) and the most frequent mechanism of injury was fall (80.4%). Mild TBI comprised 57.1% of the cases, followed by severe TBI in 25.6%. Frequent signs and symptoms were impaired consciousness (69.9%), focal motor deficits (32.3%), and gait disturbances (12.8%). The majority had reported comorbidities upon admission (79.7%), with cardiac disease (79.2%) and diabetes (24.5%) as the most frequent. Preinjury anticoagulation was reported in 18.8% and use of antiplatelet drugs in 17.3%. The most common finding in the head CT was chronic subdural hematoma (48.1%), followed by acute subdural hematoma (37.6%). Coagulation was found to be altered in 12.8% of the patients. The most common neurosurgical procedure performed was trephination for hematoma evacuation (56.3%), followed by craniotomy (21.2%). Blood product transfusion was needed in 61.7% of the patients. Overall mortality was 42.1%, with the majority in the first month after admission (83.9%). Unfavorable outcome (Glasgow Outcome Scale <5) at discharge was identified in 73% of the patients. Identified prognostic factors were TBI severity, absent pupillary reactivity, acute intracranial bleeding on head CT, basal cisterns obliteration, altered coagulation status, and need for blood transfusion.

Conclusions

TBI severity, pupillary reactivity, coagulation status, need for blood products transfusion and acute bleeding, as well as basal cisterns obliteration found in head CT, are factors that influenced the outcome in this series of elderly patients with TBI that need surgical management. It is paramount to observe the particularities of this population in this context, to optimize outcomes, avoid complications and ultimately generate awareness focused on prevention.

B-Cell Lymphoma 2 (Bcl-2) Gene Is Associated with Intracranial Hypertension after Severe Traumatic Brain Injury

Severe traumatic brain injury (TBI) activates the apoptotic cascade in neurons and glia as part of secondary cellular injury. B-cell lymphoma 2 (Bcl-2) gene encodes a pro-survival protein to suppress programmed cell death, and variation in this gene has potential to affect intracranial pressure (ICP). Participants were recruited from a single clinical center using a prospective observational study design. Inclusion criteria were: age 16-80 years; Glasgow Coma Scale (GCS) score 4-8; and at least 24 h of ICP monitoring treated between 2000-2014. Outcomes were mean ICP, spikes >20 and >25 mm Hg, edema, and surgical intervention. Odds ratios (OR), mean increases/decreases (B), and 95% confidence intervals (CIs) were reported. In 264 patients, average age was 39.2 years old and 78% of patients were male. Mean ICPs were 11.4 ± 0.4 mm Hg for patients with homozygous wild-type (AA), 12.8 ± 0.6 mm Hg for heterozygous (AG), and 14.3 ± 1.2 mm Hg for homozygous variant (GG; p = 0.023). Rs17759659 GG genotype was associated with more ICP spikes >20 mm Hg (p = 0.017) and >25 mm Hg (p = 0.048). Multi-variate analysis showed that GG relative to AA genotype had higher ICP (B = 2.7 mm Hg, 95% CI [0.5,4.9], p = 0.015), edema (OR = 2.5 [1.0, 6.0], p = 0.049) and need for decompression (OR = 3.7 [1.5-9.3], p = 0.004). In this prospective severe TBI cohort, Bcl-2 rs17759659 was associated with increased risk of intracranial hypertension, cerebral edema, and need for surgical intervention. The variant allele may impact programmed cell death of injured neurons, resulting in elevated ICP and post-traumatic secondary insults. Further risk stratification and targeted genotype-based therapies could improve outcomes after severe TBI.

The potential of mitochondrial modulation by neuroglobin in treatment of neurological disorders

Neuroglobin is the third member of the globin family to be identified in 2000 in neurons of both human and mouse nervous systems. Neuroglobin is an oxygen-binding globin found in neurons within the central nervous system as well as in peripheral neurons, that produces a protective effect against hypoxic/ischemic damage induced by promoting oxygen availability within the mitochondria. Numerous investigations have demonstrated that impaired neuroglobin functioning is implicated in the pathogenesis of multiple neurodegenerative disorders. Several in vitro and animal studies have reported the potential of neuroglobin upregulation in improving the neuroprotection through modulation of mitochondrial functions, such as ATP production, clearing reactive oxygen species (ROS), promoting the dynamics of mitochondria, and controlling apoptosis. Neuroglobin acts as a stress-inducible globin, which has been associated hypoxic/ischemic insults where it acts to protect the heart and brain, providing a wide range of applicability in the treatment of human disorders. This review article discusses normal physiological functions of neuroglobin in mitochondria-associated pathways, as well as outlining how dysregulation of neuroglobin is associated with the pathogenesis of neurodegenerative disorders.

Understanding Traumatic Brain Injury in Females: A State-of-the-Art Summary and Future Directions

In this report, we identify existing issues and challenges related to research on traumatic brain injury (TBI) in females and provide future directions for research. In 2017, the National Institutes of Health, in partnership with the Center for Neuroscience and Regenerative Medicine and the Defense and Veterans Brain Injury Center, hosted a workshop that focused on the unique challenges facing researchers, clinicians, patients, and other stakeholders regarding TBI in women. The goal of this "Understanding TBI in Women" workshop was to bring together researchers and clinicians to identify knowledge gaps, best practices, and target populations in research on females and/or sex differences within the field of TBI. The workshop, and the current literature, clearly highlighted that females have been underrepresented in TBI studies and clinical trials and have often been excluded (or ovariectomized) in preclinical studies. Such an absence in research on females has led to an incomplete, and perhaps inaccurate, understanding of TBI in females. The presentations and discussions centered on the existing knowledge regarding sex differences in TBI research and how these differences could be incorporated in preclinical and clinical efforts going forward. Now, a little over 2 years later, we summarize the issues and state of the science that emerged from the "Understanding TBI in Women" workshop while incorporating updates where they exist. Overall, despite some progress, there remains an abundance of research focused on males and relatively little explicitly on females.

Functional outcome, dependency and well-being after traumatic brain injury in the elderly population: A systematic review and meta-analysis

Introduction

Traumatic brain injury (TBI) rates in the elderly are increasing worldwide, mainly due to fall accidents. However, TBI's impact on elderly patients' lives has not been thoroughly investigated.

Research question

This systematic review and meta-analysis aims at describing post-TBI incidence of functional decline, dependency, nursing home admission, reduced quality of life and depression in the elderly.

Materials and methods

A systematic literature search was performed in PubMed, EMBASE, Web Of Science, BIOSIS, Current Contents Connect, Data Citation Index, MEDLINE, SciELO, Cochrane library and CINAHL. Study selection was conducted by two independent reviewers. Meta-analysis was performed using a random-effects model.

Results

Twenty-seven studies were included in the qualitative synthesis and twenty-five in a random-effects meta-analysis. The prevalence of unfavorable functional outcomes after TBI was 65.2% (95% CI: 51.1–78.0). Admission to a nursing home had a pooled prevalence of 28.5% (95% CI: 17.1–41.6) and dependency rates ranged between 16.9% and 74.0%. A reduced quality of life was documented throughout follow-up with SF12/36 scores between 35.3 and 52.3/100.2.6–4.8% of the patients with mild TBI reported depressive symptoms. A large heterogeneity was found among studies for functional outcomes and discharge destination.

Discussion and conclusion

In conclusion, elderly patients have a significant risk for functional decline, dependency, nursing home admission and low quality of life following TBI. Moreover, more severe injuries lead to worse outcomes. These findings are important to provide accurate patient and family counseling, set realistic treatment targets and aim at relevant outcome variables in prognostic models for TBI in elderly patients.

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Traumatic Brain Injury in the elderly has a major impact on functional outcomes.

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Traumatic Brain Injury in elderly leads to dependency and nursing home admission.

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Elderly patients have a lower quality of life after Traumatic Brain Injury.

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Older age and injury severity are risk factors for poor functional outcome.

Fixation stability as a biomarker for differentiating mild traumatic brain injury from age matched controls in pediatrics

OBJECTIVES

Traumatic brain injury (TBI) is an increasingly significant health concern worldwide, compounded by the difficultly in detection and diagnosis. Fortunately, a growing body of research has identified oculomotor behavior, specifically fixations, saccades and smooth pursuit eye movements as a promising endophenotype for neurotrauma. To date, limited research exists using fixation stability in a comparative study to indicate the presence of a mild TBI (mTBI), especially in the pediatric population.

METHODS

The present study examined data from 91 individuals clinically diagnosed with mTBI and a further 140 age- and gender-matched controls. They all completed the RightEye fixation stability test using a remote eye tracker. Participants were compared on five fixation metrics: Bivariate Contour Ellipse Area (BCEA), Convergence Point, Depth, Disassociated Phoria, and Targeting Displacement.

RESULTS

Results were analyzed using one-way univariate ANOVAs, ROC analysis, and stepwise logistic regression. BCEA results revealed significant differences between groups with the mTBI group showing a larger gaze spread, indicative of less ability to keep the eyes close to the target without deviating.

CONCLUSIONS

Fixation stability is detrimentally impacted by mTBI in pediatric patients, and the oculomotor test can be used to differentiate between those with and without an mTBI.

Disentangling the effects of age and mild traumatic brain injury on brain network connectivity: A resting state fMRI study

INTRODUCTION

Cognitive complaints are common shortly after mild traumatic brain injury (mTBI) but may persist up to years. Age-related cognitive decline can worsen these symptoms. However, effects of age on mTBI sequelae have scarcely been investigated.

METHODS

Fifty-four mTBI patients (median age: 35 years, range 19-64 years, 67% male) and twenty age- and sex-matched healthy controls were studied using resting state functional magnetic resonance imaging in the sub-acute phase. Independent component analysis was used to identify intrinsic connectivity networks (ICNs). A multivariate approach was adopted to evaluate the effects of age and group on the ICNs in terms of (static) functional network connectivity (FNC), intensities of spatial maps (SMs) and time-course spectral power (TC).

RESULTS

We observed significant age-related changes for a) FNC: changes between 10 pairs of ICNs, mostly involving the default mode (DM) and/or the cognitive-control (CC) domains; b) SMs: intensity decrease in clusters across three domains and intensity increase in clusters across two domains, including the CC but not the DM and c) TC: spectral power decrease within the 0-0.15 Hz range and increase within the 0.20-0.25 Hz range for increasing age within networks located in frontal areas, including the anterior DM. Groups only differed for TC within the 0.065-0.10 Hz range in the cerebellar ICN and no age × group interaction effect was found.

CONCLUSIONS

We showed robust effects of age on connectivity between and within ICNs that are associated with cognitive functioning. Differences between mTBI patients and controls were only found for activity in the cerebellar network, increasingly recognized to participate in cognition. Our results suggest that to allow for capturing the true effects related to mTBI and its effects on cognitive functioning, age should be included as a covariate in mTBI studies, in addition to age-matching groups.

Cognitive Training for Mild Traumatic Brain Injury and Posttraumatic Stress Disorder

Although there is evidence of mild cognitive impairments for many individuals with mild traumatic brain injury (mTBI) and posttraumatic stress disorder (PTSD), little research evaluating the effectiveness of cognitive training interventions has been conducted. This randomized controlled trial examined the effectiveness of a 9-h group cognitive training targeting higher-order functions, Strategic Memory Advanced Reasoning Training (SMART), compared to a 9-h psychoeducational control group in improving neurocognitive functioning in adults with mTBI and PTSD. A sample of 124 adults with histories of mild TBI (n = 117) and/or current diagnoses of PTSD (n = 84) were randomized into SMART (n = 66) or Brain Health Workshop (BHW; n = 58) and assessed at three time points: baseline, following training, and 6 months later. Participants completed a battery of neurocognitive tests, including a test of gist reasoning (a function directly targeted by SMART) as well as tests of verbal, visual, and working memory and executive functioning, functions commonly found to be mildly impaired in mTBI and PTSD. The two groups were compared on trajectories of change over time using linear mixed-effects models with restricted maximum likelihood (LMM). Contrary to our hypothesis that SMART would result in superior improvements compared to BHW, both groups displayed statistically and clinically significant improvements on measures of memory, executive functioning, and gist reasoning. Over 60% of the sample showed clinically significant improvements, indicating that gains can be found through psychoeducation alone. A longer SMART protocol may be warranted for clinical samples in order to observe gains over the comparison group.

Oculomotor Behavior as a Biomarker for Differentiating Pediatric Patients With Mild Traumatic Brain Injury and Age Matched Controls

IMPORTANCE

Children have the highest incidence of mild traumatic brain injury (mTBI) in the United States. However, mTBI, specifically pediatric patients with mTBI, are notoriously difficult to detect, and with a reliance on traditional, subjective measurements of eye movements, the subtle but key oculomotor deficits are often missed.

OBJECTIVE

The purpose of this project is to determine if the combined measurement of saccades, smooth pursuit, fixations and reaction time represent a biomarker for differentiating pediatric patients with mild traumatic brain injury compared to age matched controls.

DESIGN

This study used cross-sectional design. Each participant took part in a suite of tests collectively labeled the "Brain Health EyeQ" to measure saccades, smooth pursuit, fixations and reaction time.

PARTICIPANTS

The present study recruited 231 participants - 91 clinically diagnosed with a single incident mTBI in the last 2 days as assessed by both the Glasgow Coma Scale (GCS) and Graded Symptoms Checklist (GSC), and 140 age and gender-matched controls (n = 165 male, n = 66 female, M age = 14.20, SD = 2.78).

RESULTS

One-way univariate analyses of variance examined the differences in performance on the tests between participants with mTBI and controls. ROC curve analysis examined the sensitivity and specificity of the tests. Results indicated that together, the "Brain Health EyeQ" tests were successfully able to identify participants with mTBI 75.3% of the time, providing further validation to a growing body of literature supporting the use of eye tracking technology for mTBI identification and diagnosis.

Characteristics, injuries, and clinical outcomes of geriatric trauma patients in Japan: an analysis of the nationwide trauma registry database

Geriatric trauma is a major socio-economic problem, especially among the aging Japanese society. Geriatric people are more vulnerable to trauma than younger people; thus, their outcomes are often severe. This study evaluates the characteristics of geriatric trauma divided by age in the Japanese population. We evaluated trauma characteristics in patients (n = 131,088) aged ≥ 65 years by segregating them into 2 age-based cohorts: age 65–79 years (65–79 age group; n = 70,707) and age ≥ 80 years (≥ 80 age group; n = 60,381). Clinical characteristics such as patient background, injury mechanism, injury site and severity, treatment, and outcome were examined. Injuries among men were more frequent in the 65–79 age group (58.6%) than in the ≥ 80 age group (36.3%). Falls were the leading cause of trauma among the 65–79 age group (56.7%) and the ≥ 80 age group (78.9%). In-hospital mortality was 7.7% in the 65–79 age group and 6.6% in the ≥ 80 age group. High fall in the ≥ 80 age group showed 30.5% mortality. The overall in-hospital mortality was 11.8% (the 65–79 age group, 12.3%; the ≥ 80 age group, 11.2%). Most hospitalized patients were transferred to another hospital (the 65–79 age group, 52.5%; the ≥ 80 age group, 66.2%). We demonstrated the epidemiological characteristics of Japanese geriatric trauma patients. The overall in-hospital mortality was 11.8%, and fall injury in the ≥ 80 age group required caution of trauma care.

Is There Any Difference in the Outcome of Geriatric and Non-Geriatric Severely Injured Patients?-A Seven-Year, Retrospective, Observational Cohort Study with Matched-Pair Analysis

Geriatric trauma is expected to increase due to the lifestyle and activity of the aging population and will be among the major future challenges in health care. Therefore, the aim of this study was to investigate differences between polytraumatized geriatric and non-geriatric patients regarding mortality, length-of-stay and complications with a matched pair analysis. We included patients older than 17 years with an Injury Severity Score (ISS) of 16 or more admitted to our level 1 trauma center between January 2008 and December 2015. The cohort was stratified into two groups (age < 70 and ≥ 70 years). One-to-one matching was performed based on gender, ISS, mechanism of injury (penetrating/blunt), Glasgow coma scale (GCS), base excess, and the presence of coagulopathy (international normalized ratio (INR) ≥ 1.4). Outcome was compared using the paired t-test and McNemar-test. A total of 1457 patients were identified. There were 1022 male (70%) and 435 female patients. Three hundred and sixty-four patients (24%) were older than 70 years. Matching resulted in 57 pairs. Mortality as well as length-of-stay were comparable between geriatric and non-geriatric polytraumatized patients. Complication rate (34% vs. 56%, p = 0.031) was significantly higher in geriatric patients. This indicates the possibility of similar outcomes in geriatric polytraumatized patients receiving optimal care.

Cognitive-communication difficulties following traumatic brain injury sustained in older adulthood: a scoping review

BACKGROUND

Older adults are a peak incidence group for traumatic brain injury (TBI). However, empirical evidence on TBI in older adults is often limited to extrapolated findings from studies involving younger adults. While cognitive-communication deficits are an established consequence of TBI with substantial impact on social outcome for younger adults, little is known about the nature of cognitive-communication changes experienced by older adults following a new-onset TBI. In order to inform evidence-based service delivery and support older adults who sustain TBI, it is important to understand how these difficulties manifest in older adults.

AIMS

To review the empirical literature to determine the nature and breadth of research that has addressed the influence of older age on cognitive-communication outcomes following TBI sustained in older adulthood.

METHODS & PROCEDURES

A scoping review framework was used. Five electronic databases (Medline, PsycINFO, Embase, CINAHL and Scopus) were searched to locate peer-reviewed studies addressing cognitive-communication following TBI sustained at ≥ 55 years. Given the absence of dedicated investigations within the search yield, studies were included where at least 30% of participants were aged ≥ 55 years at injury, and age was a stated focus of the investigation.

OUTCOMES & RESULTS

A total of 2468 unique records were identified and reduced to 225 after title and abstract screening. Full-text review revealed only three studies that met the criteria. Collectively these studies included adults aged 55-93 years at injury. Two studies focused on age as a predictor for acute cognitive-communication difficulty, and one on the impact of age on facial emotion recognition in the chronic stages of injury. None of the studies had a dedicated focus on cognitive-communication outcomes for older adults who sustained a TBI within the defined period of older adulthood.

CONCLUSIONS & IMPLICATIONS

This scoping review produced limited results and insufficient evidence to inform rehabilitation for older adults. Indeed, very little is known about cognitive-communication outcomes for older adults who sustain a TBI. This review highlights the need, in the context of an ageing population, for research within this area to be prioritized. What this paper adds What is already known on the subject Empirical evidence to support the management of post-TBI cognitive-communication difficulties in adults predominantly stems from studies with young adults. However, the broader TBI literature suggests that outcome for older adults requires specific consideration due to its distinct nature and occurrence during a stage of life when there is the potential for subtle change to the processes of cognition and communication as part of typical ageing. What this paper adds to existing knowledge This scoping review identifies that research related to cognitive-communication outcomes for older adults who have sustained a TBI is very much in its infancy. Overarching statements about post-TBI cognitive-communication outcomes for older adults cannot be drawn, nor can it be determined if outcomes for older adults differ from younger adults. What are the potential or actual clinical implications of this work? The lack of research in this area means that tangible guidance cannot be provided to clinicians working with older adults following TBI to support evidence-based practice for cognitive-communication. This scoping review strongly supports the need for further research in this area.

Geographical Variation in Traumatic Brain Injury Mortality by Proximity to the Nearest Neurosurgeon

BACKGROUND

Trauma mortality disproportionately affects populations farther from potentially lifesaving trauma care, and traumatic brain injury (TBI) is no exception. Previous examinations have examined proximity to trauma centers as an explanation for trauma mortality, but little is known about the relationship between proximity to neurosurgeons specifically in TBI mortality.

MATERIALS AND METHODS

In this cross-sectional study, county-level TBI mortality rates from 2008 to 2014 were examined in relation to the distance to the nearest neurosurgeon and trauma facility. The locations of practicing neurosurgeons and trauma facilities in the United States were determined by geocoding data from the 2017 Medicare Physician and Other Supplier and Provider of Services files (respectively). The association between TBI mortality and the distance from the population-weighted centroid of the county to a closest neurosurgeon and trauma facility was examined using multivariate negative binomial regression.

RESULTS

A total of 761 of the 3108 counties (24.5%) in the continental United States were excluded from the analysis because they had 20 or fewer TBI deaths during this time, producing unstable estimates. Excluded counties accounted for 1.67% of the US population. Multivariate analysis revealed a county's mortality increased 10% for every 25 miles from the nearest neurosurgeon (adjusted incident rate ratio: 1.10 [95% confidence interval: 1.08-1.12]; P < 0.001). The distance to the nearest trauma facility was not found to be significantly associated with mortality (adjusted incident rate ratio: 1.01 [95% confidence interval: 0.99-1.03]; P = 0.36).

CONCLUSIONS

These findings suggest that proximity to neurosurgeons may influence county-level TBI mortality. Further research into this topic with more granular data may help to allocate scarce public health resources.

Influence of Caretakers' Health Literacy on Delays to Traumatic Brain Injury Care in Uganda

Background

Traumatic brain injury (TBI) is a life-altering condition, and delays to care can significantly impact outcomes. In Uganda, where nurse shortages are prevalent, patients' family members are the primary caretakers of these patients and play an important role in ensuring patients' access to timely care. However, caretakers often have little or no knowledge of appropriate patient care. Caretakers' ability to navigate the healthcare system and find and use health information to support their patients can impact delays in seeking, reaching, and receiving care.

Objectives

This study seeks to determine the factors that impact TBI patient caretakers' health literacy and examine how these factors influence delays in care.

Methods

This study was carried out in the Mulago National Referral Hospital neurosurgical ward, where 27 adult caretakers were interviewed using semi-structured, in-depth, qualitative interviews. "The Three Delay Framework" was utilized to understand participants' experiences in seeking, reaching, and receiving care for TBI patients. Thematic content analysis and manual coding was used to analyze interview transcripts and identify overarching themes in participant responses.

Findings

The main health literacy themes identified were Extrinsic, Intrinsic and Health System Factors. Nine sub-themes were identified: Government Support, Community Support, Financial Burdens, Lack of Medical Resources, Access to Health Information, Physician Support, Emotional Challenges, Navigational Skills, and Understanding of Health Information. These components were found to influence the delays to care to varying degrees. Financial Burdens, Government Support, Emotional Challenges, Physician Support and Lack of Medical Resources were recurring factors across the three delays.

Conclusion

The health literacy factors identified in this study influence caretakers' functional health literacy and delays to care in a co-dependent manner. A better understanding of how these factors impact patient outcomes is necessary for the development of interventions targeted at improving a caretaker's ability to maneuver the healthcare system and support patients in resource-poor settings.

Prevalence of Medical and Psychiatric Comorbidities Following Traumatic Brain Injury

OBJECTIVE

To examine the prevalence of selected medical and psychiatric comorbidities that existed prior to or up to 10 years following traumatic brain injury (TBI) requiring acute rehabilitation.

DESIGN

Retrospective cohort.

SETTING

Six TBI Model Systems (TBIMS) centers.

PARTICIPANTS

In total, 404 participants in the TBIMS National Database who experienced TBI 10 years prior.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURE

Self-reported medical and psychiatric comorbidities and the onset time of each endorsed comorbidity.

RESULTS

At 10 years postinjury, the most common comorbidities developing postinjury, in order, were back pain, depression, hypertension, anxiety, fractures, high blood cholesterol, sleep disorders, panic attacks, osteoarthritis, and diabetes. Comparing those 50 years and older to those younger than 50 years, diabetes (odds ratio [OR] = 3.54; P = .0016), high blood cholesterol (OR = 2.04; P = .0092), osteoarthritis (OR = 2.02; P = .0454), and hypertension (OR = 1.84; P = .0175) were significantly more prevalent in the older cohort while panic attacks (OR = 0.33; P = .0022) were significantly more prevalent in the younger cohort. No significant differences in prevalence rates between the older and younger cohorts were found for back pain, depression, anxiety, fractures, or sleep disorders.

CONCLUSIONS

People with moderate-severe TBI experience other medical and mental health comorbidities during the long-term course of recovery and life after injury. The findings can inform further investigation into comorbidities associated with TBI and the role of medical care, surveillance, prevention, lifestyle, and healthy behaviors in potentially modifying their presence and/or prevalence over the life span.

Correlations Between the Glasgow Score and the Survival Period in Patients with Severe Traumatic Brain Injury

Traumatic brain injury (TBI) contributes by 30% to the mortality induced by traumatic injuries, also being one of the major causes of invalidity worldwide. The clinical classification of the severity of mild, moderate or severe TBI is made according to the Glasgow scale, according to the patient's conscious state, motric changes, speech changes and eye opening. In our study, we evaluated the correlation between the Glasgow score at admission and the survival period of patients suffering from TBI, using the data recorded in the Forensic Medicine Institute of Craiova between 2011-2017 on 1005 cases with the diagnosis of death by TBI. We observed that TBI affects persons of all ages, starting from babies up to the elderly aged over 90 years old. Regarding the generation mechanism, most deaths were caused by fallings (438 cases, 43.58%), followed by car accidents (333 cases, representing 33.13%). The number of patients who presented a post-traumatic survival period was 802 (79.80%), of which 779 adults (77.51%) and 23 children (2.29%). Among these, 785 (78.11%-764 adults and 21 children) were hospitalized, while in 64.58% of the TBI patients there was recorded the Glasgow score at admission. 75% of the TBI patients in whom there was recorded the Glasgow score presented a 1st-4th coma degree, with a Glasgow score from 3 to 8 and only 25% had a slightly altered or preserved conscious state, with a Glasgow score=9-15. The survival period varied from less than 24 hours to over 15 days. In the hospitalized patients, there were performed emergency surgeries in 269 (26.76%) cases, the surgical intervention being temporized in 108 (10.74%) patients.

The physiological roles of tau and Aβ: implications for Alzheimer's disease pathology and therapeutics

Tau and amyloid beta (Aβ) are the prime suspects for driving pathology in Alzheimer's disease (AD) and, as such, have become the focus of therapeutic development. Recent research, however, shows that these proteins have been highly conserved throughout evolution and may have crucial, physiological roles. Such functions may be lost during AD progression or be unintentionally disrupted by tau- or Aβ-targeting therapies. Tau has been revealed to be more than a simple stabiliser of microtubules, reported to play a role in a range of biological processes including myelination, glucose metabolism, axonal transport, microtubule dynamics, iron homeostasis, neurogenesis, motor function, learning and memory, neuronal excitability, and DNA protection. Aβ is similarly multifunctional, and is proposed to regulate learning and memory, angiogenesis, neurogenesis, repair leaks in the blood-brain barrier, promote recovery from injury, and act as an antimicrobial peptide and tumour suppressor. This review will discuss potential physiological roles of tau and Aβ, highlighting how changes to these functions may contribute to pathology, as well as the implications for therapeutic development. We propose that a balanced consideration of both the physiological and pathological roles of tau and Aβ will be essential for the design of safe and effective therapeutics.

Cutaneous impact location: a new tool to predict intracranial lesion among the elderly with mild traumatic brain injury?

Background

Mild traumatic brain injury is the leading cause of arrivals to emergency department due to trauma in the 65-year-old population and over. Recent studies conducted in ED suggested a low intracranial lesion prevalence. The objectives of this study were to assess the prevalence and risk factors of intracranial lesion in older patients admitted to emergency department for mild traumatic brain injury by reporting in the emergency department the precise anamnesis of injury and clinical findings.

Methods

Patients of 65 years old and over admitted in emergency department were prospectively included in this monocentric study. The primary outcome was the prevalence of intracranial lesion threw neuroimaging.

Results

Between January and June 2019, 365 patients were included and 66.8% were women. Mean age was 86.5 years old (SD = 8.5). Ground-level fall was the most common cause of mild traumatic brain injury and occurred in 335 patients (91.8%). Overall, 26 out of 365 (7.2%) patients had an intracranial lesion. Compared with cutaneous frontal impact (medium risk group), the relative risk of intracranial lesion was 2.54 (95% CI 1.20 to 5.42) for patients with temporoparietal or occipital impact (high risk group) and 0.12 (95% CI 0.01 to 0.93) for patients with facial impact or no cutaneous impact (low risk group). There was not statistical increase in risk of intracranial injury with patients receiving antiplatelets (RR = 1.43; 95% CI 0.68 to 2.99) or anticoagulants (RR = 0.98; 95% CI 0.45 to 2.14).

Conclusion

Among patients of 65 years old and over, the prevalence of intracranial lesion after a mild traumatic brain injury was similar to the younger adult population. The cutaneous impact location on clinical examination at the emergency department may identify older patients with low, medium and high risk for intracranial lesion.

Prognostic Factors in Trauma Patients Transported by Physician-Staffed Helicopter in Japan: An Investigation Based on the Japan Trauma Data Bank

OBJECTIVE

We retrospectively investigated prognostic factors for patients evacuated by the physician-staffed helicopter emergency medical service using the Japan Trauma Data Bank.

METHODS

The study period was from January 2004 to May 2019. The subjects were divided into 2 groups according to the outcome: the survival group and the fatal group.

RESULTS

A total of 19,370 patients were enrolled as subjects. There were 17,080 patients in the survival group and 2,290 in the fatal group. In a multivariate analysis of factors that showed statistical significance in a univariate analysis, the Revised Trauma Score, age, Injury Severity Score, Maximum Abbreviated Injury Scale (MAX-AIS) for the upper extremity (negative), year of helicopter dispatch, Japan Coma Scale, MAX-AIS for the head, MAX-AIS for the abdomen/pelvis, and MAX-AIS for the spine were identified as significant predictors of a fatal outcome .

CONCLUSION

This is the first report to investigate the prognostic factors of patients evacuated by helicopter emergency medical service using the Japan Trauma Data Bank. The results suggest that physiological abnormality, age, traumatic anatomic abnormality (other than upper extremity abnormality), and year of helicopter dispatch may be prognostic factors.

Traumatic brain injury causing intestinal dysfunction: A review

Traumatic brain injuries (TBI) and its sequelae are becoming one of the most pressing public health concerns worldwide. It is one of the leading causes of increased morbidity and mortality. The primary insult to the brain can cause ischemic brain injury, paralysis, concussions, death, and other serious complications. Brain injury also involves other systems through a secondary pathway resulting in multiple complications during and after hospitalization. The focus of our article is to assess the literature available on traumatic brain injury and intestinal dysfunctional to highlight the aspects of epidemiology, pathophysiology, and different diagnostic approaches for early diagnosis of gut dysfunction. We review studies done in both humans and animals, to better understand this underrated topic, as it costs billions of dollars to the healthcare industry because of delayed diagnosis.

Plasma Phospholipid Metabolites Associate With Functional Outcomes Following Mild Traumatic Brain Injury in Older Adults

OBJECTIVE

To compare differences using a metabolomics approach in older adults (≥55) with mild traumatic brain injury (mTBI) to control adults and to identify a signature profile related to functional outcome 3-6 months post-injury.

METHODS

We performed metabolomics analysis using LC-MS of untargeted aqueous metabolites on plasma samples taken from a parent prospective cohort study. Older adults with mTBI (n = 14) were purposively sampled to include participants with worsening (decrease in GOS-E of at least 1 level) and improved (increase in GOS-E of at least 1 level) outcomes from 3 to 6 months. The data were analyzed using PLS-DA with VIP scores, Random Forest, and spline fit between the different groups as a function of time for exposure on outcome.

RESULTS

Separation of comparisons were seen at 24 hours (negative ionization) and 6 months (positive ionization), revealing two metabolites of interest, phosphatidylcholine and phosphatidylethanolamine. Phosphatidylcholine levels were higher in those with mTBI compared to controls (p < 0.05), while lower concentration of phosphatidylethanolamine was seen in those with mTBI compared to controls (p < 0.05). Phosphatidylinositol-3,4,5-trisphosphate was significant in those with mTBI compared to controls (n = 10) based on improved (n = 6) versus worsened (n = 8) outcomes from 3 to 6 months.

CONCLUSION

We identified plasma metabolites related to phospholipid metabolism in older adults following mTBI and associated with long-term functional outcome. These findings may underly pathological mechanisms of outcome differences in older adults who experience mTBI.

Reference Values of the QOLIBRI from General Population Samples in the United Kingdom and The Netherlands

The Quality of Life after Traumatic Brain Injury (QOLIBRI) instrument is an internationally validated patient-reported outcome measure for assessing disease-specific health-related quality of life (HRQoL) in individuals after traumatic brain injury (TBI). However, no reference values for general populations are available yet for use in clinical practice and research in the field of TBI. The aim of the present study was, therefore, to establish these reference values for the United Kingdom (UK) and the Netherlands (NL). For this purpose, an online survey with a reworded version of the QOLIBRI for general populations was used to collect data on 4403 individuals in the UK and 3399 in the NL. This QOLIBRI version was validated by inspecting descriptive statistics, psychometric criteria, and comparability of the translations to the original version. In particular, measurement invariance (MI) was tested to examine whether the items of the instrument were understood in the same way by different individuals in the general population samples and in the TBI sample across the two countries, which is necessary in order to establish reference values. In the general population samples, the reworded QOLIBRI displayed good psychometric properties, including MI across countries and in the non-TBI and TBI samples. Therefore, differences in the QOLIBRI scores can be attributed to real differences in HRQoL. Individuals with and without a chronic health condition did differ significantly, with the latter reporting lower HRQoL. In conclusion, we provided reference values for healthy individuals and individuals with at least one chronic condition from general population samples in the UK and the NL. These can be used in the interpretation of disease-specific HRQoL assessments after TBI applying the QOLIBRI on the individual level in clinical as well as research contexts.

Mild head trauma in elderly patients: experience of an emergency department

INTRODUCTION

We evaluated the risk profile of elderly patients who came to the emergency department for mild head trauma. The primary goal was to determine the difference in the incidence of posttraumatic intracranial hemorrhage (ICH) after minor head injury (MHI). The secondary objective was to assess worse outcome, such as: hospitalization rate, rate of re-admission, need of neurosurgery. We also assess the admission process times and length of hospital stay. The ultimate goal was to optimize the diagnostic-observational management of minor head trauma in elderly patients.

MATERIAL AND METHODS

We evaluated all patients with MHI who came to our emergency department during 2017 and 2018. All patients underwent computed tomography.

RESULTS

We enrolled 2325 patients, of whom 1094 were 75 years of age or older. The population was divided into two categories according to age: The "elderly population" was 75 or older, and the younger patients were younger than 75. The elderly population, in comparison with the younger patients, had a higher rate of ICH (12.1% versus 5.1%), a higher hospitalization rate (11.7% versus 5.5%), and a higher rate of readmission within 30 days (6.8% versus 3.2%). The elderly population also had longer admission process times (8 h, 25 min, versus 4 h, 09 min) and longer lengths of hospital stay (9 h, 41 min, versus 5 h, 29 min). Of the younger patients, 92% (versus 41% of the elderly population) did not take any drugs, 6% (versus 39%) were receiving antiplatelet therapy, 1% (versus 13%) took vitamin K antagonists, and 1% (versus 7%) took oral direct-acting anticoagulants. Logistic regression models revealed that a 1-year increase in age raised the risk of bleeding by 2% on average; this finding was statistically significant (odds ratio [OR], 1023/year, p < 0.001). The rate of ICH increased significantly after the age of 75, by 180% (OR, 2.82; p < 0.001).

CONCLUSIONS

These data suggest that age is an independent risk factor for ICH, whereby the age of 75 entails a 180% increase in the risk of bleeding.

Comparison of traumatic brain injury patients with brain computed tomography in the emergency department by age group

Objective

Traumatic brain injury (TBI) is an important public health concern due to its high prevalence and mortality rate among young people. We investigated the clinical and social characteristics of patients who visited the emergency department due to TBI in whom brain computed tomography, was performed by age.

Methods

We retrospectively analyzed 15,567 TBI patients who received a brain computed tomography evaluation at the emergency department of Korea University Hospital from March 2013 to February 2016. We divided patients into age groups by decade and analyzed factors such as sex, trauma mechanism, need for operation, hospitalization, and results of treatment.

Results

The mean age was 42.0±22.8 years; the most common age group was the 50s (16.5%). Except for the age group over 70 years, males predominated. Under 9 years of age, public ambulance usage rate was lower than in other age groups. Regarding severity based on the Glasgow Coma Scale score, the proportion of mild cases was higher in those under 9 years of age (99.3%) and the proportion of severe cases was higher in those in their 20s (4.6%). The most common injury mechanism was blunt trauma, followed by car accidents. For those under 9 years of age, falls were more common than in other age groups. Only 20.5% of TBI patients were hospitalized and 11.9% were treated surgically, while 70.6% of patients were discharged home after treatment.

Conclusion

TBI may present with different characteristics depending on the age of the patients, thus prevention policies and clinical practice should be tailored to age.

Predictors of 1-Year Global Outcomes After Traumatic Brain Injury Among Older Adults: A NIDILRR Traumatic Brain Injury Model Systems Study

Objective: To assess predictors of global function and driving status among older adults (50 years and older) who survived 1 year following inpatient rehabilitation for moderate-to-severe traumatic brain injury (TBI). Methods: Functional status at 1-year post-TBI was determined for 1,845 individuals. The relationship age category to function was studied using associations and predictive modeling. Results: The final model accounted for 34% variance in Glasgow Outcome Scale-Extended (GOS-E) among 60- to 69-year-olds and 70- to 79-year-olds, and 25% variance in 50- to 59-year-olds and 80+-year-olds. FIM Motor at rehabilitation discharge made the greatest contribution to GOS-E variance across all age groups. Inpatient rehabilitation discharge to nursing home or adult home and rehospitalization were associated with a one-level decrease in GOS-E. Alcohol use predicted lower GOS-E among the 70- to 79-year-olds. Gender, ethnicity, and rehospitalizations were negatively associated driving. Discussion: Rehabilitation approaches to older adults with TBI may help maximize function and, thereby, improve later outcomes and decrease rehospitlaizations. Such strategies may include longer and more intensive acute rehabilitation with greater patient engagement and enhanced transitions of care.

Injury Diagnosis and Affected Body Part for Nonfatal Fall-Related Injuries in Community-Dwelling Older Adults Treated in Emergency Departments

Objective: To estimate frequency and type of older adult fall-related injuries treated in emergency departments (EDs). Methods: We used the 2015 National Electronic Injury Surveillance System: All Injury Program. Patient data were abstracted from the narratives describing the circumstance of injury. Data for community-dwelling older adults (n = 34,336) were analyzed to explore differences in injury diagnosis by demographic characteristics, location of fall, and disposition. Results: 70% of head-related injuries were internal injuries, suggestive of a traumatic brain injury. Most hip injuries were fractures or dislocations (73.3%). Women had higher percentages of fractures/dislocations but lower percentages of internal injuries than men. About a third of fall-related ED visits required hospitalization or transfer. Discussion: Falls in older adults result in array of injuries and pose a burden on the healthcare system. Understanding how fall injuries vary by different characteristics can help inform targeted prevention strategies.

Short-term outcome following significant trauma: increasing age per se has only a relatively low impact

PURPOSE

Ongoing demographic changes go hand in hand with an increasing number of elderly injured. Given the conflicting literature we wanted to know how much age per se, apart from other factors, actually explains the outcome for elderly trauma patients.

METHODS

Retrospective analysis of prospectively collected data on all significantly injured (new injury severity score, NISS  ≥ 8) adult patients treated at a Swiss trauma center between 01.01.2010 and 31.12.2017. The association of age and other demographic, trauma or treatment-related variables on parameters of short-term outcome was examined using uni- and multivariate analyses (mean ± SD; R²; p < 0.05).

RESULTS

2692 consecutive patients (33.4% female; mean age 58.1 ± 21.7; hospital mortality 10.1%) were studied. Detailed analysis of quinquennial age groups demonstrated a significant decline in outcome with regard to mortality or return-to-home rate following hospital discharge after the age of 60 years (p < 0.001). In univariate analysis, age explained 4.6% and the number of years ≥ 60 5.9% of hospital mortality. In multivariate analysis, the investigated demographic, trauma or treatment-related parameters contributed at 36.5% to prediction of mortality, age added another 1.5% and number of years  ≥ 60 another 2.1% (R²).

CONCLUSION

This monocenter evaluation showed a significant decline in short-term outcome and an increase in hospital resource requirements by the trauma patients investigated after the age of 60 years. Even so, after controlling for demographic, injury and treatment variables, age per se only added less than 2% to the prediction of hospital mortality.

Anatomical Localization of Traumatic Brain Injury Cases in Eastern Macedonia and Thrace, Greece: a 10-year Retrospective Observational Study

Objective

Brain trauma is an extremely important economical and social issue with increasing daily incidence. It is important to observe and report brain trauma, in order to provide better conditions for improvement of the trauma prevention and management.

Methods

A ten-year retrospective observational analysis was performed on 292 (fatal and non-fatal) incidents of traumatic brain injury among 2,847 totally examined cases in the records of the laboratory of forensic sciences at Democritus University of Thrace between January 1, 2007 and December 31, 2016. The results were further analyzed and classified into pertinent categories associated with the purpose of the study.

Results

The average age was estimated at 47.24 years with an obvious male domination. The most common cause of TBI, according to the results, is transport accidents (61.85%) followed by trauma inflicted by blunt instrument (22.49%), fall from height (11.65%) and occupational accidents (4.02%). Mortality rates were evaluated for each type, revealing extremely disturbing numbers. Regarding the anatomical localization on the skull, the most common region of cranial fractures is the cranial base (16.48%), followed by the frontal (12.87%), occipital (11.29%) and parietal bones (11.06%). In the majority of the cases, there were associated injuries.

Conclusion

The management of traumatic brain injuries is difficult and sometimes impossible. Better prevention measures are required to minimize as much as possible the incidence of brain trauma.

Is trauma center designation associated with disparities in discharge to rehabilitation centers among elderly patients with Traumatic Brain Injury?

BACKGROUND

We sought to evaluate the role of trauma center designation in the association of race and insurance status with disposition to rehabilitation centers among elderly patients with Traumatic Brain Injury (TBI).

METHODS

The National Trauma Data Bank (2014-2015) was used to identify elderly (age ≥ 65) patients with isolated moderate to severe blunt TBI who survived to discharge. Race, insurance status, and outcomes were stratified by trauma center designation and compared.

RESULTS

3,292 patients met the inclusion criteria. Black patients were 1.5 times less likely (AOR 0.64, p = 0.01) and Latino patients were 1.7 times less likely (AOR 0.58, p = 0 0.007) to be discharged to rehabilitation centers as compared with White patients. Asian patients at Level I hospitals were more likely to be discharged to rehabilitation centers if they had private vs. non-private insurance (42.9% versus 12.7%, p = 0.01).

CONCLUSION

Black and Latino patients were less likely to be discharged to rehabilitation centers compared to White patients. The etiology of these disparities deserves further study.

The Association of Trauma Center Transport and Long-term Functional Outcomes in Head-injured Older Adults Transported by Emergency Medical Services

OBJECTIVE

It is unclear whether trauma center care is associated with improved outcomes in older adults with traumatic brain injury (TBI) compared to management at nontrauma centers. Our primary objectives were to describe the long-term outcomes of older adults with TBI and to evaluate the association of trauma center transport with long-term functional outcome.

METHODS

This was a prospective, observational study at five emergency medical services (EMS) agencies and 11 hospitals representing all 9-1-1 transfers within a county. Older adults (≥55 years) with TBI (defined as closed head injury associated with loss of consciousness and/or amnesia, abnormal Glasgow Coma Scale [GCS] score, or traumatic intracranial hemorrhage) and transported by EMS from August 2015 to September 2016 were eligible. EMS providers completed standardized data forms and emergency department (ED) and hospital data were abstracted. Functional outcomes were measured using the Extended Glasgow Outcome Scale (GOS-E) at 3- and 6-month intervals by telephone follow-up. Reasons for disabilities were coded as due to head injury, due to illness or injury to other part of body, or due to a mixture of both. To evaluate the association of trauma center transport and functional outcomes, we conducted multivariate ordinal logistic regression analyses on multiple imputed data for 1) all patients with TBI and 2) patients with traumatic intracranial hemorrhage.

RESULTS

We enrolled 350 patients with TBI; the median (Q1, Q3) age was 70 (61, 84) years, 187 (53%) were male, and 91 patients (26%) had traumatic intracranial hemorrhage on initial ED cranial computed tomography (CT) imaging. A total of 257 patients (73%) were transported by EMS to a Level I or II trauma center. Sixty-nine patients (20%) did not complete follow-up at 3 or 6 months. Of the patients with follow-up, 119 of 260 patients (46%) had moderate disability or worse at 6 months, including 55 of 260 patients (21%) who were dead at 6-month follow-up. Death or severe disabilities were more commonly attributed to non-TBI causes while moderate disabilities or better were more commonly due to TBI. On adjusted analysis, an abnormal GCS score, higher Charlson Comorbidity Index scores, and the presence of traumatic intracranial hemorrhage on initial ED cranial imaging were associated with worse GOS-E scores at 6 months. Trauma center transport was not associated with GOS-E scores at 6 months for TBI patients and in patients with traumatic intracranial hemorrhage on initial ED CT imaging.

CONCLUSIONS

In older adults with TBI, moderate disability or worse is common 6 months after injury. Over one in five of older adults with TBI died by 6 months, usually due to nonhead causes. Patients with TBI or traumatic intracranial hemorrhage did not have improved functional outcomes with initial triage to a trauma center.

National Trends in Imaging Rates for Eye-Related Emergency Department Visits in the United States

PURPOSE

To identify nationwide trends and factors associated with advanced imaging (computed tomography [CT] and magnetic resonance imaging [MRI]) use for eye-related emergency department (ED) visits.

DESIGN

Retrospective, trend study.

METHODS

Setting: National Hospital Ambulatory Medical Care Survey 2007-2015.

PATIENT POPULATION

Eye-related ED patients who underwent CT or MRI.

MAIN OUTCOME MEASURE(S)

Population-based CT/MR imaging rates and independent factors associated with imaging.

RESULTS

An estimated 7 million eye-related ED visits occurred between 2007 and 2015. Adjusted for annual eye-related ED visits, the rate of imaging use rose 94%, from 121.7 per 1,000 eye-related ED visits in 2007 to 236.0 per 1,000 eye-related ED visits in 2015. Visual disturbances, contusion of the eye and/or adnexa, open globes and open wounds of ocular adnexa, diplopia, superficial corneal and/or conjunctival injuries, and orbital fractures accounted for 73.2% of all visits where imaging was performed. On multivariable analysis, older patients (odds ratio [OR] = 1.02, 95% confidence interval [CI] 1.01-1.03) and females (OR=2.07, 95% CI 1.18-3.63) were more likely to undergo imaging than younger patients and males. Imaging was also more likely to be performed for Medicare beneficiaries (OR=2.12, 95% CI 1.08-4.15) than for privately insured patients. Patients who were admitted to the hospital were 6 times more likely (OR=6.39, 95% CI 2.04-20.0) to undergo imaging than those who were not admitted.

CONCLUSIONS

Advanced imaging for eye-related ED visits has escalated at a higher rate than ED visits for eye complaints. Future studies to develop evidence-based algorithms for use of CT/MR imaging for eye complaints that can help balance benefits against financial costs and health risk are warranted.