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Molero Y, Sharp DJ, D’Onofrio BM, Lichtenstein P, Larsson H, Fazel S, Rostami E. Medication utilization in traumatic brain injury patients-insights from a population-based matched cohort study. Front Neurol 2024; 15:1339290. [PMID: 38385038 PMCID: PMC10879380 DOI: 10.3389/fneur.2024.1339290] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2023] [Accepted: 01/23/2024] [Indexed: 02/23/2024] Open
Abstract
Introduction Traumatic brain injury (TBI) is associated with health problems across multiple domains and TBI patients are reported to have high rates of medication use. However, prior evidence is thin due to methodological limitations. Our aim was thus to examine the use of a wide spectrum of medications prescribed to address pain and somatic conditions in a population-based cohort of TBI patients, and to compare this to a sex- and age-matched cohort. We also examined how patient factors such as sex, age, and TBI severity were associated with medication use. Methods We assessed Swedish nationwide registers to include all individuals treated for TBI in hospitals or specialist outpatient care between 2006 and 2012. We examined dispensed prescriptions for eight different non-psychotropic medication classes for the 12 months before, and 12 months after, the TBI. We applied a fixed-effects model to compare TBI patients with the matched population cohort. We also stratified TBI patients by sex, age, TBI severity and carried out comparisons using a generalized linear model. Results We identified 239,425 individuals with an incident TBI and 239,425 matched individuals. TBI patients were more likely to use any medication [Odds ratio (OR) = 2.03, 95% Confidence Interval (CI) = 2.00-2.05], to present with polypharmacy (OR = 1.96, 95% CI = 1.90-2.02), and to use each of the eight medication classes before their TBI, as compared to the matched population cohort. Following the TBI, TBI patients were more likely to use any medication (OR = 1.83, 95% CI = 1.80-1.86), to present with polypharmacy (OR = 1.74, 95% CI = 1.67-1.80), and to use all medication classes, although differences were attenuated. However, differences increased for antibiotics/antivirals (OR = 2.02, 95% CI = 1.99-2.05) and NSAIDs/antirheumatics (OR = 1.62, 95% CI = 1.59-1.65) post-TBI. We also found that females and older patients were more likely to use medications after their TBI than males and younger patients, respectively. Patients with more severe TBIs demonstrated increased use of antibiotics/ antivirals and NSAIDs/antirheumatics than those with less severe TBIs. Discussion Taken together, our results point to poor overall health in TBI patients, suggesting that medical follow-up should be routine, particularly in females with TBI, and include a review of medication use to address potential polypharmacy.
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Affiliation(s)
- Yasmina Molero
- Department of Clinical Neuroscience, Centre for Psychiatry Research, Karolinska Institutet, Stockholm, Sweden
- Stockholm Health Care Services, Stockholm County Council, Stockholm, Sweden
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden
| | - David J. Sharp
- Department of Brain Sciences, Imperial College London, London, United Kingdom
| | - Brian M. D’Onofrio
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden
- Department of Psychological and Brain Sciences, Indiana University, Bloomington, IN, United States
| | - Paul Lichtenstein
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden
| | - Henrik Larsson
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden
- School of Medical Sciences, Örebro University, Örebro, Sweden
| | - Seena Fazel
- Department of Psychiatry, University of Oxford, Oxford, United Kingdom
| | - Elham Rostami
- Department of Neuroscience, Karolinska Institutet, Stockholm, Sweden
- Department of Medical Sciences, Uppsala University, Uppsala, Sweden
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Kinney AR, Schneider AL, King SE, Yan XD, Forster JE, Bahraini NH, Brenner LA. Identifying and Predicting Subgroups of Veterans With Mild Traumatic Brain Injury Based on Distinct Configurations of Postconcussive Symptom Endorsement: A Latent Class Analysis. J Head Trauma Rehabil 2024:00001199-990000000-00103. [PMID: 38259092 DOI: 10.1097/htr.0000000000000890] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2024]
Abstract
OBJECTIVE To identify distinct subgroups of veterans with mild traumatic brain injury (mTBI) based on configurations of postconcussive symptom (PCS) endorsement, and to examine predictors of subgroup membership. SETTING Outpatient Veterans Health Administration (VHA). PARTICIPANTS Veterans with clinician-confirmed mTBI who completed the Neurobehavioral Symptom Inventory (NSI), determined using the Comprehensive Traumatic Brain Injury Evaluation database. Individuals who tended to overreport symptoms were excluded via an embedded symptom validity scale. DESIGN Retrospective cohort study leveraging national VHA clinical data from 2012 to 2020. Latent class analysis (LCA) with a split-sample cross-validation procedure was used to identify subgroups of veterans. Multinomial logistic regression was used to examine predictors of subgroup membership. MAIN MEASURES Latent classes identified using NSI items. RESULTS The study included 72 252 eligible veterans, who were primarily White (73%) and male (94%). The LCA supported 7 distinct subgroups of veterans with mTBI, characterized by diverging patterns of risk for specific PCS across vestibular (eg, dizziness), somatosensory (eg, headache), cognitive (eg, forgetfulness), and mood domains (eg, anxiety). The most prevalent subgroup was Global (20.7%), followed by Cognitive-Mood (16.3%), Headache-Cognitive-Mood (H-C-M; 16.3%), Headache-Mood (14.2%), Anxiety (13.8%), Headache-Sleep (10.3%), and Minimal (8.5%). The Global class was used as the reference class for multinomial logistic regression because it was distinguished from others based on elevated risk for PCS across all domains. Female (vs male), Black (vs White), and Hispanic veterans (vs non-Hispanic) were less likely to be members of most subgroups characterized by lesser PCS endorsement relative to the Global class (excluding Headache-Mood). CONCLUSION The 7 distinct groups identified in this study distill heterogenous patterns of PCS endorsement into clinically actionable phenotypes that can be used to tailor clinical management of veterans with mTBI. Findings reveal empirical support for potential racial, ethnic, and sex-based disparities in PCS among veterans, informing efforts aimed at promoting equitable recovery from mTBI in this population.
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Affiliation(s)
- Adam R Kinney
- Veteran Affairs Rocky Mountain Mental Illness Research, Education, and Clinical Center (MIRECC) for Suicide Prevention, Aurora, Colorado (Drs Kinney, Forster, Bahraini, and Brenner, Ms Schneider, and Messrs King and Yan); and Departments of Physical Medicine and Rehabilitation (Drs Kinney, Forster, Bahraini, and Brenner), Psychiatry (Drs Bahraini and Brenner), and Neurology (Dr Brenner), Anschutz Medical Campus, University of Colorado, Aurora
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Moore G, Evans RE, Hawkins J, Shenderovich Y, Young H. What does 'following the guidance' mean in an era of increasingly pluralistic guidance for the development, evaluation and implementation of interventions? J Epidemiol Community Health 2023; 77:753-754. [PMID: 37734935 DOI: 10.1136/jech-2023-220880] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2023] [Accepted: 08/29/2023] [Indexed: 09/23/2023]
Affiliation(s)
- Graham Moore
- Centre for Development, Evaluation, Complexity and Implementation in Public Health Improvement, School of Social Sciences, Cardiff University, Cardiff, UK
| | - Rhiannon E Evans
- Centre for Development, Evaluation, Complexity and Implementation in Public Health Improvement, School of Social Sciences, Cardiff University, Cardiff, UK
| | - Jemma Hawkins
- Centre for Development, Evaluation, Complexity and Implementation in Public Health Improvement, School of Social Sciences, Cardiff University, Cardiff, UK
| | - Yulia Shenderovich
- Centre for Development, Evaluation, Complexity and Implementation in Public Health Improvement, School of Social Sciences, Cardiff University, Cardiff, UK
| | - Honor Young
- Centre for Development, Evaluation, Complexity and Implementation in Public Health Improvement, School of Social Sciences, Cardiff University, Cardiff, UK
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Swan AA, Kennedy E, Cooper DB, Amuan ME, Mayo J, Tate DF, Song K, Eapen BC, Van Cott AC, Lopez MR, Pugh MJ. Comorbidity and polypharmacy impact neurobehavioral symptoms and symptom validity failure among post-9/11 veterans with mild traumatic brain injury. Front Neurol 2023; 14:1228377. [PMID: 37538260 PMCID: PMC10395329 DOI: 10.3389/fneur.2023.1228377] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2023] [Accepted: 06/26/2023] [Indexed: 08/05/2023] Open
Abstract
Objective The study aimed to examine the association between post-concussive comorbidity burdens [post-traumatic stress disorder (PTSD), depression, and/or headache] and central nervous system (CNS) polypharmacy (five or more concurrent medications) with reported neurobehavioral symptoms and symptom validity screening among post-9/11 veterans with a history of mild traumatic brain injury (mTBI). Setting Administrative medical record data from the Department of Veterans Affairs (VA) were used in the study. Participants Post-9/11 veterans with mTBI and at least 2 years of VA care between 2001 and 2019 who had completed the comprehensive traumatic brain injury evaluation (CTBIE) were included in the study. Design Retrospective cross-sectional design was used in the study. Main measures Neurobehavioral Symptom Inventory (NSI), International Classification of Diseases, Ninth Revision, and Clinical Modification diagnosis codes were included in the study. Results Of the 92,495 veterans with a history of TBI, 90% had diagnoses of at least one identified comorbidity (PTSD, depression, and/or headache) and 28% had evidence of CNS polypharmacy. Neurobehavioral symptom reporting and symptom validity failure was associated with comorbidity burden and polypharmacy after adjusting for sociodemographic characteristics. Veterans with concurrent diagnoses of PTSD, depression, and headache were more than six times more likely [Adjusted odds ratio = 6.55 (99% CI: 5.41, 7.92)]. to fail the embedded symptom validity measure (Validity-10) in the NSI. Conclusion TBI-related multimorbidity and CNS polypharmacy had the strongest association with neurobehavioral symptom distress, even after accounting for injury and sociodemographic characteristics. Given the regular use of the NSI in clinical and research settings, these findings emphasize the need for comprehensive neuropsychological evaluation for individuals who screen positively for potential symptom overreporting, the importance of multidisciplinary rehabilitation to restore functioning following mTBI, and the conscientious utilization of symptom validity measures in research efforts.
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Affiliation(s)
- Alicia A. Swan
- Polytrauma Rehabilitation Center, South Texas Veterans Health Care System, San Antonio, TX, United States
- Department of Psychology, The University of Texas at San Antonio, San Antonio, TX, United States
| | - Eamonn Kennedy
- Veterans Affairs Salt Lake City Health Care System, Informatics Decision Enhancement and Analytic Sciences Center of Innovation, Salt Lake City, UT, United States
- Division of Epidemiology, University of Utah School of Medicine Department of Internal Medicine, Salt Lake City, UT, United States
- University of Utah School of Medicine Department of Neurology, Salt Lake City, UT, United States
| | - Douglas B. Cooper
- Polytrauma Rehabilitation Center, South Texas Veterans Health Care System, San Antonio, TX, United States
- Departments of Rehabilitation Medicine and Psychiatry, The University of Texas Health San Antonio, San Antonio, TX, United States
| | - Megan E. Amuan
- Veterans Affairs Salt Lake City Health Care System, Informatics Decision Enhancement and Analytic Sciences Center of Innovation, Salt Lake City, UT, United States
- Division of Epidemiology, University of Utah School of Medicine Department of Internal Medicine, Salt Lake City, UT, United States
| | - Jamie Mayo
- Veterans Affairs Salt Lake City Health Care System, Informatics Decision Enhancement and Analytic Sciences Center of Innovation, Salt Lake City, UT, United States
- Division of Epidemiology, University of Utah School of Medicine Department of Internal Medicine, Salt Lake City, UT, United States
| | - David F. Tate
- Veterans Affairs Salt Lake City Health Care System, Informatics Decision Enhancement and Analytic Sciences Center of Innovation, Salt Lake City, UT, United States
- University of Utah School of Medicine Department of Neurology, Salt Lake City, UT, United States
| | - Kangwon Song
- Augusta University Medical Center, Augusta University, Augusta, GA, United States
| | - Blessen C. Eapen
- Department of Physical Medicine and Rehabilitation, VA Greater Los Angeles Healthcare System, Los Angeles, CA, United States
- Division of Physical Medicine and Rehabilitation, Department of Medicine, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, CA, United States
| | - Anne C. Van Cott
- Department of Neurology, University of Pittsburgh, Pittsburgh, PA, United States
- Department of Veterans Affairs, Pittsburgh Healthcare System, Pittsburgh, PA, United States
| | - Maria R. Lopez
- Bruce Carter Hospital, Miami Veterans Health Administration, Miami, FL, United States
- Miller School of Medicine, University of Miami, Miami, FL, United States
| | - Mary Jo Pugh
- Veterans Affairs Salt Lake City Health Care System, Informatics Decision Enhancement and Analytic Sciences Center of Innovation, Salt Lake City, UT, United States
- Division of Epidemiology, University of Utah School of Medicine Department of Internal Medicine, Salt Lake City, UT, United States
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Kumar RG, Klyce D, Nakase-Richardson R, Pugh MJ, Walker WC, Dams-O'Connor K. Associations of Military Service History and Health Outcomes in the First Five Years After Traumatic Brain Injury. J Neurotrauma 2023; 40:1173-1186. [PMID: 36401499 PMCID: PMC10259615 DOI: 10.1089/neu.2022.0340] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
For many years, experts have recognized the importance of studying traumatic brain injury (TBI) among active-duty service members and veterans. A majority of this research has been conducted in Veterans Administration (VA) or Department of Defense settings. However, far less is known about military personnel who seek their medical care outside these settings. Studies that have been conducted in civilian settings have either not enrolled active duty or veteran participants, or failed to measure military history, precluding study of TBI outcomes by military history. The purpose of the present study was to determine associations between military history and medical (prevalence of 25 comorbid health conditions), cognition (Brief Test of Adult Cognition by Telephone), and psychological health (Patient Health Questionnaire-9 [PHQ-9], Generalized Anxiety Disorder-7, suicidality [9th item from PHQ-9]) in the first 5 years after TBI. In this prospective study, we analyzed data from the TBI Model Systems National Database. Participants were 7797 individuals with TBI admitted to one of 21 civilian inpatient rehabilitation facilities from April 1, 2010, to November 19, 2020, and followed up to 5 years. We assessed the relationship between military history (any versus none, combat exposure, service era, and service duration) and TBI outcomes. We found specific medical conditions were significantly more prevalent 1 year post-TBI among individuals who had a history of combat deployment (lung disorders, post-traumatic stress disorder [PTSD], and sleep disorder), served in post-draft era (chronic pain, liver disease, arthritis), and served >4 years (high cholesterol, PTSD, sleep disorder). Individuals with military history without combat deployment had modestly more favorable cognition and psychological health in the first 5 years post-injury relative to those without military history. Our data suggest that individuals with TBI with military history are heterogeneous, with some favorable and other deleterious health outcomes, relative to their non-military counterparts, which may be driven by characteristics of service, including combat exposure and era of service.
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Affiliation(s)
- Raj G. Kumar
- Department of Rehabilitation and Human Performance, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Daniel Klyce
- Department of Physical Medicine and Rehabilitation, School of Medicine, Virginia Commonwealth University (VCU), Richmond, Virginia, USA
- Mental Health Service, Central Virginia VA Health Care System, Richmond, Virginia, USA
- Sheltering Arms Institute, Richmond, Virginia, USA
| | - Risa Nakase-Richardson
- Mental Health and Behavior Sciences, Defense Health Agency TBI Center of Excellence, James A. Haley Veterans Hospital, Tampa, Florida, USA
- Pulmonary/Sleep Medicine Division, Department of Internal Medicine, University of South Florida, Tampa, Florida, USA
| | - Mary Jo Pugh
- Informatics, Decision-Enhancement and Analytic Sciences Center, VA Salt Lake City Health Care System, Salt Lake City, Utah, USA
- Department of Medicine, University of Utah, Salt Lake City, Utah, USA
| | - William C. Walker
- Department of Physical Medicine and Rehabilitation, School of Medicine, Virginia Commonwealth University (VCU), Richmond, Virginia, USA
- Sheltering Arms Institute, Richmond, Virginia, USA
- PM&R Service, Richmond Veterans Affairs Medical Center, Central Virginia Veterans Affairs Health Care System, Richmond, Virginia, USA
| | - Kristen Dams-O'Connor
- Department of Rehabilitation and Human Performance, Icahn School of Medicine at Mount Sinai, New York, New York, USA
- Department of Neurology, Icahn School of Medicine at Mount Sinai, New York, New York, USA
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Mayo J, Panahi S, Roghani A, Van Cott AC, Pugh MJ. Treatment of Epilepsy in the Setting of Cognitive Decline in Older Adults. Curr Treat Options Neurol 2022. [DOI: 10.1007/s11940-022-00740-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
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