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Lee I, Davis B, Purt B, DesRosiers T. Ocular Trauma and Traumatic Brain Injury on the Battlefield: A Systematic Review After 20 Years of Fighting the Global War on Terror. Mil Med 2023; 188:2916-2923. [PMID: 35869887 DOI: 10.1093/milmed/usac226] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2022] [Revised: 07/05/2022] [Accepted: 07/19/2022] [Indexed: 08/31/2023] Open
Abstract
INTRODUCTION Operations Iraqi Freedom and Enduring Freedom saw higher rates of combat ocular trauma (COT) than any past U.S. conflict. The improvised explosive device, the signature weapon of the conflicts, as well as improved personal protective equipment and combat medical care all attributed to COT being the fourth most common injury sustained by wounded U.S. service members. This review describes the epidemiology, mechanisms, and treatment patterns and discusses the relationship of traumatic brain injuries (TBIs) to ocular injuries sustained by U.S. service members during the War on Terror. MATERIALS AND METHODS A mixed-methods review of the literature was conducted by extracting data from PubMed, Embase, and Cochrane research databases between December 15, 2020, and January 25, 2021, using the COVIDENCE review management software. RESULTS Of 827 articles for review, 50 were deemed relevant. Articles were separated using the Birmingham Eye Trauma Terminology into open globe, closed globe, mixed/injury management only, and TBI. Seventeen articles were found to discuss data pertaining to particular databases. Overall, six articles discussed open-globe injuries in the setting of overall COT with a reported rate of 38-64%. Three articles discussed closed-globe injuries in the context of overall COT with a rate of 39-47%. Numerous articles discussed the relationship between COT and TBI. Within the Walter Reed Ocular Trauma Database, 40% of patients with ocular trauma had concomitant TBI. Additionally, the visual sequelae of ocular trauma ranged from 9% to 50% among reporting studies. Other ocular injury patterns receiving attention include neuro-ophthalmic and oculoplastic injuries. By far the most common mechanism of COT was blast injury (64-84%), with improvised explosive devices (IEDs) accounting for 51-69% of ocular injuries. Among the large reporting databases, 41-45% of COT required surgical treatment with an overall enucleation rate of 12-17%. CONCLUSIONS The Global War on Terrorism saw an evolution in the types of ocular injuries sustained by U.S. service members compared to previous conflicts. The widespread use of IEDs led to injury patterns not encountered in previous conflicts. Weapons of today utilize blast and shrapnel as the mechanism for destruction. Sequelae such as TBIs and complicated head and neck trauma have pushed innovation in the field of ophthalmology. Improvements in medical technology and personal protective equipment have resulted in not only survival of previously life-threatening injuries, but also a greater chance of severe loss of vision. By analyzing ocular injury data from the trauma literature, improvements in education and training can lead to improvements in point-of-injury care and eye protection for the next generation of warfighters.
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Affiliation(s)
- Ian Lee
- Uniformed Services University of the Health Sciences, Bethesda, MD 20814, USA
| | - Brian Davis
- Uniformed Services University of the Health Sciences, Bethesda, MD 20814, USA
| | - Boonkit Purt
- Uniformed Services University of the Health Sciences, Bethesda, MD 20814, USA
- Department of Ophthalmology, Walter Reed National Military Medical Center, Bethesda, MD 20889, USA
| | - Taylor DesRosiers
- Uniformed Services University of the Health Sciences, Bethesda, MD 20814, USA
- Combat Trauma Research Group, U.S. Navy, Portsmouth, VA 23708, USA
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2
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Nowomiejska K, Adamczyk K, Haszcz D, Preys N, Rejdak R. Case report: Bilateral eye injuries in members of one family due to a cluster munition in Ukraine. Front Med (Lausanne) 2023; 10:1171954. [PMID: 37275384 PMCID: PMC10232851 DOI: 10.3389/fmed.2023.1171954] [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: 02/22/2023] [Accepted: 04/24/2023] [Indexed: 06/07/2023] Open
Abstract
The aim of the study was to report the effects of surgical treatment of three victims of a cluster munition in Ukraine. A 32-year-old woman and her sons-6-year-old male twins-presented in Poland after 18 days of delay in treatment. All ocular injuries were bilateral. One of the boys presented with total retinal detachment and a post-traumatic cataract as well as corneal sutures in one eye and a post-traumatic cataract in the other eye. The other boy had already developed atrophy in one eye and a vitreous hemorrhage in the other eye. The woman suffered from bilateral post-traumatic cataract with multiple glass intraocular foreign bodies (IOFBs). The surgical treatment included cataract surgery with intraocular lens implantation in three eyes, removal of IOFBs in one eye, and enucleation of the atrophic eye with implantation of an ocular prosthesis preventing constriction of face tissues. The eye with retinal detachment underwent pars plana vitrectomy, and the vitreous hemorrhage resolved itself. Postoperatively, visual acuity improved significantly in four of six eyes. Only in the eye with an open-globe injury and persistent retinal detachment, the final visual acuity was still poor. In conclusion, cluster munition may lead to bilateral ocular trauma with IOFBs, open-and close-globe injuries, and severe vision loss if left untreated. Modern ophthalmic surgery leads to vision with IOL improvement and solving the eyes after severe combat injury.
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Affiliation(s)
- Katarzyna Nowomiejska
- Chair and Department of General and Pediatric Ophthalmology, Medical University of Lublin, Lublin, Poland
| | - Katarzyna Adamczyk
- Chair and Department of General and Pediatric Ophthalmology, Medical University of Lublin, Lublin, Poland
| | - Dariusz Haszcz
- Chair and Department of General and Pediatric Ophthalmology, Medical University of Lublin, Lublin, Poland
| | | | - Robert Rejdak
- Chair and Department of General and Pediatric Ophthalmology, Medical University of Lublin, Lublin, Poland
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3
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Hamilton JA, Ketchum JM, Hammond FM, Peterson MD, Zasler ND, Eapen BC, Adamson MM, Galhorta PP, Harris O, Nakase-Richardson R. Comparison of veterans affairs and NIDILRR traumatic brain injury model systems participants with disorders of consciousness. Brain Inj 2023; 37:282-292. [PMID: 36539996 DOI: 10.1080/02699052.2022.2158226] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
OBJECTIVE To characterize demographic, pre-injury, and outcome data within the National Institute on Disability, Independent Living, and Rehabilitation Research (NIDILRR) and Veterans Affairs (VA) Traumatic Brain Injury Model Systems (TBIMS) cohorts with severe traumatic brain injury (TBI) with no command-following ability at time of admission to acute rehabilitation. DESIGN Retrospective cohort. SETTING NIDILRR and VA TBI Model Systems (TBIMS) centers. PARTICIPANTS 396 NIDILRR and 72 VA participants without command-following ability who experienced TBI with subsequent Disorder of Consciousness (DoC). MAIN OUTCOME MEASURE Pre-injury and injury characteristics, rehabilitation outcomes, and 1-year self-reported outcomes. RESULTS VA TBIMS cohort included individuals who were active duty or had military service before their injury. The VA cohort were more likely to be re-hospitalized at 1-year follow-up or residing in a long-term care or rehab setting. The NIDILRR TBIMS cohort had higher FIM and DRS scores at rehabilitation discharge, while the VA participants saw longer lengths of stay and higher numbers of "violent" injury types. CONCLUSIONS This study allows for a better understanding of the comparability between VA and NIDILRR DoC cohorts providing guidance on how veteran and civilian samples might be merged in future TBIMS studies to explore predictors of recovery from a DoC.
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Affiliation(s)
| | | | - Flora M Hammond
- Department Physical Medicine and Rehabilitation, Indiana University School of Medicine, Rehabilitation Hospital of Indiana, Carolinas Rehabilitation, 4141 Shore Drive 46254, Indianapolis, Indiana
| | | | - Nathan D Zasler
- Department of Physical Medicine and Rehabilitation, Virginia Commonwealth University, Richmond, Virginia
| | - Blessen C Eapen
- Division of Physical Medicine and Rehabilitation, Physical Medicine and Rehabilitation Service, VA Greater Los Angeles Health Care System, Los Angeles, California
| | - Maheen Mausoof Adamson
- Department of Neurosurgery, Rehabilitation Service, VA Palo Alto Health Care System, Palo Alto, California
| | - Pawan P Galhorta
- VA Palo Alto Health Care System, Palo Alto, CA, Program Director, Polytrauma Rehabilitation Center
| | - Odette Harris
- Department of Neurosurgery, Director, Brain Injury, Stanford University School of Medicine
| | - Risa Nakase-Richardson
- Mental Health and Behavioral Sciences, James A. Haley Veterans Hospital, Defense Health Agency TBI Center of Excellence at James A. Haley Veterans Hospital, Tampa, Florida
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4
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Belanger HG, Toyinbo P, Barrett B, King E, Sayer NA. Concussion coach for postconcussive symptoms: A randomized, controlled trial of a smartphone application with Afghanistan and Iraq war Veterans. Clin Neuropsychol 2022; 36:2093-2119. [PMID: 34184976 DOI: 10.1080/13854046.2021.1936188] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
Objective: Investigate the effectiveness of Concussion Coach, an interactive smartphone application, as a treatment for residual neurobehavioral symptoms and distress in Veterans with a history of mild traumatic brain injury (mild TBI). Methods: Veterans with mild TBI were randomized to Concussion Coach (n = 238) or Treatment-as-Usual (TAU) (n = 241) in a 3-month randomized controlled trial. Primary outcome measures included postconcussive symptom (PCS) severity as measured by the Neurobehavioral Symptom Inventory (NSI), and psychological distress as measured by the Brief Symptom Inventory-18 (BSI-18). Measures of self-efficacy, social support, and comfort with technology were administered as potential moderators and mediators. An intention-to-treat (ITT) analysis was performed (N = 461: Concussion Coach = 231 and TAU = 230) using Bayesian Network (BN)modeling. Results: The probability of decreased PCS severity was significantly greater for those assigned to Concussion Coach, .35 [.32,.37], than for TAU, .29 (.27, .32), with an odds ratio (OR) of 1.29. Also, Concussion Coach showed a significantly greater probability of increased self-efficacy (.36 [.32, .39]) than did TAU (.28 [.25, .30], OR = 1.42). In turn, self-efficacy (increased vs. decreased) showed a significantly greater probability of decreased PCS severity (.51 [.47, .54] vs. .27 [.24, .30], OR = 2.71) and decreased psychological distress (.53 [.49, .56] vs. .32 [.29, .35], OR = 2.35), suggesting that self-efficacy may have mediated Concussion Coach effects. Conclusions: Concussion Coach is effective at reducing PCS severity and psychological distress. Increased self-efficacy/perception of self-management of symptoms may be key to successful treatment of residual symptoms in those with history of concussion.
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Affiliation(s)
- Heather G Belanger
- Research and Development Service, James A. Haley Veterans' Hospital, Tampa, FL, USA.,United States Special Operations Command (USSOCOM), Tampa, FL, USA.,Department of Psychology and Psychiatry & Behavioral Neurosciences, University of South Florida, Tampa, FL, USA.,St Michael's Inc, Tampa, FL, USA
| | - Peter Toyinbo
- Research and Development Service, James A. Haley Veterans' Hospital, Tampa, FL, USA
| | - Blake Barrett
- Research and Development Service, James A. Haley Veterans' Hospital, Tampa, FL, USA
| | | | - Nina A Sayer
- Minneapolis VA Health Care System, Minneapolis, MN, USA.,Center for Care Delivery and Outcomes Research, Minneapolis VA Health Care System and Departments of Medicine and Psychiatry, University of Minnesota, Minneapolis, MN, USA
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Martindale SL, Ord AS, Rule LG, Rowland JA. Effects of blast exposure on psychiatric and health symptoms in combat veterans. J Psychiatr Res 2021; 143:189-195. [PMID: 34500348 DOI: 10.1016/j.jpsychires.2021.09.021] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/26/2021] [Revised: 08/25/2021] [Accepted: 09/01/2021] [Indexed: 11/28/2022]
Abstract
Blast exposure is common among service members, but the chronic psychiatric effects associated with blast exposure are not well-characterized independent of a resulting mild traumatic brain injury (TBI). This analysis evaluated whether blast exposure severity was independently associated with or exacerbated symptom report beyond posttraumatic stress disorder (PTSD) and mild TBI. Participants were Iraq and Afghanistan combat veterans (N = 275; 86.55% male), 71.27% with history of blast exposure, 29.82% current diagnosis of PTSD, and 45.45% with mild TBI. All participants completed diagnostic interviews for PTSD, lifetime TBI, and lifetime blast exposure. Self-reported psychiatric and health outcomes included posttraumatic stress symptoms, depressive symptoms, neurobehavioral symptoms, sleep quality, pain interference, and quality of life. Blast severity was associated with PTSD (B = 2.00), depressive (B = 0.76), and neurobehavioral (B = 1.69) symptoms beyond PTSD diagnosis and mild TBI history. Further, blast severity accounted entirely (i.e., indirect/mediation effect) for the association between TBI and posttraumatic stress (B = 1.62), depressive (B = 0.61), and neurobehavioral (B = 1.38) symptoms. No interaction effects were present. Exposure to blast is an independent factor influencing psychiatric symptoms in veterans beyond PTSD and mild TBI. Results highlight that blast exposure severity may be a more relevant risk factor than deployment mild TBI in combat veterans and should be considered in the etiology of psychiatric symptom presentation and complaints. Further, severity of psychological distress due to the combat environment may be an explanatory mechanism by which blast exposure mediates the relationship between mild TBI and symptom outcomes.
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Affiliation(s)
- Sarah L Martindale
- Mid-Atlantic Mental Illness Research, Education, and Clinical Center (MA-MIRECC), Research & Academic Affairs Service Line, W. G. (Bill) Hefner VA Healthcare System, Salisbury, NC, USA; Department of Physiology & Pharmacology, Wake Forest School of Medicine, Winston-Salem, NC, USA.
| | - Anna S Ord
- Mid-Atlantic Mental Illness Research, Education, and Clinical Center (MA-MIRECC), Research & Academic Affairs Service Line, W. G. (Bill) Hefner VA Healthcare System, Salisbury, NC, USA; Department of Physiology & Pharmacology, Wake Forest School of Medicine, Winston-Salem, NC, USA
| | - Lakeysha G Rule
- Mid-Atlantic Mental Illness Research, Education, and Clinical Center (MA-MIRECC), Research & Academic Affairs Service Line, W. G. (Bill) Hefner VA Healthcare System, Salisbury, NC, USA
| | - Jared A Rowland
- Mid-Atlantic Mental Illness Research, Education, and Clinical Center (MA-MIRECC), Research & Academic Affairs Service Line, W. G. (Bill) Hefner VA Healthcare System, Salisbury, NC, USA; Department of Physiology & Pharmacology, Wake Forest School of Medicine, Winston-Salem, NC, USA
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6
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Dementia in military and veteran populations: a review of risk factors-traumatic brain injury, post-traumatic stress disorder, deployment, and sleep. Mil Med Res 2021; 8:55. [PMID: 34645526 PMCID: PMC8515715 DOI: 10.1186/s40779-021-00346-z] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/07/2021] [Accepted: 09/26/2021] [Indexed: 12/13/2022] Open
Abstract
The military population face a unique set of risk factors that may increase the risk of being diagnosed with dementia. Traumatic brain injury (TBI) and post-traumatic stress disorder (PTSD) have a higher prevalence in this group in comparison to the civilian population. By delving into the individual relationships between TBI and dementia, and PTSD and dementia, we are able to better explore dementia in the military and veteran populations. While there are some inconsistencies in results, the TBI-dementia association has become more widely accepted. Moderate-to-severe TBI has been found to increase the risk of being diagnosed with Alzheimer's disease. A correlation between PTSD and dementia has been established, however, whether or not it is a causal relationship remains unclear. Factors such as blast, combat and chemical exposure may occur during a deployment, along with TBI and/or PTSD diagnosis, and can impact the risk of dementia. However, there is a lack of literature exploring the direct effects of deployment on dementia risk. Sleep problems have been observed to occur in those following TBI, PTSD and deployment. Poor sleep has been associated with possible dementia risk. Although limited studies have focused on the link between sleep and dementia in military and veteran populations, sleep is a valuable factor to study due to its association and interconnection with other military/veteran factors. This review aims to inform of various risk factors to the cognitive health of military members and veterans: TBI, PTSD, deployment, and sleep.
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7
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Eagle SR, Collins MW, Dretsch MN, Uomoto JM, Connaboy C, Flanagan SD, Kontos AP. Network Analysis of Research on Mild Traumatic Brain Injury in US Military Service Members and Veterans During the Past Decade (2010-2019). J Head Trauma Rehabil 2021; 36:E345-E354. [PMID: 33741827 DOI: 10.1097/htr.0000000000000675] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE To evaluate trends in the extant literature on mild traumatic brain injury (mTBI) in military service members and veterans using network analysis based on a comprehensive search of original, peer-reviewed research articles involving human participants published between January 1, 2010, and December 31, 2019. Specifically, we employed network analysis to evaluate associations in the following areas: (1) peer-reviewed journals, (2) authors, (3) organizations/institutions, and (4) relevant key words. PARTICIPANTS Included studies were published in peer-reviewed journals available on Web of Science database, using US military service members or veterans. DESIGN Bibliometric network analytical review. MAIN MEASURES Outcomes for each analysis included number of articles, citations, total link strength, and clusters. RESULTS The top publishing journals were (1) Journal of Head Trauma and Rehabilitation, (2) Military Medicine, (3) Brain Injury, (4) Journal of Neurotrauma, and (5) Journal of Rehabilitation Research and Development. The top publishing authors were (1) French, (2) Lange, (3) Cooper, (4) Vanderploeg, and (5) Brickell. The top research institutions were (1) Defense and Veterans Brain Injury Center, (2) Uniformed Services University of the Health Sciences, (3) University of California San Diego, (4) Walter Reed National Military Medical Center, and (5) Boston University. The top co-occurring key words in this analysis were (1) posttraumatic stress disorder (PTSD), (2) persistent postconcussion symptoms (PPCS), (3) blast injury, (4) postconcussion syndrome (PCS), and (5) Alzheimer's disease. CONCLUSIONS The results of this network analysis indicate a clear focus on veteran health, as well as investigations on chronic effects of mTBI. Research in civilian mTBI indicates that delaying treatment for symptoms and impairments related to mTBI may not be the most precise treatment strategy. Increasing the number of early, active, and targeted treatment trials in military personnel could translate to meaningful improvements in clinical practices for managing mTBI in this population.
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Affiliation(s)
- Shawn R Eagle
- Departments of Orthopaedic Surgery (Drs Eagle, Collins, and Kontos) and Sports Medicine and Nutrition (Drs Connaboy and Flanagan), University of Pittsburgh, Pittsburgh, Pennsylvania; UPMC Sports Medicine Concussion Program, Pittsburgh, Pennsylvania (Drs Collins and Kontos); US Army Medical Research Directorate-West, Walter Reed Army Institute of Research, Joint Base Lewis-McChord, Washington (Dr Dretsch); and VA Puget Sound Health Care System-American Lake Division, Tacoma, Washington (Dr Uomoto)
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8
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Belding JN, Egnoto M, Englert RM, Fitzmaurice S, Thomsen CJ. Getting on the Same Page: Consolidating Terminology to Facilitate Cross-Disciplinary Health-Related Blast Research. Front Neurol 2021; 12:695496. [PMID: 34248831 PMCID: PMC8264539 DOI: 10.3389/fneur.2021.695496] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2021] [Accepted: 05/25/2021] [Indexed: 11/25/2022] Open
Abstract
The consequences of blast exposure (including both high-level and low-level blast) have been a focal point of military interest and research for years. Recent mandates from Congress (e.g., National Defense Authorization Act for Fiscal Year 2018, section 734) have further accelerated these efforts, facilitating collaborations between research teams from a variety of disciplinary backgrounds. Based on findings from a recent scoping review, we argue that the scientific field of blast research is plagued by inconsistencies in both conceptualization of relevant constructs and terminology used to describe them. These issues hamper our ability to interpret study methods and findings, hinder efforts to integrate findings across studies to reach scientific consensus, and increase the likelihood of redundant efforts. We argue that multidisciplinary experts in this field require a universal language and clear, standardized terminology to further advance the important work of examining the effects of blast exposure on human health, performance, and well-being. To this end, we present a summary of descriptive conventions regarding the language scientists currently use when discussing blast-related exposures and outcomes based on findings from a recent scoping review. We then provide prescriptive conventions about how these terms should be used by clearly conceptualizing and explicitly defining relevant constructs. Specifically, we summarize essential concepts relevant to the study of blast, precisely distinguish between high-level blast and low-level blast, and discuss how the terms acute, chronic, exposure, and outcome should be used when referring to the health-related consequences of blast exposure.
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Affiliation(s)
- Jennifer N Belding
- Leidos, San Diego, CA, United States.,Health and Behavioral Sciences Department, Naval Health Research Center, San Diego, CA, United States
| | - Michael Egnoto
- Study of Terrorism and Responses to Terrorism, University of Maryland, College Park, MD, United States
| | - Robyn M Englert
- Leidos, San Diego, CA, United States.,Health and Behavioral Sciences Department, Naval Health Research Center, San Diego, CA, United States
| | - Shannon Fitzmaurice
- Leidos, San Diego, CA, United States.,Health and Behavioral Sciences Department, Naval Health Research Center, San Diego, CA, United States
| | - Cynthia J Thomsen
- Health and Behavioral Sciences Department, Naval Health Research Center, San Diego, CA, United States
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Day MA, Williams RM, Turner AP, Ehde DM, Jensen MP. Transdiagnostic Cognitive Processes in Chronic Pain and Comorbid PTSD and Depression in Veterans. Ann Behav Med 2021; 56:157-167. [PMID: 34038509 DOI: 10.1093/abm/kaab033] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Chronic pain in Veterans is a major problem compounded by comorbid posttraumatic stress disorder (PTSD) and depression. Adopting a transdiagnostic framework to understanding "shared territory" among these diagnoses has the potential to inform our understanding of the underlying cognitive processes and mechanisms that transverse diagnostic boundaries. PURPOSE To examine the associations between pain-related cognitive processes (diversion, distancing, absorption, and openness), pain intensity, PTSD and depressive symptoms, and the extent to which Veterans with chronic pain with and without comorbid PTSD and depression engage in different/similar pain-related cognitive processes. METHODS Secondary analysis of pretreatment data with a subsample (n = 147) of Veterans with chronic pain from a larger clinical trial. Pretreatment PCL-5 and PROMIS Depression scales were used to categorize participants into three groups: (a) Pain-only; (b) Pain-PTSD; and (c) Pain-PTSD-DEP. RESULTS Compared to the Pain-only group, the Pain-PTSD and Pain-PTSD-DEP groups reported significantly greater pain intensity, PTSD and depressive symptoms, and ruminative pain absorption. The Pain-PTSD-DEP group had significantly lower pain diversion and pain openness scores. When diversion and openness were used within the Pain-PTSD-DEP group, however, they were both associated with lower pain intensity and openness was additionally associated with lower PTSD scores. However, in the Pain-PTSD group, pain openness was associated with higher depression scores. CONCLUSIONS Across increasing complexity of comorbidity profiles (i.e., one vs. two comorbid conditions), ruminative absorption with pain emerged as a cognitive process that transverses diagnoses and contributes to worse outcomes. Nonjudgmental acceptance may not be universally beneficial, potentially depending upon the nature of comorbidity profiles.
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Affiliation(s)
- Melissa A Day
- School of Psychology, University of Queensland, 330 McElwain Building, Brisbane, QLD 4072, Australia.,Department of Rehabilitation Medicine, University of Washington, Seattle, WA, USA
| | - Rhonda M Williams
- Department of Rehabilitation Medicine, University of Washington, Seattle, WA, USA.,VA Puget Sound Health Care System, Seattle, WA, USA
| | - Aaron P Turner
- Department of Rehabilitation Medicine, University of Washington, Seattle, WA, USA.,VA Puget Sound Health Care System, Seattle, WA, USA
| | - Dawn M Ehde
- Department of Rehabilitation Medicine, University of Washington, Seattle, WA, USA
| | - Mark P Jensen
- Department of Rehabilitation Medicine, University of Washington, Seattle, WA, USA
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10
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Kroma RB, Giordano NA, Highland KB, Bedocs P, McDuffie M, Buckenmaier CC. Implementation of the Uniformed Services University Pain Registry Biobank: A Military and Veteran Population Focused Biobank and Registry. PAIN MEDICINE 2021; 22:2950-2963. [PMID: 33983447 DOI: 10.1093/pm/pnab166] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
OBJECTIVE The objective of this overview is to discuss the development, implementation, data content, and structure of the Uniformed Services University Pain Registry Biobank. Additionally, procedures and policies for accessing samples for pain-related research purposes are detailed. DESIGN Cross-sectional overview. SETTING Multiple military treatment facilities. SUBJECTS Adult beneficiaries seeking care within the Military Health System. METHODS Participants complete a baseline battery of biopsychosocial survey measures, including PROMIS® measures, provide biologic samples (e.g. blood and saliva), and relevant health history, including medications and surgical history, is extracted from medical records. During the course of the next year, enrolled participants complete surveys and provide biologic samples at 3-months, 6-months, and 12-months. Thereafter, participants are contacted once annually to complete self-reported assessments and provide biologic samples. RESULTS In the first year alone 86 subjects have participated in the Uniformed Services University Pain Registry Biobank and provided 390 observations (e.g. biological samples and biopsychosocial patient-reported outcomes). The Uniformed Services University Pain Registry Biobank's integration of biological samples, patient-reported outcomes, and health record data over a longitudinal period across a diverse sample recruited from multiple military facilities addresses many of the limitations faced by other pain-related registries or biorepositories. CONCLUSIONS The Uniformed Services University Pain Registry Biobank will serve as a platform for conducting research closely aligned with the Federal Pain Research Strategy. The inclusion of active duty service members, beneficiaries, and civilians living with and without acute or chronic pain provides a unique data repository for all investigators interested in advancing pain science.
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Affiliation(s)
- Raymond B Kroma
- Defense and Veterans Center for Integrative Pain Management, Uniformed Services University, Rockville, Maryland, USA
- Henry M. Jackson Foundation for the Advancement of Military Medicine Inc., Bethesda, Maryland, USA
| | - Nicholas A Giordano
- Nell Hodgson Woodruff School of Nursing, Emory University, Atlanta, Georgia, USA
| | - Krista B Highland
- Defense and Veterans Center for Integrative Pain Management, Uniformed Services University, Rockville, Maryland, USA
- Henry M. Jackson Foundation for the Advancement of Military Medicine Inc., Bethesda, Maryland, USA
| | - Peter Bedocs
- Defense and Veterans Center for Integrative Pain Management, Uniformed Services University, Rockville, Maryland, USA
- Henry M. Jackson Foundation for the Advancement of Military Medicine Inc., Bethesda, Maryland, USA
| | - Mary McDuffie
- Defense and Veterans Center for Integrative Pain Management, Uniformed Services University, Rockville, Maryland, USA
- Henry M. Jackson Foundation for the Advancement of Military Medicine Inc., Bethesda, Maryland, USA
| | - Chester C Buckenmaier
- Defense and Veterans Center for Integrative Pain Management, Uniformed Services University, Rockville, Maryland, USA
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Moriarty H, Robinson KM, Winter L. The additional burden of PTSD on functioning and depression in veterans with traumatic brain injury. Nurs Outlook 2021; 69:167-181. [PMID: 33608113 DOI: 10.1016/j.outlook.2020.11.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2020] [Revised: 10/20/2020] [Accepted: 11/03/2020] [Indexed: 11/19/2022]
Abstract
BACKGROUND Many United States veterans and active military with a history of traumatic brain injury (TBI) also experience challenges from comorbid posttraumatic stress disorder (PTSD), yet the additional burden of PTSD is not clear. PURPOSE To address this knowledge gap, this study examined the relationship of PTSD to cognitive, social, and physical functioning and depressive symptoms in veterans recently diagnosed with TBI. METHODS Veterans were recruited from a VA rehabilitation clinic. The Patient Competency Rating Scale and Center for Epidemiologic Studies Depression Scale measured functioning and depression, respectively. Chart review captured PTSD diagnosis. FINDINGS In the sample of 83 veterans, 65% had a current PTSD diagnosis. After controlling for sociodemographic variables and TBI severity, PTSD was a significant predictor of lower cognitive, social, and physical functioning and higher depressive symptomatology. DISCUSSION Clinicians should incorporate PTSD assessment in their work with veterans with TBI. Integrated behavioral health and rehabilitation interventions that provide strategies for veterans to manage TBI symptoms and PTSD are critical.
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Affiliation(s)
- Helene Moriarty
- Villanova University, M. Louise Fitzpatrick College of Nursing, Villanova, PA; Corporal Michael J. Crescenz Veterans Affairs Medical Center, Nursing Service, Philadelphia, PA.
| | - Keith M Robinson
- University of Pennsylvania, Perelman School of Medicine, Department of Physical Medicine and Rehabilitation, Philadelphia, PA; Corporal Michael J. Crescenz Veterans Affairs Medical Center, Rehabilitation Medicine Service, Philadelphia, PA
| | - Laraine Winter
- Corporal Michael J. Crescenz Veterans Affairs Medical Center, Nursing Service, Philadelphia, PA
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12
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Winter L, Moriarty HJ, Robinson KM. Effect of an in-home, family-inclusive rehabilitation programme on depressive symptoms in veterans with traumatic brain injury and its mediation by activity engagement. INTERNATIONAL JOURNAL OF THERAPY AND REHABILITATION 2020. [DOI: 10.12968/ijtr.2019.0054] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Background/Aims Depression, the most common psychiatric sequela of traumatic brain injury in both civilians and veterans, produces serious and wide-ranging problems. Although medication and cognitive behavioural therapy are the most common treatments, some rehabilitation approaches designed to enhance functioning and/or community reintegration may decrease depression by facilitating active engagement in life – the key component of some depression therapies. The present secondary analysis of a community reintegration-focused rehabilitation programme for veterans with traumatic brain injury posed two questions: Did the programme affect depressive symptoms? If so, was this effect mediated by engagement in activities? Methods A secondary analysis was undertaken of an intervention study of 83 former members of the United States Armed Forces (veterans) with traumatic brain injury, who were interviewed in their homes. Depressive symptoms were assessed using the short-form Centre for Epidemiological Studies-Depression Scale, activity engagement using an 8-item subscale derived from the Community Reintegration of Injured Service Members Scale, and physical and emotional functioning using the SF-36V. Sociodemographic, medical and military characteristics were elicited during the first interview, and medical and military characteristics were identified through a medical chart review. Results Depressive symptoms significantly decreased among the veterans in the treatment group. That effect was mediated by activity engagement. Thus, the intervention's impact on depressive symptoms was attributable to the increased activity that it produced. Conclusions Research on rehabilitation that enhances engagement in activities should examine its possible benefits for improving mood.
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Affiliation(s)
- Laraine Winter
- Corporal Michael J. Crescenz Veterans Affairs Medical Center, Philadelphia, PA, USA
- M. Louise Fitzpatrick College of Nursing, Villanova University, Villanova, PA, USA
| | - Helene J Moriarty
- M. Louise Fitzpatrick College of Nursing, Villanova University, Villanova, PA, USA
- Nursing Service, Corporal Michael J. Crescenz Veterans Affairs Medical Center, Philadelphia, PA, USA
| | - Keith M Robinson
- Rehabilitation Medicine Service, Corporal Michael J. Crescenz Veterans Affairs Medical Center, Philadelphia, PA, USA
- Department of Physical Medicine and Rehabilitation, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
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13
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Norman RS, Swan AA, Jenkins A, Ballard M, Amuan M, Pugh MJ. Updating and Refining Prevalence Rates of Traumatic Brain Injury–Related Communication Disorders Among Post-9/11 Veterans: A Chronic Effects of Neurotrauma Consortium Study. ACTA ACUST UNITED AC 2020. [DOI: 10.1044/2020_persp-20-00011] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
Purpose
To describe the prevalence of communication disorders in a cohort of 84,377 deployed post-9/11 veterans stratified by blast traumatic brain injury (TBI) exposure. Secondary aim was to evaluate the association between postconcussion symptoms, such as posttraumatic stress disorder, depression, anxiety, insomnia, pain, headache, substance use disorder, and auditory problems, among veterans with and without a communication disorder diagnosis.
Method
This is a retrospective study of the prevalence of aphasia, apraxia of speech and dysarthria, cognitive-communication disorder, fluency, and voice disorders among veterans, stratified by TBI severity and blast status. Data were obtained from the national Operation Enduring Freedom, Operation Iraqi Freedom, and Operation New Dawn roster file provided by the Department of Veterans Affairs Office of Public Health and the Veterans Affairs' TBI screening and subsequent comprehensive TBI evaluation.
Results
Cognitive-communication disorder was the most prevalent diagnosis, comprising 57.1% of all communication disorder diagnoses, followed by voice disorder (19%) and aphasia (16%). Increased age was significantly associated with higher rates of aphasia, apraxia of speech/dysarthria, and voice disorder.
Conclusions
The current study shows that, while the overall total number of communication disorder diagnoses was higher in the blast groups than in the nonblast groups, TBI severity was a more significant risk factor for a diagnosis, with veterans in the more severe groups at a higher risk of being diagnosed with a communication disorder when compared to those with mild TBI and no blast exposure. In order to better inform rehabilitation and clinical management of communication conditions, it is critical to examine the influence of blast and postconcussive symptoms in post-9/11 veterans.
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Affiliation(s)
- Rocío S. Norman
- Department of Communication Sciences and Disorders, School of Health Professions, University of Texas Health Science Center at San Antonio
| | - Alicia A. Swan
- Department of Psychology, University of Texas at San Antonio
| | - Angela Jenkins
- Department of Communication Sciences and Disorders, School of Health Professions, University of Texas Health Science Center at San Antonio
| | - Matthew Ballard
- Department of Communication Sciences and Disorders, School of Health Professions, University of Texas Health Science Center at San Antonio
| | - Megan Amuan
- VA Salt Lake City Health Care System, Informatics, Decision-Enhancement, and Analytic Sciences Center, UT
| | - Mary Jo Pugh
- VA Salt Lake City Health Care System, Informatics, Decision-Enhancement, and Analytic Sciences Center, UT
- Department of Internal Medicine, School of Medicine, University of Utah, Salt Lake City
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14
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Edwards KA, Leete JJ, Tschiffely AE, Moore CY, Dell KC, Statz JK, Carr W, Walker PB, LoPresti ML, Ahlers ST, Yarnell AM, Gill J. Blast exposure results in tau and neurofilament light chain changes in peripheral blood. Brain Inj 2020; 34:1213-1221. [DOI: 10.1080/02699052.2020.1797171] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Affiliation(s)
- Katie A. Edwards
- National Institute of Nursing Research, National Institutes of Health, Bethesda, MD, USA
- Henry M. Jackson Foundation, Bethesda, MD, USA
| | - Jacqueline J. Leete
- National Institute of Nursing Research, National Institutes of Health, Bethesda, MD, USA
| | - Anna E. Tschiffely
- Department of Neurotrauma, Naval Medical Research Center, Silver Spring, MD, USA
| | - Candace Y. Moore
- National Institute of Nursing Research, National Institutes of Health, Bethesda, MD, USA
| | - Kristine C. Dell
- Department of Psychology, Pennsylvania State University, University Park, PA, USA
| | - Jonathan K. Statz
- Henry M. Jackson Foundation, Bethesda, MD, USA
- Department of Neurotrauma, Naval Medical Research Center, Silver Spring, MD, USA
| | - Walter Carr
- Oak Ridge Institute for Science and Education, Oak Ridge, TN, USA
| | - Peter B. Walker
- Joint Artificial Intelligence Center, Arlington, VA, USA
- National Institute of Neurological Disorders and Stroke, National Institutes of Health, Bethesda, MD, USA
- Department of Radiology and Medical Imaging, University of Virginia, Charlottesville, VA, USA
- Military Emergency Medicine Department, Uniformed Services, University of the Health Sciences, Bethesda, MD, USA
| | - Matthew L. LoPresti
- Center for Military Psychiatry & Neuroscience, Walter Reed Army Institute of Research, Silver Spring, MD, USA
| | - Stephen T. Ahlers
- Operational & Undersea Medicine Directorate, Naval Medical Research Center, Silver Spring, MD, USA
| | - Angela M. Yarnell
- Operational & Undersea Medicine Directorate, Naval Medical Research Center, Silver Spring, MD, USA
| | - Jessica Gill
- National Institute of Nursing Research, National Institutes of Health, Bethesda, MD, USA
- Center for Neuroscience and Regenerative Medicine, Uniformed Services University of the Health Sciences, Bethesda, MD, USA
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15
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Ord AS, Lad SS, Shura RD, Rowland JA, Taber KH, Martindale SL. Pain interference and quality of life in combat veterans: Examining the roles of posttraumatic stress disorder, traumatic brain injury, and sleep quality. Rehabil Psychol 2020; 66:31-38. [PMID: 32378923 DOI: 10.1037/rep0000333] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
OBJECTIVE The goal of this study was to examine the associations among posttraumatic stress disorder (PTSD), traumatic brain injury (TBI), sleep quality, pain interference, and quality of life in combat veterans. METHOD Veterans (N = 289, 86.51% male) completed the Mid-Atlantic MIRECC Assessment of Traumatic Brain Injury, the Clinician-Administered PTSD Scale for DSM-5, and measures of sleep quality, pain interference, and quality of life. RESULTS Hierarchical linear regressions evaluated associations between PTSD severity, deployment TBI severity, sleep quality, and the outcomes of pain interference and quality of life after adjusting for demographic variables and the number of nondeployment TBIs. PTSD severity, B = 0.15, SE B = 0.04, deployment TBI severity, B = 3.98, SE B = 1.01, and sleep quality, B = 0.74, SE B = 0.13, were significantly associated with pain interference, p < .001. PTSD severity, B = -0.57, SE B = 0.07, and pain interference, B = -0.45, SE B = 0.11, were significantly, independently associated with quality of life, p < .001. However, pain interference, B = -0.24, SE B = 0.11, was no longer significantly associated with quality of life when sleep quality, B = -1.56, SE B = 0.25, was included in the model. There was no significant association between deployment TBI severity and quality of life. Interactions among the studied variables were not significant for either of the outcome variables. CONCLUSIONS PTSD symptom severity, deployment TBI history, and sleep quality may be important to consider in treatment planning for veterans experiencing pain-related functional interference. For veterans with numerous conditions comorbid with pain, treatment plans may include interventions targeting sleep and PTSD to maximize quality of life improvements. (PsycInfo Database Record (c) 2021 APA, all rights reserved).
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Affiliation(s)
- Anna S Ord
- Mid-Atlantic Mental Illness Research, Education, and Clinical Center (MA-MIRECC)
| | - Sagar S Lad
- Mid-Atlantic Mental Illness Research, Education, and Clinical Center (MA-MIRECC)
| | - Robert D Shura
- Mid-Atlantic Mental Illness Research, Education, and Clinical Center (MA-MIRECC)
| | - Jared A Rowland
- Mid-Atlantic Mental Illness Research, Education, and Clinical Center (MA-MIRECC)
| | - Katherine H Taber
- Mid-Atlantic Mental Illness Research, Education, and Clinical Center (MA-MIRECC)
| | - Sarah L Martindale
- Mid-Atlantic Mental Illness Research, Education, and Clinical Center (MA-MIRECC)
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16
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MacGregor AJ, Zouris JM, Watrous JR, McCabe CT, Dougherty AL, Galarneau MR, Fraser JJ. Multimorbidity and quality of life after blast-related injury among US military personnel: a cluster analysis of retrospective data. BMC Public Health 2020; 20:578. [PMID: 32345277 PMCID: PMC7189580 DOI: 10.1186/s12889-020-08696-4] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2019] [Accepted: 04/13/2020] [Indexed: 11/25/2022] Open
Abstract
Background Blast injury emerged as a primary source of morbidity among US military personnel during the recent conflicts in Iraq and Afghanistan, and led to an array of adverse health outcomes. Multimorbidity, or the presence of two or more medical conditions in an individual, can complicate treatment strategies. To date, there is minimal research on the impact of multimorbidity on long-term patient-reported outcomes. We aimed to define multimorbidity patterns in a population of blast-injured military personnel, and to examine these patterns in relation to long-term quality of life (QOL). Methods A total of 1972 US military personnel who sustained a blast-related injury during military operations in Iraq and Afghanistan were identified from clinical records. Electronic health databases were used to identify medical diagnoses within the first year postinjury, and QOL was measured with a web-based assessment. Hierarchical cluster analysis methods using Ward’s minimum variance were employed to identify clusters with related medical diagnosis categories. Duncan’s multiple range test was used to group clusters into domains by QOL. Results Five distinct clusters were identified and grouped into three QOL domains. The lowest QOL domain contained one cluster with a clinical triad reflecting musculoskeletal pain, concussion, and mental health morbidity. The middle QOL domain had two clusters, one with concussion/anxiety predominating and the other with polytrauma. The highest QOL domain had two clusters with little multimorbidity aside from musculoskeletal pain. Conclusions The present study described blast-related injury profiles with varying QOL levels that may indicate the need for integrated health services. Implications exist for current multidisciplinary care of wounded active duty and veteran service members, and future research should determine whether multimorbidity denotes distinct post-blast injury syndromes.
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Affiliation(s)
- Andrew J MacGregor
- Medical Modeling, Simulation, and Mission Support Department, Naval Health Research Center, 140 Sylvester Road, San Diego, CA, 92106, USA.
| | - James M Zouris
- Medical Modeling, Simulation, and Mission Support Department, Naval Health Research Center, 140 Sylvester Road, San Diego, CA, 92106, USA
| | - Jessica R Watrous
- Medical Modeling, Simulation, and Mission Support Department, Naval Health Research Center, 140 Sylvester Road, San Diego, CA, 92106, USA.,Leidos, Inc., 140 Sylvester Road, San Diego, CA, 92106, USA
| | - Cameron T McCabe
- Medical Modeling, Simulation, and Mission Support Department, Naval Health Research Center, 140 Sylvester Road, San Diego, CA, 92106, USA.,Leidos, Inc., 140 Sylvester Road, San Diego, CA, 92106, USA
| | - Amber L Dougherty
- Medical Modeling, Simulation, and Mission Support Department, Naval Health Research Center, 140 Sylvester Road, San Diego, CA, 92106, USA.,Leidos, Inc., 140 Sylvester Road, San Diego, CA, 92106, USA
| | - Michael R Galarneau
- Medical Modeling, Simulation, and Mission Support Department, Naval Health Research Center, 140 Sylvester Road, San Diego, CA, 92106, USA
| | - John J Fraser
- Warfighter Performance Department, Naval Health Research Center, 140 Sylvester Road, San Diego, CA, 92106, USA
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17
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Kalayci M, Er S, Tahtabasi M. Bomb Explosion: Ocular Effects of Primary, Secondary and Tertiary Mechanisms. Clin Ophthalmol 2020; 14:1145-1151. [PMID: 32425500 PMCID: PMC7196204 DOI: 10.2147/opth.s253438] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2020] [Accepted: 04/19/2020] [Indexed: 11/23/2022] Open
Abstract
Purpose To report the type and severity of ocular injuries sustained by the survivors of a bomb-loaded explosion that occurred in Mogadishu, Somalia on December 28, 2019. Patients and Methods The recorded data included age, gender, wounded eye, initial examination of ocular injuries and associated systemic injuries, initial visual acuity, anterior and posterior segment examinations. The type of injury (open vs closed globe), the injured zone of the globe, and the presence of a relative afferent pupil defect were evaluated in all cases where possible. Results After the explosion, ocular injuries were detected in 28 of 114 patients in our hospital. Thirty-two eyes of 28 patients were included in the study. The mean age was 32.4±6.7 years. The number of open-globe injuries was more than that of closed-globe injuries (26 vs 6; 81.25% vs 18.75%, respectively). Zone 1 was the most affected zone in open-globe injuries (18/26 eyes, 61.6%), followed by Zone 3 in six (23%) patients and Zone 2 in four (15.4%) patients. Sixteen open-globe injuries were laceration type (61.5%) and 10 (38.5%) were rupture type. An intraocular foreign body was detected in eight (30.8%) eyes with open-globe injuries. A total of 28 patients had 11 (39.3%) isolated eye injuries, whereas 17 (60.7%) had concomitant systemic injuries. Conclusion The frequency of blast-related ocular injuries is increasing. Today, the increase in the use of vehicle-borne improvised explosives in terrorist-related explosions leads to more frequent and serious ocular injuries.
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Affiliation(s)
- Mustafa Kalayci
- Somalia Mogadishu - Turkey Education and Research Hospital, Department of Ophthalmology, Banadir, Mogadishu, Somalia
| | - Sadettin Er
- Somalia Mogadishu - Turkey Education and Research Hospital, Department of General Surgery, Banadir, Mogadishu, Somalia
| | - Mehmet Tahtabasi
- Somalia Mogadishu - Turkey Education and Research Hospital, Department of Radiology, Banadir, Mogadishu, Somalia
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18
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Gray M, Adamson MM, Thompson RC, Kapphahn KI, Han S, Chung JS, Harris OA. Sex differences in symptom presentation and functional outcomes: a pilot study in a matched sample of veterans with mild TBI. Brain Inj 2020; 34:535-547. [DOI: 10.1080/02699052.2020.1725979] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Affiliation(s)
- Max Gray
- Defense and Veterans Brain Injury Center (DVBIC), VA Palo Alto Health Care System (VAPAHCS), Palo Alto, CA, USA
| | - Maheen M. Adamson
- Defense and Veterans Brain Injury Center (DVBIC), VA Palo Alto Health Care System (VAPAHCS), Palo Alto, CA, USA
| | - Ryan C. Thompson
- Defense and Veterans Brain Injury Center (DVBIC), VA Palo Alto Health Care System (VAPAHCS), Palo Alto, CA, USA
| | | | - Summer Han
- Department of Neurosurgery, Stanford School of Medicine, Palo Alto, CA, USA
| | - Joyce S. Chung
- Department of Polytrauma, VA Palo Alto Health Care System (VAPAHCS), Palo Alto, CA, USA
| | - Odette A. Harris
- Defense and Veterans Brain Injury Center (DVBIC), VA Palo Alto Health Care System (VAPAHCS), Palo Alto, CA, USA
- Department of Neurosurgery, Stanford School of Medicine, Palo Alto, CA, USA
- Department of Polytrauma, VA Palo Alto Health Care System (VAPAHCS), Palo Alto, CA, USA
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19
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Outcomes Associated With Blast Versus Nonblast-Related Traumatic Brain Injury in US Military Service Members and Veterans: A Systematic Review. J Head Trauma Rehabil 2019; 33:E16-E29. [PMID: 28422897 DOI: 10.1097/htr.0000000000000304] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES To systematically review the literature on comparative clinical and functional outcomes following blast-related versus nonblast-related traumatic brain injury (TBI) among US service members and Veterans. DESIGN MEDLINE search (January 2001 to June 2016) supplemented with hand search of reference lists and input from peer reviewers. RESULTS Thirty-one studies (in 33 articles) reported on health outcomes; only 2 were rated low risk of bias. There was variation in outcomes reported and methods of assessment. Blast and nonblast TBI groups had similar rates of depression, sleep disorders, alcohol misuse, vision loss, vestibular dysfunction, and functional status. Comparative outcomes were inconsistent with regard to posttraumatic stress disorder diagnosis or symptoms, headache, hearing loss, and neurocognitive function. Mortality, burn, limb loss, and quality of life were each reported in few studies, most with small sample sizes. Only 4 studies reported outcomes by blast injury mechanism. CONCLUSIONS Most clinical and functional outcomes appeared comparable in military service members and Veterans with TBI, regardless of blast exposure. Inconsistent findings and limited outcomes reporting indicate that more research is needed to determine whether there is a distinct pattern of impairments and comorbidities associated with blast-related TBI.
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20
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Ungar OJ, Shilo S, Anat W, Cavel O, Handzel O, Oron Y. Blast-Induced Cholesteatomas After Spontaneous Tympanic Membrane Healing. Ann Otol Rhinol Laryngol 2019; 128:1147-1151. [PMID: 31366214 DOI: 10.1177/0003489419865568] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
OBJECTIVES To characterize blast-induced cholesteatomas (BIC) in terms of symptoms, presentation, and location within the middle ear cleft (MEC). DESIGN A search for all English language articles in "MEDLINE" via "PubMed" and "Google Scholar" was conducted. RESULTS A total of 67 ears with BIC were included. Fifty-eight ears in which the traumatic perforation failed to spontaneously close were excluded, leaving seven case reports (eight patients, nine ears) for statistical analysis. Time between blast exposure to spontaneous tympanic membrane (TM) closure was 16 days to 10 months. Time between blast exposure and cholesteatoma diagnosis was 5 months to 4 years. The cholesteatomas were diagnosed due to symptoms in two ears, as asymptomatic finding on physical examination in one ear and as asymptomatic finding in axial imaging in three ears. CONCLUSIONS BICs can develop behind intact tympanic membrane or along with TM perforation. Based on the current review, when a TM perforation and spontaneous healing were documented, after blast exposure, MRI scan is an integral component of the follow-up. The optimal timing for MRI performance after blast exposure, is yet to be identified.
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Affiliation(s)
- Omer J Ungar
- Department of Otolaryngology-Head and Neck Surgery and Maxillofacial Surgery, Tel-Aviv Sourasky Medical Center, Tel-Aviv, Israel.,Sackler School of Medicine. Tel-Aviv University, Tel-Aviv, Israel
| | - Shahaf Shilo
- Department of Otolaryngology-Head and Neck Surgery and Maxillofacial Surgery, Tel-Aviv Sourasky Medical Center, Tel-Aviv, Israel.,Sackler School of Medicine. Tel-Aviv University, Tel-Aviv, Israel
| | - Wengier Anat
- Department of Otolaryngology-Head and Neck Surgery and Maxillofacial Surgery, Tel-Aviv Sourasky Medical Center, Tel-Aviv, Israel.,Sackler School of Medicine. Tel-Aviv University, Tel-Aviv, Israel
| | - Oren Cavel
- Department of Otolaryngology-Head and Neck Surgery and Maxillofacial Surgery, Tel-Aviv Sourasky Medical Center, Tel-Aviv, Israel.,Sackler School of Medicine. Tel-Aviv University, Tel-Aviv, Israel
| | - Ophir Handzel
- Department of Otolaryngology-Head and Neck Surgery and Maxillofacial Surgery, Tel-Aviv Sourasky Medical Center, Tel-Aviv, Israel.,Sackler School of Medicine. Tel-Aviv University, Tel-Aviv, Israel
| | - Yahav Oron
- Department of Otolaryngology-Head and Neck Surgery and Maxillofacial Surgery, Tel-Aviv Sourasky Medical Center, Tel-Aviv, Israel.,Sackler School of Medicine. Tel-Aviv University, Tel-Aviv, Israel
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21
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Haran FJ, Handy JD, Servatius RJ, Rhea CK, Tsao JW. Acute neurocognitive deficits in active duty service members following subconcussive blast exposure. APPLIED NEUROPSYCHOLOGY-ADULT 2019; 28:297-309. [PMID: 31269805 DOI: 10.1080/23279095.2019.1630627] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Military service members are frequently subjected to subconcussive blast events during training and deployment. Emerging evidence suggests blast exposures of these magnitudes may have long-term consequences for dimensions of cognitive function. Less is known about cognitive sequelae acutely following deployment-related subconcussive blast events. The current study addressed this knowledge gap by assessing the extent to which subconcussive blast exposure affected performance on the Automated Neuropsychological Assessment Metrics 4 TBI-MIL (ANAM). Baseline-referenced and normative comparisons of archival ANAM data were analyzed for a cohort of personnel who were exposed to blast (blast group; n = 27) and personnel who were not exposed to blast (no-blast group; n = 36) that were otherwise asymptomatic for a concussion. The blast group exhibited statistically significant lower scores compared to the no-blast group (between-subjects), baseline assessments (within-subjects), and an age-matched normative population. Normative comparisons revealed that the scores for the reaction time subtests (i.e., procedural and both simple reaction time tasks) were outside the range of normal functioning (1 SD) and reliable change indices revealed clinically meaningful change only for simple reaction time. The results highlight covert effects of subconcussive blast exposure that may warrant further monitoring in the immediate aftermath of a blast event.
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Affiliation(s)
- F J Haran
- Neurotrauma Department, Naval Medical Research Center, Silver Spring, Maryland, USA.,Department of Psychiatry, Uniformed Services University of the Health Sciences, Bethesda, Maryland, USA.,Department of Kinesiology, University of North Carolina at Greensboro, Greensboro, North Carolina, USA
| | - Justin D Handy
- Stress and Motivated Behavior Institute, Syracuse, New York, USA
| | - Richard J Servatius
- Stress and Motivated Behavior Institute, Syracuse, New York, USA.,Research & Development, Syracuse VA Medical Center, Syracuse, New York, USA.,Department of Psychiatry, State University of New York Upstate Medical University, Syracuse, New York, USA
| | - Christopher K Rhea
- Department of Kinesiology, University of North Carolina at Greensboro, Greensboro, North Carolina, USA
| | - Jack W Tsao
- Department of Neurology, University of Tennessee Health Science Center, Memphis, Tennessee, USA.,Children's Foundation Research Institute, Le Bonheur Children's Hospital, Memphis, Tennessee, USA.,Department of Neurology, Memphis Veterans Affairs Medical Center, Memphis, Tennessee, USA
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22
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Winter L, Moriarty H, Robinson K. Employment Status Among U.S. Military Veterans With Traumatic Brain Injury: Mediation Analyses and the Goal of Tertiary Prevention. Front Neurol 2019; 10:190. [PMID: 30930830 PMCID: PMC6428699 DOI: 10.3389/fneur.2019.00190] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2018] [Accepted: 02/14/2019] [Indexed: 12/03/2022] Open
Abstract
For most individuals with traumatic brain injury (TBI), the ability to work is crucial to financial and psychological well-being. TBI produces a wide range of cognitive, physical, emotional, and interpersonal impairments that may undermine the ability to work. Employment is therefore a primary goal of TBI rehabilitation and has been the focus of extensive research. Although this literature has identified predictors of employment outcomes, few studies have examined the mechanisms that underlie these associations. Mediation analysis can identify these mechanisms, provide a more nuanced view of how predictors jointly affect rehabilitation outcomes, and identify predictors that, if treatable conditions, could be useful targets for tertiary prevention. Such efforts are aimed at reducing long-term impairments, disability, or suffering resulting from the injury. The study sample comprised 83 U.S. military veterans with TBI who had participated in a larger rehabilitation study and were interviewed in their homes. Bivariate tests revealed significant associations of employment with pain, cognitive functioning, self-rated health, depressive symptoms and physical functioning; the latter variable was operationalized in two ways—using the Patient Competency Rating Scale and the SF–36V physical functioning subscales. Because these physical functioning measures were highly intercorrelated (r = 0.69, p < 0.0001), separate regression models were conducted. In the hierarchical binary logistic regression models, predictors were entered in order of modifiability, with comorbidities (pain) entered in block 1, physical health/functioning sequelae in block 2, and depressive symptoms in block 3. In the regression using the SF-36V measure of physical functioning, pain's effect was mediated by the physical functioning/health predictors, with only physical functioning emerging as significant, but this effect was itself mediated by depressive symptoms. In the regression using the PCRS physical-function measure, only depressive symptoms emerged as a mediator of other effects. Findings underscore the central role of depression in the employment status of veterans with TBI, suggesting that negative effects of other problems/limitations could be mitigated by more effective treatment of depression. Thus, for many with chronic TBI who live with vocational limitations, outcomes may improve with lower depression. Findings argue for the wider use of mediation approaches in TBI research as a means of identifying targets for tertiary prevention of poor outcomes.
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Affiliation(s)
- Laraine Winter
- Corporal Michael J. Crescenz VA Medical Center, Philadelphia, PA, United States
| | - Helene Moriarty
- Corporal Michael J. Crescenz VA Medical Center, Philadelphia, PA, United States.,M. Louise Fitzpatrick College of Nursing, Villanova University, Villanova, PA, United States
| | - Keith Robinson
- Corporal Michael J. Crescenz VA Medical Center, Philadelphia, PA, United States
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23
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Carlozzi NE, Kallen MA, Ianni PA, Hahn EA, French LM, Lange RT, Brickell TA, Hanks R, Sander AM. The Development of a New Computer-Adaptive Test to Evaluate Strain in Caregivers of Individuals With TBI: TBI-CareQOL Caregiver Strain. Arch Phys Med Rehabil 2019; 100:S13-S21. [PMID: 29966647 PMCID: PMC6389439 DOI: 10.1016/j.apmr.2018.05.033] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2018] [Revised: 05/25/2018] [Accepted: 05/31/2018] [Indexed: 11/24/2022]
Abstract
OBJECTIVE To develop a new measure of caregiver strain for use in caregivers of individuals with traumatic brain injury (TBI), Traumatic Brain Injury Caregiver Quality of Life (TBI-CareQOL) Caregiver Strain. DESIGN Qualitative data, literature reviews, and cross-sectional survey study. SETTING Three TBI Model Systems rehabilitation hospitals, an academic medical center, and a military medical treatment facility. PARTICIPANTS Caregivers (N=560) of civilians (n=344) or service members/veterans (SMVs) with TBI (n=216). INTERVENTIONS Not applicable. MAIN OUTCOME MEASURE TBI-CareQOL Caregiver Strain Item Bank. RESULTS Exploratory and confirmatory factor analyses, a graded response model (GRM) and differential item functioning supported the retention of 33 items in the final measure. GRM calibration data was used to inform the selection of a 6-item static short form, and to program the TBI-CareQOL Caregiver Strain computer-adaptive test (CAT). CAT simulation analyses indicated a 0.97 correlation between the CAT scores and the full item-bank. Three-week test-retest reliability was strong (r=0.83). CONCLUSIONS The new TBI-CareQOL Caregiver Strain CAT and corresponding 6-item short form were developed using established rigorous measurement development standards; this is the first self-reported measure developed to evaluate caregiver strain in caregivers of individuals with TBI.
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Affiliation(s)
- Noelle E Carlozzi
- Department of Physical Medicine and Rehabilitation, University of Michigan, Ann Arbor, MI.
| | - Michael A Kallen
- Department of Medical Social Sciences, Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Phillip A Ianni
- Department of Physical Medicine and Rehabilitation, University of Michigan, Ann Arbor, MI
| | - Elizabeth A Hahn
- Department of Medical Social Sciences, Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Louis M French
- Defense and Veterans Brain Injury Center, Walter Reed National Military Medical Center, Bethesda, MD; National Intrepid Center of Excellence, Walter Reed National Military Medical Center, Bethesda, MD; Uniformed Services University of the Health Sciences, Bethesda, MD
| | - Rael T Lange
- Defense and Veterans Brain Injury Center, Walter Reed National Military Medical Center, Bethesda, MD; National Intrepid Center of Excellence, Walter Reed National Military Medical Center, Bethesda, MD; University of British Columbia, Vancouver, British Columbia, Canada
| | - Tracey A Brickell
- Defense and Veterans Brain Injury Center, Walter Reed National Military Medical Center, Bethesda, MD; National Intrepid Center of Excellence, Walter Reed National Military Medical Center, Bethesda, MD; Uniformed Services University of the Health Sciences, Bethesda, MD
| | - Robin Hanks
- Rehabilitation Institute of Michigan, Department of Psychology and Neuropsychology, Detroit, MI; Department of Physical Medicine and Rehabilitation, Wayne State University, Detroit, MI
| | - Angelle M Sander
- H. Ben Taub Department of Physical Medicine and Rehabilitation, Baylor College of Medicine & Harris Health System, Houston, TX; Brain Injury Research Center, TIRR Memorial Hermann, Houston, TX
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Cortical thinning in military blast compared to non-blast persistent mild traumatic brain injuries. NEUROIMAGE-CLINICAL 2019; 22:101793. [PMID: 30939340 PMCID: PMC6446073 DOI: 10.1016/j.nicl.2019.101793] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/01/2018] [Revised: 01/28/2019] [Accepted: 03/24/2019] [Indexed: 01/07/2023]
Abstract
In the military, explosive blasts are a significant cause of mild traumatic brain injuries (mTBIs). The symptoms associated with blast mTBIs causes significant economic burdens and a diminished quality of life for many service members. At present, the distinction of the injury mechanism (blast versus non-blast) may not influence TBI diagnosis. However, using noninvasive imaging, this study reveals significant distinctions between the blast and non-blast TBI mechanisms. A cortical whole-brain thickness analysis was performed using structural high-resolution T1-weighted MRI to identify the effects of blasts in persistent mTBI (pmTBI) subjects. A total of 41 blast pmTBI subjects were individually age- and gender-matched to 41 non-blast pmTBI subjects. Using FreeSurfer, cortical thickness was quantified for the blast group, relative to the non-blast group. Cortical thinning was identified within the blast mTBI group, in two clusters bilaterally. In the left hemisphere, the cluster overlapped with the lateral orbitofrontal, rostral middle frontal, medial orbitofrontal, superior frontal, rostral anterior cingulate and frontal pole cortices (p < 0.02, two-tailed, size = 1680 mm2). In the right hemisphere, the cluster overlapped with the lateral orbitofrontal, rostral middle frontal, medial orbitofrontal, pars orbitalis, pars triangularis and insula cortices (p < 0.002, two-tailed, cluster size = 2453 mm2). Self-report assessments suggest significant differences in the Post-Traumatic Stress Disorder Checklist-Civilian Version (p < 0.05, Bonferroni-corrected) and the Neurobehavioral Symptom Inventory (p < 0.01, uncorrected) between the blast and non-blast mTBI groups. These results suggest that blast may cause a unique injury pattern related to a reduction in cortical thickness within specific brain regions which could affect symptoms. No other study has found cortical thickness difference between blast and non-blast mTBI groups and further replication is needed to confirm these initial observations.
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Zhou Y, Greenwald BD. Update on Insomnia after Mild Traumatic Brain Injury. Brain Sci 2018; 8:brainsci8120223. [PMID: 30551607 PMCID: PMC6315624 DOI: 10.3390/brainsci8120223] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2018] [Revised: 12/08/2018] [Accepted: 12/11/2018] [Indexed: 12/16/2022] Open
Abstract
Sleep disturbance after traumatic brain injury (TBI) has received growing interest in recent years, garnering many publications. Insomnia is highly prevalent within the mild traumatic brain injury (mTBI) population and is a subtle, frequently persistent complaint that often goes undiagnosed. For individuals with mTBI, problems with sleep can compromise the recovery process and impede social reintegration. This article updates the evidence on etiology, epidemiology, prognosis, consequences, differential diagnosis, and treatment of insomnia in the context of mild TBI. This article aims to increase awareness about insomnia following mTBI in the hopes that it may improve diagnosis, evaluation, and treatment of sleeping disturbance in this population while revealing areas for future research.
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Affiliation(s)
- Yi Zhou
- Rutgers Robert Wood Johnson Medical School, Piscataway, NJ 08854, USA.
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26
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Studlack PE, Keledjian K, Farooq T, Akintola T, Gerzanich V, Simard JM, Keller A. Blast-induced brain injury in rats leads to transient vestibulomotor deficits and persistent orofacial pain. Brain Inj 2018; 32:1866-1878. [PMID: 30346868 DOI: 10.1080/02699052.2018.1536282] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Blast-induced traumatic brain injury (blast-TBI) is associated with vestibulomotor dysfunction, persistent post-traumatic headaches and post-traumatic stress disorder, requiring extensive treatments and reducing quality-of-life. Treatment and prevention of these devastating outcomes require an understanding of their underlying pathophysiology through studies that take advantage of animal models. Here, we report that cranium-directed blast-TBI in rats results in signs of pain that last at least 8 weeks after injury. These occur without significantly elevated behavioural markers of anxiety-like conditions and are not associated with glial up-regulation in sensory thalamic nuclei. These injuries also produce transient vestibulomotor abnormalities that resolve within 3 weeks of injury. Thus, blast-TBI in rats recapitulates aspects of the human condition.
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Affiliation(s)
- Paige E Studlack
- a Program in Neuroscience and Department of Anatomy and Neurobiology , University of Maryland School of Medicine , Baltimore , MD , USA
| | - Kaspar Keledjian
- b Department of Neurosurgery , University of Maryland School of Medicine , Baltimore , MD , USA
| | - Tayyiaba Farooq
- a Program in Neuroscience and Department of Anatomy and Neurobiology , University of Maryland School of Medicine , Baltimore , MD , USA
| | - Titilola Akintola
- a Program in Neuroscience and Department of Anatomy and Neurobiology , University of Maryland School of Medicine , Baltimore , MD , USA
| | - Volodymyr Gerzanich
- b Department of Neurosurgery , University of Maryland School of Medicine , Baltimore , MD , USA
| | - J Marc Simard
- b Department of Neurosurgery , University of Maryland School of Medicine , Baltimore , MD , USA
| | - Asaf Keller
- a Program in Neuroscience and Department of Anatomy and Neurobiology , University of Maryland School of Medicine , Baltimore , MD , USA
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Concentrated Conditioned Media from Adipose Tissue Derived Mesenchymal Stem Cells Mitigates Visual Deficits and Retinal Inflammation Following Mild Traumatic Brain Injury. Int J Mol Sci 2018; 19:ijms19072016. [PMID: 29997321 PMCID: PMC6073664 DOI: 10.3390/ijms19072016] [Citation(s) in RCA: 41] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2018] [Revised: 07/03/2018] [Accepted: 07/09/2018] [Indexed: 02/08/2023] Open
Abstract
Blast concussions are a common injury sustained in military combat today. Inflammation due to microglial polarization can drive the development of visual defects following blast injuries. In this study, we assessed whether anti-inflammatory factors released by the mesenchymal stem cells derived from adipose tissue (adipose stem cells, ASC) can limit retinal tissue damage and improve visual function in a mouse model of visual deficits following mild traumatic brain injury. We show that intravitreal injection of 1 μL of ASC concentrated conditioned medium from cells pre-stimulated with inflammatory cytokines (ASC-CCM) mitigates loss of visual acuity and contrast sensitivity four weeks post blast injury. Moreover, blast mice showed increased retinal expression of genes associated with microglial activation and inflammation by molecular analyses, retinal glial fibrillary acidic protein (GFAP) immunoreactivity, and increased loss of ganglion cells. Interestingly, blast mice that received ASC-CCM improved in all parameters above. In vitro, ASC-CCM not only suppressed microglial activation but also protected against Tumor necrosis alpha (TNFα) induced endothelial permeability as measured by transendothelial electrical resistance. Biochemical and molecular analyses demonstrate TSG-6 is highly expressed in ASC-CCM from cells pre-stimulated with TNFα and IFNγ but not from unstimulated cells. Our findings suggest that ASC-CCM mitigates visual deficits of the blast injury through their anti-inflammatory properties on activated pro-inflammatory microglia and endothelial cells. A regenerative therapy for immediate delivery at the time of injury may provide a practical and cost-effective solution against the traumatic effects of blast injuries to the retina.
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Moriarty H, Winter L, Short TH, True G. Exploration of Factors Related to Depressive Symptomatology in Family Members of Military Veterans With Traumatic Brain Injury. JOURNAL OF FAMILY NURSING 2018; 24:184-216. [PMID: 29848196 DOI: 10.1177/1074840718773470] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/06/2023]
Abstract
Traumatic brain injury (TBI) is a family affair, affecting those with the injury and their families. Psychological distress, often measured as depression or depressive symptoms, is highly prevalent among family members. Predictors of depression in family members of civilians with TBI have been examined, but predictors of depression in family members of military veterans have received very little research attention and are poorly understood. To address the knowledge gap, this study explored factors related to depressive symptoms in family members of veterans in the United States, using an ecological framework. Baseline data from 83 family members were used. Family members with higher caregiver burden, presence of a veteran with posttraumatic stress disorder (PTSD), and greater financial difficulty experienced significantly more depressive symptoms. Findings suggest that efforts to support family members and decrease their depression should aim to reduce caregiver burden and financial difficulty, and help family members cope with veteran PTSD and TBI. Family-focused interventions are needed.
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Affiliation(s)
- Helene Moriarty
- 1 Villanova University, Villanova, PA, USA
- 2 Corporal Michael J. Crescenz Veterans Affairs Medical Center, Philadelphia, PA, USA
| | - Laraine Winter
- 2 Corporal Michael J. Crescenz Veterans Affairs Medical Center, Philadelphia, PA, USA
| | | | - Gala True
- 4 Tulane University, New Orleans, Louisiana, USA
- 5 South Central Mental Illness Research, Education and Clinical Center, Southeast Louisiana Veterans Health Care System, New Orleans, Louisiana, USA
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Masri S, Zhang LS, Luo H, Pace E, Zhang J, Bao S. Blast Exposure Disrupts the Tonotopic Frequency Map in the Primary Auditory Cortex. Neuroscience 2018; 379:428-434. [PMID: 29625214 DOI: 10.1016/j.neuroscience.2018.03.041] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2017] [Revised: 03/25/2018] [Accepted: 03/26/2018] [Indexed: 12/14/2022]
Abstract
Blast exposure can cause various auditory disorders including tinnitus, hyperacusis, and other central auditory processing disorders. While this is suggestive of pathologies in the central auditory system, the impact of blast exposure on central auditory processing remains poorly understood. Here we examined the effects of blast shockwaves on acoustic response properties and the tonotopic frequency map in the auditory cortex. We found that multiunits recorded from the auditory cortex exhibited higher acoustic thresholds and broader frequency tuning in blast-exposed animals. Furthermore, the frequency map in the primary auditory cortex was distorted. These changes may contribute to central auditory processing disorders.
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Affiliation(s)
- Samer Masri
- Neuroscience Graduate Program, University of Arizona, Tucson, AZ 85724, United States
| | - Li S Zhang
- Department of Physiology, University of Arizona, Tucson, AZ 85724, United States
| | - Hao Luo
- Department of Otolaryngology, Wayne State University, Detroit, MI 48201, United States
| | - Edward Pace
- Department of Otolaryngology, Wayne State University, Detroit, MI 48201, United States
| | - Jinsheng Zhang
- Department of Otolaryngology, Wayne State University, Detroit, MI 48201, United States; Department of Communication Sciences & Disorders, Wayne State University, Detroit, MI 48201, United States
| | - Shaowen Bao
- Neuroscience Graduate Program, University of Arizona, Tucson, AZ 85724, United States; Department of Physiology, University of Arizona, Tucson, AZ 85724, United States.
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Long-Term Neurobehavioral Symptoms and Return to Productivity in Operation Enduring Freedom/Operation Iraqi Freedom Veterans With and Without Traumatic Brain Injury. Arch Phys Med Rehabil 2018; 99:S50-S57. [DOI: 10.1016/j.apmr.2016.11.026] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2016] [Revised: 11/22/2016] [Accepted: 11/30/2016] [Indexed: 11/22/2022]
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31
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Depressive Symptomatology Mediates Associations With Community Reintegration in Veterans With TBI. MILITARY PSYCHOLOGY 2017. [DOI: 10.1037/mil0000122] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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32
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Gray M, Chung J, Aguila F, Williams TG, Teraoka JK, Harris OA. Long-Term Functional Outcomes in Military Service Members and Veterans After Traumatic Brain Injury/Polytrauma Inpatient Rehabilitation. Arch Phys Med Rehabil 2017; 99:S33-S39. [PMID: 28866009 DOI: 10.1016/j.apmr.2017.08.465] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2017] [Revised: 08/09/2017] [Accepted: 08/16/2017] [Indexed: 11/18/2022]
Abstract
OBJECTIVE To determine the effect of the established polytrauma/traumatic brain injury (TBI) infrastructure on immediate posttreatment functional gains, the long-term sustainability of any gains, and participation-related community reintegration outcomes in a baseline cohort of patients 8 years postadmission. DESIGN Retrospective review and prospective repeated measures of an inception cohort. SETTING Polytrauma rehabilitation center (PRC). PARTICIPANTS Patients consecutively admitted to the PRC inpatient rehabilitation unit during its first full fiscal year, 2006 (N=44). INTERVENTIONS The PRC infrastructure and formalized rehabilitation for polytrauma/TBI. MAIN OUTCOME MEASURES FIM scores at admission, discharge, 3 months, and 8 years postdischarge; participation-related socioeconomic factors reflecting community reintegration 8 years after admission. RESULTS Functional gains were statistically significantly increased from admission to discharge. Improvements were maintained at both 3 months postdischarge and 8 years postdischarge. The socioeconomic data collected at 8-year follow-up showed >50% either competitively employed or continuing their education and 100% living in a noninstitutionalized setting. CONCLUSIONS This study addresses a concern regarding the long-term functional outcomes of rehabilitation patients treated by the established infrastructure of the Polytrauma System of Care inpatient rehabilitation centers. The results suggest that polytrauma/TBI rehabilitation care using a comprehensive, integrated approach is effective and durable in achieving functional gains and successful community reintegration within our initial PRC cohort. Follow-up of subsequent fiscal year cohorts would add to the validity of these outcome findings.
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Affiliation(s)
- Max Gray
- Department of Veterans Affairs Palo Alto Health Care System, Palo Alto, CA
| | - Joyce Chung
- Department of Veterans Affairs Palo Alto Health Care System, Palo Alto, CA
| | - Fatima Aguila
- Department of Veterans Affairs Palo Alto Health Care System, Palo Alto, CA
| | - T Gavin Williams
- Department of Veterans Affairs Palo Alto Health Care System, Palo Alto, CA; Physical Medicine and Rehabilitation, Stanford University School of Medicine, Stanford, CA
| | - Jeffrey K Teraoka
- Department of Veterans Affairs Palo Alto Health Care System, Palo Alto, CA.
| | - Odette A Harris
- Department of Veterans Affairs Palo Alto Health Care System, Palo Alto, CA; The Defense and Veterans Brain Injury Center, Palo Alto, CA; Department of Neurosurgery, Stanford University School of Medicine, Stanford, CA
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Seal KH, Bertenthal D, Barnes DE, Byers AL, Strigo I, Yaffe K. Association of Traumatic Brain Injury With Chronic Pain in Iraq and Afghanistan Veterans: Effect of Comorbid Mental Health Conditions. Arch Phys Med Rehabil 2017; 98:1636-1645. [DOI: 10.1016/j.apmr.2017.03.026] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2016] [Revised: 03/10/2017] [Accepted: 03/30/2017] [Indexed: 10/19/2022]
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Predictors of Employment Outcomes in Veterans With Traumatic Brain Injury: A VA Traumatic Brain Injury Model Systems Study. J Head Trauma Rehabil 2017; 32:271-282. [DOI: 10.1097/htr.0000000000000275] [Citation(s) in RCA: 36] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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35
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Swan A, Nelson J, Swiger B, Jaramillo C, Eapen B, Packer M, Pugh M. Prevalence of hearing loss and tinnitus in Iraq and Afghanistan Veterans: A Chronic Effects of Neurotrauma Consortium study. Hear Res 2017; 349:4-12. [DOI: 10.1016/j.heares.2017.01.013] [Citation(s) in RCA: 51] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/30/2016] [Revised: 01/10/2017] [Accepted: 01/22/2017] [Indexed: 11/15/2022]
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36
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Scholten J, Danford E, Leland A, Malecki H, Bidelspach D, Taylor B, Sayer N. Templated Interdisciplinary Rehabilitation Care Plan Documentation for Veterans With Traumatic Brain Injury. Prof Case Manag 2017; 21:266-276. [PMID: 27749702 PMCID: PMC5120540 DOI: 10.1097/ncm.0000000000000165] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF STUDY Individualized interdisciplinary care is the hallmark for rehabilitation following traumatic brain injury (TBI). Veterans Health Administration (VHA) utilizes an electronic note template to document Interdisciplinary Rehabilitation and Community Reintegration (IRCR) care plans for Veterans with TBI requiring rehabilitation. All Veterans with a TBI diagnosis, receiving skilled therapy for TBI-related issues, and followed by a case manager must receive a care plan. The purpose of this study was to determine the level of compliance with the IRCR care plan requirements used to identify Veterans with TBI in need of the care plan and to evaluate the reasons for inconsistent compliance. In addition, the study sought to provide a more objective assessment of Veterans with TBI requiring an IRCR to assist in establishing a target metric. PRIMARY PRACTICE SETTING TBI outpatient clinics. METHODOLOGY AND SAMPLE Investigators conducted a retrospective medical record review of 546 Veterans with a TBI diagnosis seen at the Washington, DC VA Medical Center's outpatient polytrauma clinics in 2013. Cases were initially reviewed for referral or engagement with skilled therapy. Charts where Veterans were referred or engaged with skilled therapy were forwarded to 2 polytrauma clinicians to determine whether therapy was requested to treat a TBI-related condition. Finally, charts were reviewed for case management and analyzed for algorithm compliance. Analysis focused first on compliance with IRCR algorithm requirements and secondarily with identifying potential reasons for noncompliance. RESULTS In 2013, 42% of the TBI cohort met the criteria for an IRCR. The vast majority of cases with a TBI diagnosis complied with IRCR algorithm criteria; however, 14% of all reviewed cases required an IRCR but did not receive one. Provision of case management outside of the TBI/polytrauma clinic characterized a majority of noncompliant cases. IMPLICATIONS FOR CASE MANAGEMENT Interdisciplinary care can be challenging, particularly in the outpatient setting, due to patient availability and access to care. Improved documentation in the electronic health record may assist case managers and other clinicians in coordinating rehabilitation care for Veterans with TBI. Case managers in the VA and other settings may find templates and trackable health factors helpful to identify patients in need of care plans.
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Affiliation(s)
- Joel Scholten
- Department of Physical Medicine and Rehabilitation, Washington DC VA Medical Center, 50 Irving Street, NW, Washington, DC 20422
- Physical Medicine and Rehabilitation Program Office, Department of Veterans Affairs (VA), 810 Vermont Avenue, NW, Washington, DC 20420
- Department of Physical Medicine and Rehabilitation, Georgetown University Medical Center, 3900 Reservoir Road, NW Washington, DC 20007
| | - Ellen Danford
- Research Service, Washington DC VA Medical Center, 50 Irving Street, NW, Washington DC 20422
| | - Azadeh Leland
- Department of Physical Medicine and Rehabilitation, Washington DC VA Medical Center, 50 Irving Street, NW, Washington, DC 20422
| | - Heather Malecki
- Department of Physical Medicine and Rehabilitation, Washington DC VA Medical Center, 50 Irving Street, NW, Washington, DC 20422
| | - Douglas Bidelspach
- Physical Medicine and Rehabilitation Program Office, Department of Veterans Affairs (VA), 810 Vermont Avenue, NW, Washington, DC 20420
- Rehabilitation and Prosthetics Services, Lebanon VA Medical Center, 1700 S Lincoln Avenue, Lebanon, PA 17042
| | - Brent Taylor
- Center for Chronic Disease Outcomes Research, Minneapolis VA Health Care System, One Veterans Drive, Minneapolis, MN 55417
- Department of Medicine and Epidemiology and Community Health, University of Minnesota, 100 Church Street, SE, Minneapolis, MN 55455
| | - Nina Sayer
- Center for Chronic Disease Outcomes Research, Minneapolis VA Health Care System, One Veterans Drive, Minneapolis, MN 55417
- Departments of Medicine and Psychiatry, University of Minnesota, 100 Church Street, SE, Minneapolis, MN 55455
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Carlson KF, O’Neil ME, Forsberg CW, McAndrew LM, Storzbach D, Cifu DX, Sayer NA. Risk of hospitalization due to motor vehicle crashes among Iraq and Afghanistan War Veterans diagnosed with traumatic brain injury. NeuroRehabilitation 2016; 39:351-61. [DOI: 10.3233/nre-161367] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Affiliation(s)
- Kathleen F. Carlson
- Center to Improve Veteran Involvement in Care, VA Portland Health Care System (R&D 66), Portland, OR, USA
- School of Public Health, Oregon Health and Science University, Portland, OR, USA
| | - Maya E. O’Neil
- Center to Improve Veteran Involvement in Care, VA Portland Health Care System (R&D 66), Portland, OR, USA
- Department of Psychiatry and Department of Medical Informatics and Clinical Epidemiology, Oregon Health and Science University, Portland, OR, USA
| | - Christopher W. Forsberg
- Center to Improve Veteran Involvement in Care, VA Portland Health Care System (R&D 66), Portland, OR, USA
| | - Lisa M. McAndrew
- Department of Educational and Counseling Psychology, War Related Illness and Injury Study Center, VA New Jersey Health Care System, East Orange, NJ, USA
- University at Albany, State University of New York, Albany, NY, USA
| | - Daniel Storzbach
- Neuropsychiatry Section, VA Portland Health Care System, Portland, OR, USA
- Department of Psychiatry, Oregon Health and Science University, Portland, OR, USA
| | - David X. Cifu
- Physical Medicine and Rehabilitation Services, Veterans Health Administration, Department ofVeterans Affairs, Washington, D.C., USA
- Physical Medicine and Rehabilitation Service, Hunter Holmes McGuire VA Medical Center, Richmond, VA, USA
- Department of Physical Medicine and Rehabilitation, Virginia Commonwealth University, Richmond, VA, USA
| | - Nina A. Sayer
- Center for Chronic Disease Outcomes Research, Minneapolis VA Healthcare System, Minneapolis, MN, USA
- Departments of Medicine and Psychiatry, University of Minnesota Medical School, Minneapolis, MN, USA
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Nathan DE, Bellgowan JF, Oakes TR, French LM, Nadar SR, Sham EB, Liu W, Riedy G. Assessing Quantitative Changes in Intrinsic Thalamic Networks in Blast and Nonblast Mild Traumatic Brain Injury: Implications for Mechanisms of Injury. Brain Connect 2016; 6:389-402. [PMID: 26956452 DOI: 10.1089/brain.2015.0403] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
In the global war on terror, the increased use of improvised explosive devices has resulted in increased incidence of blast-related mild traumatic brain injury (mTBI). Diagnosing mTBI is both challenging and controversial due to heterogeneity of injury location, trauma intensity, transient symptoms, and absence of focal biomarkers on standard clinical imaging modalities. The goal of this study is to identify a brain biomarker that is sensitive to mTBI injury. Research suggests the thalamus may be sensitive to changes induced by mTBI. A significant number of connections to and from various brain regions converge at the thalamus. In addition, the thalamus is involved in information processing, integration, and regulation of specific behaviors and mood. In this study, changes in task-free thalamic networks as quantified by graph theory measures in mTBI blast (N = 186), mTBI nonblast (N = 80), and controls (N = 21) were compared. Results show that the blast mTBI group had significant hyper-connectivity compared with the controls and nonblast mTBI group. However, after controlling for post-traumatic stress symptoms (PTSS), the blast mTBI group was not different from the controls, but the nonblast mTBI group showed significant hypo-connectivity. The results suggest that there are differences in the mechanisms of injury related to mTBI as reflected in the architecture of the thalamic networks. However, the effect of PTSS and its relationship to mTBI is difficult to distinguish and warrants more research.
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Affiliation(s)
- Dominic E Nathan
- 1 National Intrepid Center of Excellence (NICoE), Walter Reed National Military Medical Center , Bethesda, Maryland.,2 North Tide LLC , Dulles, Virginia.,3 Uniformed Services University of the Health Sciences , Bethesda, Maryland
| | - Julie F Bellgowan
- 1 National Intrepid Center of Excellence (NICoE), Walter Reed National Military Medical Center , Bethesda, Maryland.,2 North Tide LLC , Dulles, Virginia
| | - Terrence R Oakes
- 1 National Intrepid Center of Excellence (NICoE), Walter Reed National Military Medical Center , Bethesda, Maryland
| | - Louis M French
- 1 National Intrepid Center of Excellence (NICoE), Walter Reed National Military Medical Center , Bethesda, Maryland.,4 Center of Neuroscience and Regenerative Medicine (CNRM) , Bethesda, Maryland
| | - Sreenivasan R Nadar
- 1 National Intrepid Center of Excellence (NICoE), Walter Reed National Military Medical Center , Bethesda, Maryland.,5 Henry M. Jackson Foundation , Bethesda, Maryland
| | - Elyssa B Sham
- 1 National Intrepid Center of Excellence (NICoE), Walter Reed National Military Medical Center , Bethesda, Maryland.,2 North Tide LLC , Dulles, Virginia
| | - Wei Liu
- 1 National Intrepid Center of Excellence (NICoE), Walter Reed National Military Medical Center , Bethesda, Maryland.,2 North Tide LLC , Dulles, Virginia
| | - Gerard Riedy
- 1 National Intrepid Center of Excellence (NICoE), Walter Reed National Military Medical Center , Bethesda, Maryland.,3 Uniformed Services University of the Health Sciences , Bethesda, Maryland
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39
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Riedy G, Senseney JS, Liu W, Ollinger J, Sham E, Krapiva P, Patel JB, Smith A, Yeh PH, Graner J, Nathan D, Caban J, French LM, Harper J, Eskay V, Morissette J, Oakes TR. Findings from Structural MR Imaging in Military Traumatic Brain Injury. Radiology 2016; 279:207-15. [DOI: 10.1148/radiol.2015150438] [Citation(s) in RCA: 49] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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40
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Winter L, Moriarty HJ, Robinson K, Piersol CV, Vause-Earland T, Newhart B, Iacovone DB, Hodgson N, Gitlin LN. Efficacy and acceptability of a home-based, family-inclusive intervention for veterans with TBI: A randomized controlled trial. Brain Inj 2016; 30:373-387. [PMID: 26983578 DOI: 10.3109/02699052.2016.1144080] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
OBJECTIVE Traumatic brain injury (TBI) often undermines community re-integration, impairs functioning and produces other symptoms. This study tested an innovative programme for veterans with TBI, the Veterans' In-home Programme (VIP), delivered in veterans' homes, involving a family member and targeting the environment (social and physical) to promote community re-integration, mitigate difficulty with the most troubling TBI symptoms and facilitate daily functioning. SETTING Interviews and intervention sessions were conducted in homes or by telephone. PARTICIPANTS Eighty-one veterans with TBI at a VA polytrauma programme and a key family member. DESIGN This was a 2-group randomized controlled trial. Control-group participants received usual-care enhanced by two attention-control telephone calls. Follow-up interviews occurred up to 4 months after baseline interview. MAIN MEASURES VIP's efficacy was evaluated using measures of community re-integration, target outcomes reflecting veterans' self-identified problems and self-rated functional competence. RESULTS At follow-up, VIP participants had significantly higher community re-integration scores and less difficulty managing targeted outcomes, compared to controls. Self-rated functional competence did not differ between groups. In addition, VIP's acceptability was high. CONCLUSION A home-based, family-inclusive service for veterans with TBI shows promise for improving meaningful outcomes and warrants further research and clinical application.
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Affiliation(s)
- Laraine Winter
- a Philadelphia Research and Education Foundation.,b Nursing Service , Department of Veterans Affairs Medical Center , Philadelphia , PA , USA
| | - Helene J Moriarty
- b Nursing Service , Department of Veterans Affairs Medical Center , Philadelphia , PA , USA.,c Villanova University College of Nursing , Villanova , PA , USA
| | - Keith Robinson
- d Medical Rehabilitation Service , Department of Veterans Affairs Medical Center , Philadelphia , PA , USA.,e Perelman School of Medicine , University of Pennsylvania , PA , USA
| | - Catherine V Piersol
- f Thomas Jefferson University , School of Health Professions , Philadelphia , PA , USA
| | - Tracey Vause-Earland
- f Thomas Jefferson University , School of Health Professions , Philadelphia , PA , USA
| | - Brian Newhart
- d Medical Rehabilitation Service , Department of Veterans Affairs Medical Center , Philadelphia , PA , USA
| | - Delores Blazer Iacovone
- d Medical Rehabilitation Service , Department of Veterans Affairs Medical Center , Philadelphia , PA , USA
| | - Nancy Hodgson
- g The Center for Innovative Care in Aging, School of Nursing , Johns Hopkins University , Baltimore , MD , USA
| | - Laura N Gitlin
- g The Center for Innovative Care in Aging, School of Nursing , Johns Hopkins University , Baltimore , MD , USA
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Stemper BD, Shah AS, Budde MD, Olsen CM, Glavaski-Joksimovic A, Kurpad SN, McCrea M, Pintar FA. Behavioral Outcomes Differ between Rotational Acceleration and Blast Mechanisms of Mild Traumatic Brain Injury. Front Neurol 2016; 7:31. [PMID: 27014184 PMCID: PMC4789366 DOI: 10.3389/fneur.2016.00031] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2015] [Accepted: 02/29/2016] [Indexed: 11/20/2022] Open
Abstract
Mild traumatic brain injury (mTBI) can result from a number of mechanisms, including blunt impact, head rotational acceleration, exposure to blast, and penetration of projectiles. Mechanism is likely to influence the type, severity, and chronicity of outcomes. The objective of this study was to determine differences in the severity and time course of behavioral outcomes following blast and rotational mTBI. The Medical College of Wisconsin (MCW) Rotational Injury model and a shock tube model of primary blast injury were used to induce mTBI in rats and behavioral assessments were conducted within the first week, as well as 30 and 60 days following injury. Acute recovery time demonstrated similar increases over protocol-matched shams, indicating acute injury severity equivalence between the two mechanisms. Post-injury behavior in the elevated plus maze demonstrated differing trends, with rotationally injured rats acutely demonstrating greater activity, whereas blast-injured rats had decreased activity that developed at chronic time points. Similarly, blast-injured rats demonstrated trends associated with cognitive deficits that were not apparent following rotational injuries. These findings demonstrate that rotational and blast injury result in behavioral changes with different qualitative and temporal manifestations. Whereas rotational injury was characterized by a rapidly emerging phenotype consistent with behavioral disinhibition, blast injury was associated with emotional and cognitive differences that were not evident acutely, but developed later, with an anxiety-like phenotype still present in injured animals at our most chronic measurements.
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Affiliation(s)
- Brian D. Stemper
- Department of Neurosurgery, Medical College of Wisconsin, Milwaukee, WI, USA
- Clement J. Zablocki Veterans Affairs Medical Center, Milwaukee, WI, USA
- Neuroscience Research Center, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Alok S. Shah
- Department of Neurosurgery, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Matthew D. Budde
- Department of Neurosurgery, Medical College of Wisconsin, Milwaukee, WI, USA
- Clement J. Zablocki Veterans Affairs Medical Center, Milwaukee, WI, USA
- Neuroscience Research Center, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Christopher M. Olsen
- Neuroscience Research Center, Medical College of Wisconsin, Milwaukee, WI, USA
- Department of Pharmacology and Toxicology, Medical College of Wisconsin, Milwaukee, WI, USA
| | | | - Shekar N. Kurpad
- Department of Neurosurgery, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Michael McCrea
- Department of Neurosurgery, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Frank A. Pintar
- Department of Neurosurgery, Medical College of Wisconsin, Milwaukee, WI, USA
- Clement J. Zablocki Veterans Affairs Medical Center, Milwaukee, WI, USA
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Phillips KM, Clark ME, Gironda RJ, McGarity S, Kerns RW, Elnitsky CA, Andresen EM, Collins RC. Pain and psychiatric comorbidities among two groups of Iraq and Afghanistan era Veterans. ACTA ACUST UNITED AC 2016; 53:413-32. [PMID: 27532156 DOI: 10.1682/jrrd.2014.05.0126] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2014] [Revised: 10/02/2015] [Indexed: 11/05/2022]
Affiliation(s)
| | | | | | | | - Robert W. Kerns
- Pain Research, Informatics, Multi-morbidities, and Education, Center of Innovation, Department of Veterans Affairs (VA) Connecticut Healthcare System, West Haven, CT; and School of Medicine, Yale University, New Haven, CT
| | - Christine A. Elnitsky
- School of Nursing, College of Health and Human Services, University of North Carolina at Charlotte, Charlotte, NC
| | - Elena M. Andresen
- School of Public Health, Oregon Health and Science University; and Portland State University, Portland, OR
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Stevens LF, Pickett TC, Wilder Schaaf KP, Taylor BC, Gravely A, Van Houtven CH, Friedemann-Sánchez G, Griffin JM. The Relationship between Training and Mental Health among Caregivers of Individuals with Polytrauma. Behav Neurol 2015; 2015:185941. [PMID: 26770015 PMCID: PMC4685074 DOI: 10.1155/2015/185941] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2015] [Revised: 10/23/2015] [Accepted: 10/27/2015] [Indexed: 11/23/2022] Open
Abstract
This was a hypothesis-generating exploration of relationships between caregiver training during TBI/polytrauma rehabilitation and caregiver mental health. In this cross-sectional study, 507 informal caregivers to US service members with TBI who received inpatient rehabilitation care in a Veterans Affairs' Polytrauma Rehabilitation Center from 2001 to 2009 completed a retrospective, self-report survey. Embedded in the survey were measures of caregiver mental health, including the National Institutes of Health's Patient Reported Outcome Measurement Information System (PROMIS) Anxiety and Depression Short Forms, the Rosenberg Self-Esteem scale, and the Zarit Burden Short Form. Though no groups endorsed clinical levels, mental health symptoms varied by caregiver training category (Trained, Not Trained, and Did Not Need Training). Caregivers who did not receive training on how to navigate healthcare systems endorsed higher depression and burden and lower self-esteem than those who did. Caregivers who did not receive training in supporting their care recipients' emotions endorsed higher anxiety, depression, and burden and lower self-esteem than those who did. Analyses also suggested a different association between training and mental health based on caregivers' relationship to the care recipient and the intensity of care recipient needs. Potential hypotheses for testing in future studies raised by these findings are discussed.
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Affiliation(s)
- Lillian Flores Stevens
- Hunter Holmes McGuire VAMC, Psychology Section (116B), 1201 Broad Rock Boulevard, Richmond, VA 23249, USA
- Departments of Psychology, Physical Medicine and Rehabilitation, Virginia Commonwealth University, Richmond, VA, USA
| | - Treven C. Pickett
- Hunter Holmes McGuire VAMC, Psychology Section (116B), 1201 Broad Rock Boulevard, Richmond, VA 23249, USA
- Departments of Psychology, Psychiatry, Physical Medicine and Rehabilitation, Virginia Commonwealth University, Richmond, VA, USA
| | - Kathryn P. Wilder Schaaf
- Hunter Holmes McGuire VAMC, Psychology Section (116B), 1201 Broad Rock Boulevard, Richmond, VA 23249, USA
- Departments of Psychology, Physical Medicine and Rehabilitation, Virginia Commonwealth University, Richmond, VA, USA
| | - Brent C. Taylor
- Center for Chronic Disease Outcomes Research, Minneapolis VA Health Care System, 1 Veterans Drive (152/Building 9), Minneapolis, MN 55417, USA
| | - Amy Gravely
- Center for Chronic Disease Outcomes Research, Minneapolis VA Health Care System, 1 Veterans Drive (152/Building 9), Minneapolis, MN 55417, USA
| | - Courtney Harold Van Houtven
- Center for Health Services Research in Primary Care, Durham VA Medical Center, 508 Fulton Street, Durham, NC 27705, USA
| | - Greta Friedemann-Sánchez
- Humphrey School of Public Affairs, University of Minnesota, 267 Humphrey Center, 301 19th Avenue S., Minneapolis, MN 55455, USA
| | - Joan M. Griffin
- Center for Chronic Disease Outcomes Research, Minneapolis VA Health Care System, 1 Veterans Drive (152/Building 9), Minneapolis, MN 55417, USA
- Mayo Clinic, Department of Health Sciences Research, Division of Health Care Policy and Research, Kern Center for the Science of Health Care Delivery, 200 First Street SW, Rochester, MN 55905, USA
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Abstract
1. Musculoskeletal problems are the commonest reason for medical discharge in all the British armed forces. By definition, these problems are chronic and resistant to treatment. 2. Pain is also common in veterans who have experienced severe injuries (polytrauma), often accompanied by post-traumatic stress disorder (PTSD) and traumatic brain injury (TBI) orpostconcussive syndrome. 3. In veterans seeking treatment for chronic pain, PTSD is common. There is also evidence for elevated levels of alcohol misuse in veterans who have been deployed to conflict. However, most veterans do not have pain, PTSD or alcohol problems. 4. Pain clinicians would benefit from training in meeting veterans' needs, in order to promote their engagement and successful treatment. This should include countering stereotypes, information about the military and support for the assessment and onward referral of PTSD and alcohol problems.
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Affiliation(s)
| | - Sarah Wilson
- Bath Centre for Pain Services & Department of Psychology, University of Bath, Bath, UK
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A Randomized Controlled Trial to Evaluate the Veterans' In-home Program for Military Veterans With Traumatic Brain Injury and Their Families: Report on Impact for Family Members. PM R 2015; 8:495-509. [PMID: 26514790 DOI: 10.1016/j.pmrj.2015.10.008] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2015] [Revised: 10/14/2015] [Accepted: 10/18/2015] [Indexed: 11/23/2022]
Abstract
BACKGROUND Traumatic brain injury (TBI) creates many challenges for families as well as for patients. Few intervention studies have considered both the needs of the person with TBI and his or her family and included both in the intervention process. To address this gap, we designed an innovative intervention for veterans with TBI and families-the Veterans' In-home Program (VIP)-targeting veterans' environment, delivered in veterans' homes, and involving their families. OBJECTIVES To determine whether the VIP is more effective than standard outpatient clinic care in improving family members' well-being in 3 domains (depressive symptoms, burden, and satisfaction) and to assess its acceptability to family members. DESIGN In this randomized controlled trial, 81 dyads (veteran/family member) were randomly assigned to VIP or an enhanced usual care control condition. Randomization occurred after the baseline interview. Follow-up interviews occurred 3-4 months after baseline, and the interviewer was blinded to group assignment. SETTING Interviews and intervention sessions were conducted in veterans' homes or by telephone. PARTICIPANTS A total of 81 veterans with TBI recruited from a Veterans Affairs (VA) polytrauma program and a key family member for each participated. Of the 81 family members, 63 completed the follow-up interview. INTERVENTION The VIP, guided by the person-environment fit model, consisted of 6 home visits and 2 telephone calls delivered by occupational therapists over a 3- to 4-month period. Family members were invited to participate in the 6 home sessions. MAIN OUTCOME MEASURES Family member well-being was operationally defined as depressive symptomatology, caregiver burden, and caregiver satisfaction 3-4 months after baseline. Acceptability was operationally defined through 3 indicators. RESULTS Family members in the VIP showed significantly lower depressive symptom scores and lower burden scores when compared to controls at follow-up. Satisfaction with caregiving did not differ between groups. Family members' acceptance of the intervention was high. CONCLUSIONS VIP represents the first evidence-based intervention that considers both the veteran with TBI and the family. VIP had a significant impact on family member well-being and thus addresses a large gap in previous research and services for families of veterans with TBI.
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46
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Winter L, Moriarty H, Robinson KM, Newhart B. Rating competency in everyday activities in patients with TBI: clinical insights from a close look at patient–family differences. Disabil Rehabil 2015; 38:1280-90. [DOI: 10.3109/09638288.2015.1077531] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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Walls MK, Race N, Zheng L, Vega-Alvarez SM, Acosta G, Park J, Shi R. Structural and biochemical abnormalities in the absence of acute deficits in mild primary blast-induced head trauma. J Neurosurg 2015; 124:675-86. [PMID: 26295915 DOI: 10.3171/2015.1.jns141571] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
OBJECTIVE Blast-induced neurotrauma (BINT), if not fatal, is nonetheless potentially crippling. It can produce a wide array of acute symptoms in moderate-to-severe exposures, but mild BINT (mBINT) is characterized by the distinct absence of acute clinical abnormalities. The lack of observable indications for mBINT is particularly alarming, as these injuries have been linked to severe long-term psychiatric and degenerative neurological dysfunction. Although the long-term sequelae of BINT are extensively documented, the underlying mechanisms of injury remain poorly understood, impeding the development of diagnostic and treatment strategies. The primary goal of this research was to recapitulate primary mBINT in rodents in order to facilitate well-controlled, long-term investigations of blast-induced pathological neurological sequelae and identify potential mechanisms by which ongoing damage may occur postinjury. METHODS A validated, open-ended shock tube model was used to deliver blast overpressure (150 kPa) to anesthetized rats with body shielding and head fixation, simulating the protective effects of military-grade body armor and isolating a shock wave injury from confounding systemic injury responses, head acceleration, and other elements of explosive events. Evans Blue-labeled albumin was used to visualize blood-brain barrier (BBB) compromise at 4 hours postinjury. Iba1 staining was used to visualize activated microglia and infiltrating macrophages in areas of peak BBB compromise. Acrolein, a potent posttraumatic neurotoxin, was quantified in brain tissue by immunoblotting and in urine through liquid chromatography with tandem mass spectrometry at 1, 2, 3, and 5 days postinjury. Locomotor behavior, motor performance, and short-term memory were assessed with open field, rotarod, and novel object recognition (NOR) paradigms at 24 and 48 hours after the blast. RESULTS Average speed, maximum speed, and distance traveled in an open-field exploration paradigm did not show significant differences in performance between sham-injured and mBINT rats. Likewise, rats with mBINT did not exhibit deficits in maximum revolutions per minute or total run time in a rotarod paradigm. Short-term memory was also unaffected by mBINT in an NOR paradigm. Despite lacking observable motor or cognitive deficits in the acute term, blast-injured rats displayed brain acrolein levels that were significantly elevated for at least 5 days, and acrolein's glutathione-reduced metabolite, 3-HPMA, was present in urine for 2 days after injury. Additionally, mBINT brain tissue demonstrated BBB damage 4 hours postinjury and colocalized neuroinflammatory changes 24 hours postinjury. CONCLUSIONS This model highlights mBINT's potential for underlying detrimental physical and biochemical alterations despite the lack of apparent acute symptoms and, by recapitulating the human condition, represents an avenue for further examining the pathophysiology of mBINT. The sustained upregulation of acrolein for days after injury suggests that acrolein may be an upstream player potentiating ongoing postinjury damage and neuroinflammation. Ultimately, continued research with this model may lead to diagnostic and treatment mechanisms capable of preventing or reducing the severity of long-term neurological dysfunction following mBINT.
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Affiliation(s)
- Michael K Walls
- Department of Basic Medical Sciences, College of Veterinary Medicine; and
| | - Nicholas Race
- Weldon School of Biomedical Engineering, Purdue University, West Lafayette, Indiana
| | - Lingxing Zheng
- Department of Basic Medical Sciences, College of Veterinary Medicine; and.,Weldon School of Biomedical Engineering, Purdue University, West Lafayette, Indiana
| | | | - Glen Acosta
- Department of Basic Medical Sciences, College of Veterinary Medicine; and
| | - Jonghyuck Park
- Department of Basic Medical Sciences, College of Veterinary Medicine; and.,Weldon School of Biomedical Engineering, Purdue University, West Lafayette, Indiana
| | - Riyi Shi
- Department of Basic Medical Sciences, College of Veterinary Medicine; and.,Weldon School of Biomedical Engineering, Purdue University, West Lafayette, Indiana
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48
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Moriarty H, Winter L, Robinson K, True G, Piersol C, Vause-Earland T, Iacovone DB, Holbert L, Newhart B, Fishman D, Short TH. Exploration of Individual and Family Factors Related to Community Reintegration in Veterans With Traumatic Brain Injury. J Am Psychiatr Nurses Assoc 2015; 21:195-211. [PMID: 26156059 DOI: 10.1177/1078390315591879] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Community reintegration (CR) poses a major problem for military veterans who have experienced a traumatic brain injury (TBI). Factors contributing to CR after TBI are poorly understood. OBJECTIVE To address the gap in knowledge, an ecological framework was used to explore individual and family factors related to CR. DESIGN Baseline data from an intervention study with 83 veterans with primarily mild to moderate TBI were analyzed. Instruments measured CR, depressive symptoms, physical health, quality of the relationship with the family member, and sociodemographics. Posttraumatic stress disorder and TBI characteristics were determined through record review. RESULTS Five variables that exhibited significant bivariate relationships with CR (veteran rating of quality of relationship, physical functioning, bodily pain, posttraumatic stress disorder diagnosis, and depressive symptoms) were entered into hierarchical regression analysis. In the final analysis, the five variables together accounted for 35% of the variance, but only depression was a significant predictor of CR, with more depressed veterans exhibiting lower CR. CONCLUSIONS Efforts to support CR of Veterans with TBI should carefully assess and target depression, a modifiable factor.
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Affiliation(s)
- Helene Moriarty
- Helene Moriarty, PhD, RN, Nursing Service, Philadelphia Veterans Affairs (VA) Medical Center, Philadelphia, PA, USA; Villanova University College of Nursing, Villanova, PA, USA
| | - Laraine Winter
- Laraine Winter, PhD, Nursing Service, Philadelphia VA Medical Center, Philadelphia, PA, USA; Philadelphia Research and Education Foundation, Philadelphia VA Medical Center, Philadelphia, PA, USA
| | - Keith Robinson
- Keith Robinson, MD, Polytrauma Service, Philadelphia VA Medical Center, Philadelphia, PA, USA; Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Gala True
- Gala True, PhD, Center for Health Equity Research and Promotion, Philadelphia VA Medical Center, Philadelphia, PA, USA; Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Catherine Piersol
- Catherine Piersol, PhD, OTR/L, Thomas Jefferson University, School of Health Professions, Philadelphia, PA, USA
| | - Tracey Vause-Earland
- Tracey Vause-Earland, MS, OTR/L, Thomas Jefferson University, School of Health Professions, Philadelphia, PA, USA
| | - Dolores Blazer Iacovone
- Dolores Blazer Iacovone, MS, OTR/L, CDRS, Polytrauma Service, Philadelphia VA Medical Center, Philadelphia, PA, USA
| | - Laura Holbert
- Laura Holbert, MSW, Philadelphia Research and Education Foundation, Philadelphia VA Medical Center, Philadelphia, PA, USA
| | - Brian Newhart
- Brian Newhart, MSW, Polytrauma Service, Philadelphia VA Medical Center, Philadelphia, PA, USA
| | - Deborah Fishman
- Deborah Fishman, RN, MSN, Nursing Service, Philadelphia VA Medical Center, Philadelphia, PA, USA
| | - Thomas H Short
- Thomas H. Short, PhD, PStat®, John Carroll University, Department of Mathematics and Computer Science, University Heights, OH, USA
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49
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Finley EP, Bollinger M, Noël PH, Amuan ME, Copeland LA, Pugh JA, Dassori A, Palmer R, Bryan C, Pugh MJV. A national cohort study of the association between the polytrauma clinical triad and suicide-related behavior among US Veterans who served in Iraq and Afghanistan. Am J Public Health 2015; 105:380-7. [PMID: 25033126 DOI: 10.2105/ajph.2014.301957] [Citation(s) in RCA: 58] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
Abstract
OBJECTIVES We examined the association of posttraumatic stress disorder (PTSD), traumatic brain injury, and chronic pain-the polytrauma clinical triad (PCT)-independently and with other conditions, with suicide-related behavior (SRB) risk among Operation Enduring Freedom (OEF; Afghanistan) and Operation Iraqi Freedom (OIF) veterans. METHODS We used Department of Veterans Affairs (VA) administrative data to identify OEF and OIF veterans receiving VA care in fiscal years 2009-2011; we used International Classification of Diseases, Ninth Revision, Clinical Modification codes to characterize 211652 cohort members. Descriptive statistics were followed by multinomial logistic regression analyses predicting SRB. RESULTS Co-occurrence of PCT conditions was associated with significant increase in suicide ideation risk (odds ratio [OR] = 1.9; 95% confidence interval [CI]=1.5, 2.4) or attempt and ideation (OR=2.6; 95% CI=1.5, 4.6), but did not exceed increased risk with PTSD alone (ideation: OR=2.3; 95% CI=2.0, 2.6; attempt: OR=2.0; 95% CI=1.4, 2.9; ideation and attempt: OR=1.8; 95% CI=1.2, 2.8). Ideation risk was significantly elevated when PTSD was comorbid with depression (OR=4.2; 95% CI=3.6, 4.8) or substance abuse (OR=4.7; 95% CI = 3.9, 5.6). CONCLUSIONS Although PCT was a moderate SRB predictor, interactions among PCT conditions, particularly PTSD, and depression or substance abuse had larger risk increases.
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Affiliation(s)
- Erin P Finley
- Erin P. Finley, Mary Bollinger, Polly H. Noël, Jacqueline A. Pugh, Albana Dassori, and Mary Jo V. Pugh are with South Texas Veterans Health Care System, San Antonio. Raymond Palmer is with Department of Epidemiology and Biostatistics, University of Texas Health Science Center, San Antonio. Megan E. Amuan is with Center for Health Quality, Outcomes and Economic Research, Edith Nourse Rogers Memorial VA Hospital, Bedford, MA. Laurel A. Copeland is with Center for Applied Health Research, jointly sponsored by Central Texas Veterans, Health Care System and Scott and White Healthcare System, Temple, TX. Craig Bryan is with National Center for Veterans Studies and Department of Psychology, The University of Utah, Salt Lake City, UT
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50
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Shireman PK, Rasmussen TE, Jaramillo CA, Pugh MJ. VA Vascular Injury Study (VAVIS): VA-DoD extremity injury outcomes collaboration. BMC Surg 2015; 15:13. [PMID: 25644593 PMCID: PMC4328065 DOI: 10.1186/1471-2482-15-13] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2014] [Accepted: 01/14/2015] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND Limb injuries comprise 50-60% of U.S. Service member's casualties of wars in Afghanistan and Iraq. Combat-related vascular injuries are present in 12% of this cohort, a rate 5 times higher than in prior wars. Improvements in medical and surgical trauma care, including initial in-theatre limb salvage approaches (IILS) have resulted in improved survival and fewer amputations, however, the long-term outcomes such as morbidity, functional decline, and risk for late amputation of salvaged limbs using current process of care have not been studied. The long-term care of these injured warfighters poses a significant challenge to the Department of Defense (DoD) and Department of Veterans Affairs (VA). METHODS/DESIGN The VA Vascular Injury Study (VAVIS): VA-DoD Extremity Injury Outcomes Collaborative, funded by the VA, Health Services Research and Development Service, is a longitudinal cohort study of Veterans with vascular extremity injuries. Enrollment will begin April, 2015 and continue for 3 years. Individuals with a validated extremity vascular injury in the Department of Defense Trauma Registry will be contacted and will complete a set of validated demographic, social, behavioral, and functional status measures during interview and online/ mailed survey. Primary outcome measures will: 1) Compare injury, demographic and geospatial characteristics of patients with IILS and identify late vascular surgery related limb complications and health care utilization in Veterans receiving VA vs. non-VA care, 2) Characterize the preventive services received by individuals with vascular repair and related outcomes, and 3) Describe patient-reported functional outcomes in Veterans with traumatic vascular limb injuries. DISCUSSION This study will provide key information about the current process of care for Active Duty Service members and Veterans with polytrauma/vascular injuries at risk for persistent morbidity and late amputation. The results of this study will be the first step for clinicians in VA and military settings to generate evidence-based treatment and care approaches to these injuries. It will identify areas where rehabilitation medicine and vascular specialty care or telehealth options are needed to allow for better planning, resource utilization, and improved DoD-to-VA care transitions.
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Affiliation(s)
- Paula K Shireman
- Department of Surgery, Sam and Ann Barshop Institute for Longevity and Aging Studies, University of Texas Health Science Center San Antonio, The South Texas Veterans Health Care System, 7703 Floyd Curl Drive, MC 7790, San Antonio, TX, 78229-3900, USA.
| | - Todd E Rasmussen
- US Combat Casualty Care Research Program, Fort Detrick, Frederick, MD, 21702-5012, USA. .,The Uniformed Services University, Bethesda, MD, 20814, USA.
| | - Carlos A Jaramillo
- Department of Rehabilitation Medicine, University of Texas Health Science Center San Antonio, Polytrauma Rehabilitation Center, South Texas Veterans Healthcare System, 7400 Merton Minter BLVD, San Antonio, TX, 78229, USA.
| | - Mary Jo Pugh
- Department of Epidemiology and Biostatistics, University of Texas Health Science Center San Antonio, The South Texas Veterans Health Care System, 7400 Merton Minter BLVD, San Antonio, TX, 78229, USA.
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