Residual cognitive disability after completion of inpatient rehabilitation among injured children

Cognitive, behavioral and psychiatric symptoms in patients with spinal cord injury: a scoping review

Spinal Cord Injury (SCI) is a condition where the spinal cord is damaged and experiences partial or complete loss of motor and/or sensory function, which is typically less than normal. After SCI, patients may exhibit more severe psychiatric symptoms and experience cognitive impairments, including reduced speed and attention processing capacity, as well as difficulties with executive function and episodic memory retention. Among the behavioral and psychiatric symptoms, depression, anxiety, substance use disorder, and posttraumatic stress disorder are the most common. This review aims to investigate the cognitive, behavioral, or psychiatric symptoms of the patient with SCI and their influence on the rehabilitation process. Studies were identified from an online search of PubMed, Web of Science, Cochrane Library, and Embase databases. Studies published between 2013-2023 were selected. This review has been registered on OSF (n) 3KB2U. We have found that patients with SCI are at high risk of cognitive impairment and experience a wide range of difficulties, including tasks based on processing speed and executive function. This clinical population may experience adjustment disorders with depression and anxiety, as well as other psychiatric symptoms such as fatigue, stress, and suicidal ideation. This review has demonstrated that SCI patients may experience psychiatric symptoms and cognitive impairments that affect their functioning. At the same time, these patients may be more prone to various adjustment and mood disorders. Moreover, these two aspects may interact with each other, causing a range of symptoms, increasing the risk of hospitalization, and delaying the rehabilitation process.

Children's outcomes in road traffic accidents: challenges for personal injury assessment

Children represent a specific group of road traffic accident (RTA) victims. Performing a personal injury assessment (PIA) on a child presents a significant challenge, especially when assessing permanent disabilities and needs. However, medico-legal recommendations for PIA in such cases are lacking. The main objective of this study was to analyse the differences between children and a young- and middle-aged adult population of RTA victims to contribute to the development of relevant guidelines. Secondary objectives were to identify and characterize specifics of children's posttraumatic damages regarding: (i) temporary and permanent outcomes; and (ii) medico-legal damage parameters in the Portuguese context. We performed a retrospective study of RTA victims by comparing two groups (n = 114 each) matched for acute injury severity (SD = 0.01): G1 (children) and G2 (young- and middle-aged adults). Logistic regression was used to estimate the odds ratios. G1 presented a greater chance of evolving without or with less severe body, functional and situational outcomes (three-dimensional assessment methodology), and with lower permanent functional disability values than G2. Our findings suggest that childhood trauma generally has a better prognosis than trauma in young- and middle-aged adults. This study generated evidence on the subject and highlighted the most significant difficulties encountered by medico-legal experts when performing PIA in children.

Key points

This retrospective study of PIA in child victims of RTA in Portugal considered outcomes in victims' real-life situations.Several significant differences between children and young- and middle-aged adults were observed.Children's cases presented better results in terms of the severity of body, functional and situational outcomes, and permanent damage parameters.The average time between the RTA and final PIA date and the consolidation time were longer for children because of the need to wait for the Children's next growth phase or final pubertal period (as applicable), which increased the time for PIA conclusion.There were several difficulties in the medical-legal evaluation of children's cases, which was a complex process because the trauma affected them in their growth phase.

A neuropsychological approach in a paediatric acquired brain injury unit under the public health system

INTRODUCTION

Paediatric acquired brain injury (ABI) causes cognitive and behavioural difficulties and alters the course of child development. The ABI unit at Hospital Infantil Universitario Niño Jesús is the first within the public Spanish health system to provide comprehensive coverage to these patients and their families.

OBJECTIVE

This study aims to show the working methodology followed with patients and their families, and to describe the clinical characteristics of the patients treated and the outcomes of treatment.

PATIENTS

Fifty-three patients aged between 3 months and 16 and a half years received treatment. The conditions treated were brain tumours, stroke, traumatic brain injury, damage secondary to epilepsy surgery, and hypoxia.

METHODS

All patients were evaluated at admission and at discharge. Treatments were adapted to each patient's difficulties and their severity, as well as to the patient's age. Families received individual and group therapy.

RESULTS

Older age was associated with better cognitive recovery and shorter duration of treatment. Different conditions show differential impact on intelligence quotient and developmental quotient scores at the beginning of treatment, with hypoxia and encephalitis being associated with greatest severity. Intelligence quotient and developmental quotient scores and visual memory and attention scores at discharge improved significantly after the faceted neuropsychological treatment with respect to scores registered at admission.

CONCLUSIONS

The care of patients with ABI should include neuropsychological rehabilitation programmes and provide emotional support to the family so that they may actively participate in the recovery of the child or adolescent.

Cognitive Impairment in Individuals With Spinal Cord Injury: Findings of a Systematic Review With Robust Variance and Network Meta-analyses

BACKGROUND AND OBJECTIVES

Estimates of the prevalence (10%-60%) of cognitive impairment in individuals with spinal cord injury (SCI) are too broad, and which domains of cognition are most affected is unclear. We performed a meta-analysis to investigate impairments across domains of cognitive functioning to provide a nuanced picture of research conducted to date into cognitive impairment after SCI.

METHODS

Results of peer-reviewed studies published in English between 1980 and 2021 comparing ≥20 participants with SCI with able-bodied controls were synthesized using meta-analysis. The primary outcomes were neurocognitive test scores categorized into 5 cognitive domains as listed in the Diagnostic and Statistical Manual of Mental Disorders: Complex Attention, Executive Functioning, Learning and Memory, Language, and Perceptual Motor Function. Two researchers independently assessed and verified extracted data to comply with meta-analytic reporting guidelines. Robust variance estimation meta-analysis was conducted to determine an overall pooled effect size across all cognitive domains using data extracted from studies. Using network meta-analysis, we synthesized eligible studies and made comparisons with the 5 domains of cognitive functioning serving as the outcomes and SCI as the condition.

RESULTS

Of 4,783 potential studies, 13 met final inclusion criteria. Studies met 6 of 8 quality assessment criteria generally. Results suggested that adults with SCI experience reduced cognitive functioning (effect size: -0.84; 95% CI -1.24 to -0.44, p < 0.001) compared with able-bodied individuals, with deficits mostly in attention (g = -0.64; 95% CI -0.92 to -0.38) and executive functioning (g = -0.61, 95% CI -0.89 to -0.04). Publication bias and high heterogeneity (I2: 86%) qualify these findings and highlight the need to improve research methods in this area.

DISCUSSION

Adults with SCI seem more likely than adults who are able-bodied to display cognitive impairments mostly in areas of attention and executive functioning. Research practices must become consistent to reduce heterogeneity so that the validity and reliability of the results of future studies into cognitive impairment after SCI improves.

Inpatient Rehabilitation After Pediatric and Adolescent Trauma: Outcomes and Discharge Needs

INTRODUCTION

Traumatic injury is the leading cause of pediatric mortality and morbidity in the United States. Pediatric trauma survivors requiring inpatient rehabilitation (IPR) require coordinated, multispecialty follow-up. Knowledge of the nature and level of disability is necessary for planning this continued care that is specific to the needs of pediatric trauma patients. This study aims to describe the outcomes of pediatric and adolescent trauma patients using measures of functional progression.

MATERIALS AND METHODS

A retrospective review of trauma patients aged ≤18 y admitted to IPR between January 2018 and December 2020 at the only certified pediatric rehabilitation center in the region was performed.

RESULTS

Ninety five children and adolescents were admitted to IPR after traumatic injury with diagnoses of multitrauma (MT, N = 18), traumatic brain injury (TBI, N = 59), and spinal cord injury (SCI, N = 18). School aged children returned to school at high rates for all injury types (MT: 86.7%, TBI: 97.4%, SCI: 93.8%, P = ns). All groups had similar hospital and rehabilitation length of stay, and most patients required a durable medical equipment at discharge (79%). Using pediatric functional independence measure scoring progression from admission to discharge from IPR, SCI patients made significant improvement in bladder function and the least improvement in stair function. Patients sustaining a TBI made significant improvement in memory and comprehension tasks.

CONCLUSIONS

Pediatric and adolescent trauma patients admitted to IPR had a positive progression during their therapy but required variable ongoing care depending on the mechanism of injury. Excellent rates of returning to school were seen across the three injury types.

A Systematic Review of the Scientific Literature for Rehabilitation/Habilitation Among Individuals With Pediatric-Onset Spinal Cord Injury

Objectives

To conduct a systematic review to examine the scientific literature for rehabilitation/habilitation among individuals with pediatric-onset spinal cord injury (SCI).

Methods

A literature search of multiple databases (i.e., PubMed/MEDLINE, CINAHL, EMBASE, PsychINFO) was conducted and was filtered to include studies involving humans, published as full-length articles up to December 2020, and in English. Included studies met the following inclusion criteria: (1) ≥50% of the study sample had experienced a traumatic, acquired, nonprogressive spinal cord injury (SCI) or a nontraumatic, acquired, noncongenital SCI; (2) SCI onset occurred at ≤21 years of age; and (3) sample was assessed for a rehabilitation/habilitation-related topic. Studies were assigned a level of evidence using an adapted Sackett scale modified down to five levels. Data extracted from each study included author(s), year of publication, country of origin, study design, subject characteristics, rehabilitation/habilitation topic area, intervention (if applicable), and outcome measures.

Results

One hundred seventy-six studies were included for review (1974-2020) with the majority originating from the United States (81.3%). Most studies were noninterventional observational studies (n = 100; 56.8%) or noninterventional case report studies (n = 5; 2.8%). Sample sizes ranged from 1 to 3172 with a median of 26 (interquartile range [IQR], 116.5). Rehabilitation/habilitation topics were categorized by the International Classification of Functioning, Disability and Health (ICF); most studies evaluated ICF Body Function. There were 69 unique clinical health outcome measures reported.

Conclusion

The evidence for rehabilitation/habilitation of pediatric-onset SCI is extremely limited; nearly all studies (98%) are level 4-5 evidence. Future studies across several domains should be conducted with novel approaches to research design to alleviate issues related to sample sizes and heterogeneity.

Individualized Prognostic Prediction of the Long-Term Functional Trajectory in Pediatric Acquired Brain Injury

In pediatric acquired brain injury, heterogeneity of functional response to specific rehabilitation treatments is a key confound to medical decisions and outcome prediction. We aimed to identify patient subgroups sharing comparable trajectories, and to implement a method for the early prediction of the long-term recovery course from clinical condition at first discharge. 600 consecutive patients with acquired brain injury (7.4 years ± 5.2; 367 males; median GCS = 6) entered a standardized rehabilitation program. Functional Independent Measure scores were measured yearly, until year 7. We classified the functional trajectories in clusters, through a latent class model. We performed single-subject prediction of trajectory membership in cases unseen during model fitting. Four trajectory types were identified (post.prob. > 0.95): high-start fast (N = 92), low-start fast (N = 168), slow (N = 130) and non-responders (N = 210). Fast responders were older (chigh = 1.8; clow = 1.1) than non-responders and suffered shorter coma (chigh = -14.7; clow = -4.3). High-start fast-responders had shorter length of stay (c = -1.6), and slow responders had lower incidence of epilepsy (c = -1.4), than non-responders (p < 0.001). Single-subject trajectory could be predicted with high accuracy at first discharge (accuracy = 0.80). In conclusion, we stratified patients based on the evolution of their response to a specific treatment program. Data at first discharge predicted the response over 7 years. This method enables early detection of the slow responders, who show poor post-acute functional gains, but achieve recovery comparable to fast responders by year 7. Further external validation in other rehabilitation programs is warranted.

Acute Imaging Findings Predict Recovery of Cognitive and Motor Function after Inpatient Rehabilitation for Pediatric Traumatic Brain Injury: A Pediatric Brain Injury Consortium Study

Traumatic brain injury (TBI) is a major cause of morbidity and mortality in children; survivors experience long-term cognitive and motor deficits. To date, studies predicting outcome following pediatric TBI have primarily focused on acute behavioral responses and proxy measures of injury severity; unsurprisingly, these measures explain very little of the variance following heterogenous injury. In adults, certain acute imaging biomarkers help predict cognitive and motor recovery following moderate to severe TBI. This multi-center, retrospective study, characterizes the day-of-injury computed tomographic (CT) reports of pediatric, adolescent, and young adult patients (2 months to 21 years old) who received inpatient rehabilitation services for TBI (n = 247). The study also determines the prognostic utility of CT findings for cognitive and motor outcomes assessed by the Pediatric Functional Independence Measure, converted to age-appropriate developmental functional quotient (DFQ), at discharge from rehabilitation. Subdural hematomas (66%), contusions (63%), and subarachnoid hemorrhages (59%) were the most common lesions; the majority of subjects had less severe Rotterdam CT scores (88%, ≤ 3). After controlling for age, gender, mechanism of injury, length of acute hospital stay, and admission DFQ in multivariate regression analyses, the highest Rotterdam score (β = -25.2, p < 0.01) and complete cisternal effacement (β = -19.4, p < 0.05) were associated with lower motor DFQ, and intraventricular hemorrhage was associated with lower motor (β = -3.7, p < 0.05) and cognitive DFQ (β = -4.9, p < 0.05). These results suggest that direct detection of intracranial injury provides valuable information to aid in prediction of recovery after pediatric TBI, and needs to be accounted for in future studies of prognosis and intervention.

Cognitive Recovery During Inpatient Rehabilitation Following Pediatric Traumatic Brain Injury: A Pediatric Brain Injury Consortium Study

OBJECTIVES

To characterize the demographics, clinical course, and predictors of cognitive recovery among children and young adults receiving inpatient rehabilitation following pediatric traumatic brain injury (TBI).

DESIGN

Retrospective observational, multicenter study.

SETTING

Eight acute pediatric inpatient rehabilitation facilities in the United States with specialized programs for treating patients with TBI.

PARTICIPANTS

Children and young adults (0-21 years) with TBI (n = 234) receiving inpatient rehabilitation.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Admission and discharge status assessed by the WeeFIM Cognitive Developmental Functional Quotient (DFQ) and Cognitive and Linguistic Scale (CALS).

RESULTS

Patients admitted to pediatric inpatient rehabilitation are diverse in cognitive functioning. While the majority of patients make improvements, cognitive recovery is constrained for those admitted with the most severe cognitive impairments. Age, time since injury to rehabilitation admission, and admission WeeFIM Cognitive DFQ are significant predictors of cognitive functioning at discharge from inpatient rehabilitation.

CONCLUSIONS

This work establishes a multicenter Pediatric Brain Injury Consortium and characterized the demographics and clinical course of cognitive recovery during inpatient rehabilitation of pediatric patients with TBI to aid in prospective study design.

Multidimensional review of cognitive impairment after spinal cord injury

Cognitive impairment is highly prevalent in the population with spinal cord injury (SCI) and exerts a significant impact on functional independence and quality of life in this population. A number of neuroscientists have conducted preliminary investigations of cognitive deficits after SCI, but achieved marginally contradictory results due to some limitations such as the heterogeneity in the sample population, sample size, types of tests utilized, study design, and time since SCI. Therefore, this review mainly focuses on the characteristics, assessments, potential causality and treatment of cognitive impairment for better understanding such deficits in the SCI population.

The impact of level of injury on patterns of cognitive dysfunction in individuals with spinal cord injury

Context: While it is well recognized that physical and physiological changes are more prominent in individuals with higher neurologic levels of spinal cord injury (SCI), the impact of level of lesion on cognition is less clear. Design: Cross-sectional, 3-group. Setting: Non-profit rehabilitation research foundation. Participants: 59 individuals with SCI (30 with tetraplegia, 29 with paraplegia) and 30 age-matched healthy controls (HC). Interventions: None. Outcome Measures: Neuropsychological tests in the domains of attention, working memory, processing speed, executive control, and learning and memory. Results: Results indicated significantly lower test performance in individuals with paraplegia on new learning and memory testing compared to HC. In contrast, compared to HC the group with tetraplegia, showed a significantly impaired performance on a processing speed task, and both the tetraplegia and the paraplegia groups were similarly impaired on a verbal fluency measure. SCI groups did not differ on any cognitive measure. Conclusion: Individuals with SCI may display different patterns of cognitive performance based on their level of injury.

A neuropsychological approach in a paediatric acquired brain injury unit under the public health system

INTRODUCTION

Paediatric acquired brain injury (ABI) causes cognitive and behavioural difficulties and alters the course of child development. The ABI unit at Hospital Infantil Universitario Niño Jesús is the first within the public Spanish health system to provide comprehensive coverage to these patients and their families.

OBJECTIVE

This study aims to show the working methodology followed with patients and their families, and to describe the clinical characteristics of the patients treated and the outcomes of treatment.

PATIENTS

Fifty-three patients aged between three months and 16 and a half years received treatment. The conditions treated were brain tumours, stroke, traumatic brain injury, damage secondary to epilepsy surgery, and hypoxia.

METHODS

All patients were evaluated at admission and at discharge. Treatments were adapted to each patient's difficulties and their severity, as well as to the patient's age. Families received individual and group therapy.

RESULTS

Older age was associated with better cognitive recovery and shorter duration of treatment. Different conditions show differential impact on intelligence quotient and developmental quotient scores at the beginning of treatment, with hypoxia and encephalitis being associated with greatest severity. Intelligence quotient and developmental quotient scores and visual memory and attention scores at discharge improved significantly after the faceted neuropsychological treatment with respect to scores registered at admission.

CONCLUSIONS

The care of patients with ABI should include neuropsychological rehabilitation programmes and provide emotional support to the family so that they may actively participate in the recovery of the child or adolescent.

Age-based differences in the disability of extremity injuries in pediatric and adult occupants

Objective: The objective was to develop a disability-based metric for motor vehicle crash (MVC) upper and lower extremity injuries and compare functional outcomes between children and adults.Methods: Disability risk (DR) was quantified using Functional Independence Measure (FIM) scores within the National Trauma Data Bank-Research Data System for the top 95% most frequently occurring Abbreviated Injury Scale (AIS) 3 extremity injuries (22 unique injuries). Pediatric (7-18 years), young adult (19-45 years), middle-aged (46-65 years), and older adult (66+ years) MVC occupants with an FIM score and at least one of the 22 extremity injuries were included. DR was calculated for each injury as the proportion of occupants who were disabled of those sustaining the injury. A maximum AIS-adjusted disability risk (DR_MAIS) was also calculated for each injury, excluding occupants with AIS 4+ co-injuries.Results: Locomotion impairment was the most frequent disability type across all ages. DR and DR_MAIS of the extremity injuries ranged from 0.06 to 1.00 (6%-100% disability risk). Disability risk increased with age, with DR_MAIS increasing from 25.9% ± 8.6% (mean ± SD) in pediatric subjects to 30.4% ± 6.3% in young adults, 39.5% ± 6.6% in middle-aged adults, and 60.5 ± 13.3% in older adults. DR_MAIS for upper extremity fractures differed significantly between age groups, with higher disability in older adults, followed by middle-aged adults. DR_MAIS for pelvis, hip, shaft, knee, and other lower extremity fractures differed significantly between age groups, with older adult DR_MAIS being significantly higher for each fracture type. DR_MAIS for hip and lower extremity shaft fractures was also significantly higher in middle-aged occupants compared to pediatric and young adult occupants. The maximum AIS-adjusted mortality risk (MR_MAIS, proportion of fatalities among occupants sustaining an MAIS 3 injury) was not correlated with DR_MAIS for extremity injuries in pediatric, young adult, middle-aged, and older adult occupants (all R² < 0.01). Disability associated with each extremity injury was higher than mortality risk.Conclusions: Older adults had significantly greater disability for MVC extremity injuries. Lower disability rates in children may stem from their increased physiological capacity for bone healing and relative lack of bone disease. The disability metrics developed can supplement AIS and other severity-based metrics by accounting for the age-specific functional implications of MVC extremity injuries.

Cognitive function after spinal cord injury: A systematic review

OBJECTIVE

To systematically examine the incidence of cognitive impairment in individuals with spinal cord injury (SCI), as well as identify potential contributing and confounding factors.

METHODS

Studies quantitatively reporting cognitive ability after spinal cord injury were searched electronically via Medline, CINAHL, Embase, and PsycINFO. Manual screening for references within articles was also performed. A total of 2,481 studies were screened and a total of 70 were included in this review, 21 reporting cognitive function after SCI compared to an able-bodied control group and 49 with no able-bodied controls. Studies were analyzed for the incidence of impairment and the interactions with concomitant traumatic brain injury, psychological or somatic complaints, decentralized cardiovascular control, sleep apnea, neurologic level of injury, and age.

RESULTS

There is a high volume of evidence reporting substantial cognitive impairment in individuals with SCI. Potential co-contributors include concomitant brain injury, psychological or somatic comorbidities, decentralized cardiovascular control, and sleep apnea. Cognitive functioning was negatively correlated with age. No clear agreement was found for the incidence of cognitive impairment or its association with level of injury.

CONCLUSION

Current evidence suggests that individuals with SCI should be examined and addressed for cognitive impairment. Future studies aimed at identifying potential secondary causative factors should employ stringent controls for co-occurring brain trauma since it appears to be a major contributor and confounder to impaired cognition.

Disability risk in pediatric motor vehicle crash occupants

BACKGROUND

Mortality rates among children in motor vehicle crashes (MVCs) are typically low; however, nonfatal injuries can vary in severity by imposing differing levels of short- and long-term disability. To better discriminate the severity of nonfatal MVC injuries, a pediatric-specific disability risk (DR) metric was created.

METHODS

The National Automotive Sampling System 2000 to 2011 was used to define the top 95% most common Abbreviated Injury Scale (AIS) 2+ injuries among pediatric MVC occupants. Functional Independence Measure scores were abstracted from the National Trauma Data Bank 2002 to 2006. Multiple imputation was used to account for missing data. The DR and coinjury-adjusted DR (DRMAIS) of the most common AIS 2+ MVC-induced injuries were calculated for 7-year-old to 18-year-old children by determining the proportion of those disabled after an injury to those sustaining the injury. DR and DRMAIS values ranged from 0 to 1, representing 0% to 100% DR.

RESULTS

The mean DR and DRMAIS of all injuries were 0.290 and 0.191, respectively. DR and DRMAIS were greatest for injuries to the head (DR, 0.340; DRMAIS, 0.279), thorax (DR, 0.320; DRMAIS, 0.233), and spine (DR, 0.315; DRMAIS, 0.200). The mean DR and DRMAIS increased with increasing AIS severity but there was significant variation and overlapping values across AIS severity levels. Comparison of DRMAIS to coinjury-adjusted mortality risk (MRMAIS) revealed that among 118 injuries with MRMAIS of 0.000, DRMAIS ranged from 0.000 to 0.429.

CONCLUSION

Incorporation of DR metrics into injury severity metrics may improve the ability to distinguish between the severity of different nonfatal injuries. This is especially crucial in the pediatric population where permanent disability can result in a high number of years lost due to disability. The accuracy of such severity metrics is crucial to the success of pediatric triage algorithms such as Advanced Automatic Crash Notification algorithms.

LEVEL OF EVIDENCE

Epidemiologic/prognostic study, level III.

Variations in Utilization of Inpatient Rehabilitation Services among Pediatric Trauma Patients

OBJECTIVE

To assess clinical and nonclinical characteristics associated with the use of pediatric inpatient rehabilitation services among children with traumatic injuries. We hypothesized there would be no nonclinical variations in the use of pediatric inpatient rehabilitation services.

STUDY DESIGN

Retrospective analysis of 1139 patients who were injured seriously (0-18 years of age) from our institutional trauma registry (2004-2014). Patients' nonclinical and clinical characteristics were analyzed. We used a full matching technique to compare characteristics between those admitted to rehabilitation (cases) to those discharged home (controls). We matched patients by age category, sex, maximum Abbreviated Injury Scale, and body region of maximum Abbreviated Injury Scale. We used survey-based multivariate logistic regression to identify characteristics associated with inpatient rehabilitation services, controlling for multiple injuries, distance from home to rehabilitation center, year of service, hospital length of stay, and clinically relevant interactions.

RESULTS

Ninety-eight patients (8.6%) were admitted to inpatient rehabilitation and 968 (85.0%) were discharged home. Black and other minority patients had increased odds of receiving inpatient rehabilitation compared with white patients (OR, 7.6 [P< .001] and OR, 1.6 [P= .03], respectively). Patients with private compared with public insurance had increased odds of receiving inpatient rehabilitation (OR, 2.4; P< .001).

CONCLUSIONS

Pediatric inpatient rehabilitation beds are a scarce resource that should be available to those with the greatest clinical need. The mechanism creating differences in the use of inpatient rehabilitation based on nonclinical characteristics such as race/ethnicity or insurance status must be understood to prevent disparities in access to inpatient rehabilitation services.

Functional outcomes of motor vehicle crash head injuries in pediatric and adult occupants

OBJECTIVE

The objective of the study was to develop a disability-based metric for motor vehicle crash (MVC) injuries, with a focus on head injuries, and compare the functional outcomes between the pediatric and adult populations.

METHODS

Disability risk (DR) was quantified using Functional Independence Measure (FIM) scores within the National Trauma Data Bank-Research Data System (NTDB-RDS) for the top 95% most frequently occurring Abbreviated Injury Scale (AIS) 3, 4, and 5 head injuries in NASS-CDS 2000-2011. Pediatric (ages 7-18), adult (19-45), middle-aged (46-65), and older adult (66+) patients with an FIM score available who were alive at discharge and had an AIS 3, 4, or 5 injury were included in the study. The NTDB-RDS contains a truncated form of the FIM instrument, including 3 items (self-feed, locomotion, and verbal expression), each graded on a scale of 1 (full functional dependence) to 4 (full functional independence). Patients within each age group were classified as disabled or not disabled based on the FIM scale. The DR was calculated for each age group by dividing the number of patients who sustained a specific injury and were disabled by the number of patients who sustained the specific injury. To account for the impact of more severe associated coinjuries, a maximum AIS (MAIS) adjusted DR (DRMAIS) was also calculated for each injury. DR and DRMAIS ranged from 0 (0% disability risk) to 1 (100% disability risk).

RESULTS

An analysis of the most frequent FIM components associated with disabling MVC head injuries revealed that disability across all 3 items (self-feed, locomotion, and expression) was the most frequent for pediatric and adult patients. Only locomotion was the most frequent for middle-aged and older adults. The mean DRMAIS for MVC head injuries was 35% for pediatric patients, 36% for adults, 38% for middle-aged adults, and 44% for older adults. Further analysis was conducted by grouping the head injuries into 8 groups based on the structure of injury and injury type. The pediatric population possessed higher DRMAIS values for brain stem injuries as well as loss of consciousness injuries. Older adults possessed higher DRMAIS values for contusion/hemorrhage injuries, epidural hemorrhage, intracerebral hemorrhage, skull fracture, and subdural/subarachnoid hemorrhage.

CONCLUSION

At-risk populations such as pediatric and older adult patients possessed higher DRMAIS values for different head injuries. Disability in pediatric patients is critical due to loss of quality life years. Disability risk can supplement severity metrics to improve the ability of such metrics to discriminate the severity of different injuries that do not lead to death. Understanding of age-related differences in injury outcomes when compared to adults could inform future age-specific modifications to the AIS.

Socioeconomic Status and Hospitalization Costs for Children with Brain and Spinal Cord Injury

OBJECTIVE

To determine if household income is associated with hospitalization costs for severe traumatic brain injury (TBI) and spinal cord injury (SCI).

STUDY DESIGN

Retrospective cohort study of inpatient, nonrehabilitation hospitalizations at 43 freestanding children's hospitals for patients <19 years old with unintentional severe TBI and SCI from 2009-2012. Standardized cost of care for hospitalizations was modeled using mixed-effects methods, adjusting for age, sex, race/ethnicity, primary payer, presence of chronic medical condition, mechanism of injury, injury severity, distance from residence to hospital, and trauma center level. Main exposure was zip code level median annual household income.

RESULTS

There were 1061 patients that met inclusion criteria, 833 with TBI only, 227 with SCI only, and 1 with TBI and SCI. Compared with those with the lowest-income zip codes, patients from the highest-income zip codes were more likely to be older, white (76.7% vs 50.4%), have private insurance (68.9% vs 27.9%), and live closer to the hospital (median distance 26.7 miles vs 81.2 miles). In adjusted models, there was no significant association between zip code level household income and hospitalization costs.

CONCLUSIONS

Children hospitalized with unintentional, severe TBI and SCI showed no difference in standardized hospital costs relative to a patient's home zip code level median annual household income. The association between household income and hospitalization costs may vary by primary diagnosis.

Pathophysiology and Management of Moderate and Severe Traumatic Brain Injury in Children

Traumatic brain injury remains a leading cause of morbidity and mortality in children. Key pathophysiologic processes of traumatic brain injury are initiated by mechanical forces at the time of trauma, followed by complex excitotoxic cascades associated with compromised cerebral autoregulation and progressive edema. Acute care focuses on avoiding secondary insults, including hypoxia, hypotension, and hyperthermia. Children with moderate or severe traumatic brain injury often require intensive monitoring and treatment of multiple parameters, including intracranial pressure, blood pressure, metabolism, and seizures, to minimize secondary brain injury. Child neurologists can play an important role in acute and long-term care. Acutely, as members of a multidisciplinary team in the intensive care unit, child neurologists monitor for early signs of neurological change, guide neuroprotective therapies, and transition patients to long-term recovery. In the longer term, neurologists are uniquely positioned to treat complications of moderate and severe traumatic brain injury, including epilepsy and cognitive and behavioral issues.