Brain injury as a result of violence: preliminary findings from the traumatic brain injury model systems

Association Between Social Determinants of Health and Traumatic Brain Injury: A Scoping Review

Traumatic brain injury (TBI) is a leading cause of death and disability worldwide. Disparities exist in the populations that acquire TBIs, however, with a greater burden and poorer outcomes associated with communities of color and lower socioeconomic status. To combat health inequities such as these, institutions have begun to target social determinants of health (SDoH), which are environmental factors that affect health outcomes and risks. The SDoH may play a role in sustaining a TBI and provide modifiable targets for action to reduce the risk of TBI, especially in high-risk communities. In this study, we describe the existing literature regarding SDoH and their association with sustaining a TBI. We performed a scoping review with a comprehensive search of the Ovid MEDLINE/Embase databases. To summarize the literature, this review adapts the World Health Organization's Commission on SDoH's conceptual framework. Fifty-nine full-text articles, including five focusing on lower and middle-income countries, met our study criteria. Results of the scoping review indicate that several structural determinants of health were associated with TBI risk. Lower educational attainment and income levels were associated with higher odds of TBI. In addition, multiple studies highlight that minority populations were identified as having higher odds of TBI than their White counterparts. Literature highlighting intermediate determinants of health examined in this review describes associations between sustaining a TBI and rurality, work environment, medical conditions, medication/substance use, and adversity. Recommended exploration into lesser-researched SDoH is discussed, and the expansion of this review to other aspects of the TBI continuum is warranted.

Racial/Ethnic Differences in Traumatic Brain Injury: Pathophysiology, Outcomes, and Future Directions

Traumatic brain injury (TBI) is a major cause of death and disability in the United States, exacting a debilitating physical, social, and financial strain. Therefore, it is crucial to examine the impact of TBI on medically underserved communities in the U.S. The purpose of the current study was to review the literature on TBI for evidence of racial/ethnic differences in the U.S. Results of the review showed significant racial/ethnic disparities in TBI outcome and several notable differences in other TBI variables. American Indian/Alaska Natives have the highest rate and number of TBI-related deaths compared with all other racial/ethnic groups; Blacks/African Americans are significantly more likely to incur a TBI from violence when compared with Non-Hispanic Whites; and minorities are significantly more likely to have worse functional outcome compared with Non-Hispanic Whites, particularly among measures of community integration. We were unable to identify any studies that looked directly at underlying racial/ethnic biological variations associated with different TBI outcomes. In the absence of studies on racial/ethnic differences in TBI pathobiology, taking an indirect approach, we looked for studies examining racial/ethnic differences in oxidative stress and inflammation outside the scope of TBI as they are known to heavily influence TBI pathobiology. The literature indicates that Blacks/African Americans have greater inflammation and oxidative stress compared with Non-Hispanic Whites. We propose that future studies investigate the possibility of racial/ethnic differences in inflammation and oxidative stress within the context of TBI to determine whether there is any relationship or impact on TBI outcome.

The Evolving Need for Neuropsychology in Neurosurgical Settings: Challenges Facing Transformative Care

Clinical neuropsychology has been a valuable asset to neurologic surgery, contributing to lateralization and localization of pathologic brain tissue, identification of eloquent cortex, and evaluation of postoperative neuropsychological functioning. Moreover, neuropsychologists provide empirically driven interventions aimed at supporting preparation and/or recovery of neurosurgery patients. Nonetheless, several challenges may limit the reliability, validity, and generalizability of the assessment data obtained and reduce the usefulness of other neuropsychological services provided. Specifically, linguistic, cultural, educational, and other biases associated with demographic characteristics can lead to a narrowed view of an individual's life experiences, which must be confronted to fulfill the mission of ensuring that all patients have access to care that is appropriate to their needs. Instead of perceiving these challenges as insurmountable barriers, such issues can be viewed as opportunities to catalyze change and foster innovation for the future of neuropsychological care in neurosurgical settings. In addition to reviewing the possible mechanisms of these obstacles, the current article offers tangible solutions at both a macro level (e.g., discipline-wide transformations) and micro level (e.g., individualized patient-centric approaches). Outlined are practical techniques to potentially improve consensus and standardization of methods, advance and globalize research, expand representativeness of measures and practices to serve diverse individuals, and increase treatment adherence through engagement of patients and their families.

Exploring the measurement of pediatric cognitive-communication disorders in traumatic brain injury research: A scoping review

OBJECTIVE

To synthesize information about the constructs measured, measurement instruments used, and the timing of assessment of cognitive-communication disorders (CCDs) in pediatric traumatic brain injury (TBI) research.

METHODS AND PROCEDURES

Scoping review conducted in alignment with Arksey and O'Malley's five-stage methodological framework and reported per the PRISMA extension for Scoping Reviews. Inclusion criteria: (a) cohort description, case-control, and treatment studies; (b) participants with TBI aged 5-18 years; (c) communication or psychosocial outcomes; and (d) English full-text journal articles. The first author reviewed all titles, abstracts, and full-text articles; 10% were independently reviewed.

OUTCOMES AND RESULTS

Following screening, a total of 687 articles were included and 919 measurement instruments, measuring 2134 unique constructs, were extracted. The Child Behavior Checklist was the most used measurement instrument and 'Global Outcomes/Recovery' was the construct most frequently measured. The length of longitudinal monitoring ranged between ≤3 months and 16 years.

CONCLUSIONS AND IMPLICATIONS

We found considerable heterogeneity in the constructs measured, the measurement instruments used, and the timing of CCD assessment in pediatric TBI research. A consistent approach to measurement may support clinical decision-making and the efficient use of data beyond individual studies in systematic reviews and meta-analyses.

The impact of COVID-19 on home, social, and productivity integration of people with chronic traumatic brain injury or stroke living in the community

Compare community integration of people with stroke or traumatic brain injury (TBI) living in the community before and during the coronavirus severe acute respiratory syndrome coronavirus 2 disease (COVID-19) when stratifying by injury: participants with stroke (G1) and with TBI (G2); by functional independence in activities of daily living: independent (G3) and dependent (G4); by age: participants younger than 54 (G5) and older than 54 (G6); and by gender: female (G7) and male (G8) participants.Prospective observational cohort studyIn-person follow-up visits (before COVID-19 outbreak) to a rehabilitation hospital in Spain and on-line during COVID-19.Community dwelling adults (≥18 years) with chronic stroke or TBI.Community integration questionnaire (CIQ) the total-CIQ as well as the subscale domains (ie, home-CIQ, social-CIQ, productivity CIQ) were compared before and during COVID-19 using the Wilcoxon ranked test or paired t test when appropriate reporting Cohen effect sizes (d). The functional independence measure was used to assess functional independence in activities of daily living.Two hundred four participants, 51.4% with stroke and 48.6% with TBI assessed on-line between June 2020 and April 2021 were compared to their own in-person assessments performed before COVID-19.When analyzing total-CIQ, G1 (d = -0.231), G2 (d = -0.240), G3 (d = -0.285), G5 (d = -0.276), G6 (d = -0.199), G7 (d = -0.245), and G8 (d = -0.210) significantly decreased their scores during COVID-19, meanwhile G4 was the only group with no significant differences before and during COVID-19.In productivity-CIQ, G1 (d = -0.197), G4 (d = -0.215), G6 (d = -0.300), and G8 (d = -0.210) significantly increased their scores, meanwhile no significant differences were observed in G2, G3, G5, and G7.In social-CIQ, all groups significantly decreased their scores: G1 (d = -0.348), G2 (d = -0.372), G3 (d = -0.437), G4 (d = -0.253), G5 (d = -0.394), G6 (d = -0.319), G7 (d = -0.355), and G8 (d = -0.365).In home-CIQ only G6 (d = -0.229) significantly decreased, no significant differences were observed in any of the other groups.The largest effect sizes were observed in total-CIQ for G3, in productivity-CIQ for G6, in social-CIQ for G3 and in home-CIQ for G6 (medium effect sizes).Stratifying participants by injury, functionality, age or gender allowed identifying specific CIQ subtotals where remote support may be provided addressing them.

Ethnicity/race and service-connected disability disparities in civilian traumatic brain injury mechanism of injury and VHA health services costs in military veterans: Evidence from a Level 1 Trauma Center and VA Medical Center

Introduction

The objective of this study was to examine the association of military veteran socio-demographics and service-connected disability with civilian mechanism of traumatic brain injury and long-term Veterans Health Administration (VHA) costs.

Methods

We conducted a 17-year retrospective longitudinal cohort study of veterans with a civilian-related traumatic brain injury from a Level 1 Trauma Center between 1999 and 2013, with VHA follow-up through 2016. We merged trauma center VHA data, and used logit to model mechanism of injury, and generalized linear model to model VHA costs.

Results

African American race or Hispanic ethnicity veterans had a higher unadjusted rate of civilian assault/gun as mechanism of injury (15.38%) relative to non-Hispanic White (7.19%). African American race or Hispanic veterans who were discharged from the trauma center with traumatic brain injury and followed in VHA had more than twice the odds of assault/gun (OR 2.47; 95% CI 1.16:5.26), after adjusting for sex, age, and military service-connected disability. Veterans with service-connected disability ≥50% had more than twice the odds of assault/gun (OR 2.48; 95% CI 0.97:6.31). Assault/gun was associated with significantly higher annual VHA costs post-discharge ($16,807; 95% CI 672:32,941) among non-Hispanic White veterans. Military service-connected disability ≥50% was associated with higher VHA costs among both non-Hispanic White ($44,987; 95% CI $17,159:$72,816) and African American race or Hispanic ($37,901; 95% CI $4,543:$71,258) veterans.

Conclusions

We found that African American race or Hispanic veterans had higher adjusted likelihood of assault/gun mechanism of traumatic brain injury, and non-Hispanic White veterans had higher adjusted annual VHA resource costs associated with assault/gun, post trauma center discharge. Veterans with higher than 50% service-connected disability had higher likelihood of assault/gun and higher adjusted annual VHA resource costs. Assault/gun prevention efforts may be indicated within the VHA, especially in minority and service-connected disability veterans. More data from Level 1 Trauma Centers are needed to assess the generalizability of these findings.

Violence-related traumatic brain injury

Objectives: The purpose of this study was to determine the unique characteristics of violence-related traumatic brain injuries (TBI). Methods: All consecutive patients who underwent head CT due to an acute head injury (n = 3023) at the Emergency Department of Tampere University Hospital (Aug 2010-Jul 2012) were included. A detailed retrospective data collection was conducted in relation to demographics, injury-related data, premorbid health, clinical characteristics, and neuroimaging findings. Results: Patients with violence-related TBIs (n = 222) were compared to patients who sustained a TBI by other mechanisms (n = 2801). Statistically significant differences were found on age, gender, prior circulatory system disease, prior mental or behavioral disorders, chronic alcohol abuse, regular substance abuse, regular medication, alcohol intoxication at the time of injury, narcotics intoxication at the time of injury, and acute traumatic lesion on head CT. The groups did not differ on clinical signs of TBI severity. Conclusions: Young adult males with premorbid mental health history and chronic alcohol abuse are most prone to sustain a TBI due to a violence-related incident. Incidents are often related to alcohol intoxication. However, violence was not consistently associated with more severe TBIs than other mechanisms of injury.

Employment outcome four years after a severe traumatic brain injury: results of the Paris severe traumatic brain injury study

OBJECTIVE

To describe employment outcome four years after a severe traumatic brain injury by the assessment of individual patients' preinjury sociodemographic data, injury-related and postinjury factors.

DESIGN

A prospective, multicenter inception cohort of 133 adult patients in the Paris area (France) who had received a severe traumatic brain injury were followed up postinjury at one and four years. Sociodemographic data, factors related to injury severity and one-year functional and cognitive outcomes were prospectively collected.

METHODS

The main outcome measure was employment status. Potential predictors of employment status were assessed by univariate and multivariate analysis.

RESULTS

At the four-year follow-up, 38% of patients were in paid employment. The following factors were independent predictors of unemployment: being unemployed or studying before traumatic brain injury, traumatic brain injury severity (i.e., a lower Glasgow Coma Scale score upon admission and a longer stay in intensive care) and a lower one-year Glasgow Outcome Scale-Extended score.

CONCLUSION

This study confirmed the low rate of long-term employment amongst patients after a severe traumatic brain injury. The results illustrated the multiple determinants of employment outcome and suggested that students who had received a traumatic brain injury were particularly likely to be unemployed, thus we propose that they may require specific support to help them find work. Implications for rehabilitation Traumatic brain injury is a leading cause of persistent disablity and can associate cognitive, emotional, physical and sensory impairments, which often result in quality-of-life reduction and job loss. Predictors of post-traumatic brain injury unemployment and job loss remains unclear in the particular population of severe traumatic brain injury patients. The present study highlights the post-traumatic brain injury student population require a close follow-up and vocational rehabilitation. The study suggests that return to work post-severe traumatic brain injury is frequently unstable and workers often experience difficulties that caregivers have to consider.

Brain Injury as the Result of Violence: A Systematic Scoping Review

This scoping review investigated risk factors, impacts, outcomes, and service implications of violence-related traumatic brain injury (TBI) for individuals and their informal caregivers. A systematic search (Web of Science, PubMed, PsycInfo, ProQuest, Medline, Informit; 1990-2015) identified 17 studies meeting the inclusion and exclusion criteria. Violence was the cause of between 3% and 26% of all TBIs. Males, a non-White racial background, preinjury unemployment, and preinjury substance abuse problems all elevated the risk for sustaining a violence-related TBI compared to other-cause TBI. However, few differences were observed in 12 months postinjury outcomes. No studies investigated the impact of violence-related TBI on informal caregivers.

Long Term Symptoms and Limitations of Activity of People with Traumatic Brain Injury: A Ten-Year Follow-up

This study examined the effect of Traumatic Brain Injury 10 years post-injury. Frequencies of head injury symptoms and activity limitation by level of severity were measured in a consecutive series of 61 adults who were admitted to a tertiary-care center for traumatic brain injury. Irritability and Anxiety were the most frequently reported symptoms from the Head Injury Symptom Checklist. Bothered by noise and Bothered by light were the least frequently reported. Trouble hearing what is said in a group conversation and Trouble hearing what is said in a one-to-one conversation were the most commonly reported limitations of activity from the Health and Activity Limitations Survey. Overall, this study illustrates that symptoms remain many years following brain injury, irrespective of the injury's severity.

Screening for Post-Traumatic Stress Disorder in a Civilian Emergency Department Population with Traumatic Brain Injury

Post-traumatic stress disorder (PTSD) is a condition associated with traumatic brain injury (TBI). While the importance of PTSD and TBI among military personnel is widely recognized, there is less awareness of PTSD associated with civilian TBI. We examined the incidence and factors associated with PTSD 6 months post-injury in a civilian emergency department population using measures from the National Institute of Neurological Disorders and Stroke TBI Common Data Elements Outcome Battery. Participants with mild TBI (mTBI) from the Transforming Research and Clinical Knowledge in Traumatic Brain Injury Pilot study with complete 6-month outcome batteries (n = 280) were analyzed. Screening for PTSD symptoms was conducted using the PTSD Checklist-Civilian Version. Descriptive measures are summarized and predictors for PTSD were examined using logistic regression. Incidence of screening positive for PTSD was 26.8% at 6 months following mTBI. Screening positive for PTSD was significantly associated with concurrent functional disability, post-concussive and psychiatric symptomatology, decreased satisfaction with life, and decreased performance in visual processing and mental flexibility. Multi-variable regression showed injury mechanism of assault (odds ratio [OR] 3.59; 95% confidence interval [CI] 1.69-7.63; p = 0.001) and prior psychiatric history (OR 2.56; 95% CI 1.42-4.61; p = 0.002) remained significant predictors of screening positive for PTSD, while education (per year OR 0.88; 95% CI 0.79-0.98; p = 0.021) was associated with decreased odds of PTSD. Standardized data collection and review of pre-injury education, psychiatric history, and injury mechanism during initial hospital presentation can aid in identifying patients with mTBI at risk for developing PTSD symptoms who may benefit from closer follow-up after initial injury care.

Translation, adaptation and validation of "Community Integration Questionnaire"

OBJECTIVE

To translate, adapt, and validate the "Community Integration Questionnaire (CIQ)," a tool that evaluates community integration after traumatic brain injury (TBI).

METHODS

A study of 61 TBI survivors was carried out. The appraisal of the measurement equivalence was based on a reliability assessment by estimating inter-rater agreement, item-scale correlation and internal consistency of CIQ scales, concurrent validity, and construct validity.

RESULTS

Inter-rater agreement ranged from substantial to almost perfect. The item-scale correlations were generally higher between the items and their respective domains, whereas the intra-class correlation coefficients were high for both the overall scale and the CIQ domains. The correlation between the CIQ and Disability Rating Scale (DRS), the Extended Glasgow Outcome Scale (GOSE), and the Rancho Los Amigos Level of Cognitive Functioning Scale (RLA) reached values considered satisfactory. However, the factor analysis generated four factors (dimensions) that did not correspond with the dimensional structure of the original tool.

CONCLUSION

The resulting tool herein may be useful in globally assessing community integration after TBI in the Brazilian context, at least until new CIQ psychometric assessment studies are developed with larger samples.

Service utilisation in a public post-acute rehabilitation unit following traumatic brain injury

Traumatic brain injury (TBI) causes disability in a proportion of survivors across the spectrum of injury severity. Previous research suggests physical changes are the primary focus of rehabilitation, although cognitive, emotional and behavioural difficulties cause greater concern in the long-term. There is little information about services accessed by those with mild injuries, who often have no physical disabilities. This study investigated factors determining service utilisation in a population-based sample which included 52% mild injuries (PTA ≤ 24 hours). Chi-squares and t-tests were used to examine the impact of demographic, clinical, psychological and physical variables on referral of 175 TBI patients to clinical disciplines in a public, community-based rehabilitation facility in Hobart, Tasmania. Increased service intensity (total disciplines referred to), was associated with greater injury severity (p = .006) and previous TBI (p = .041). Less traditional rehabilitation services (nursing, psychology) received more referrals than traditional disciplines (physiotherapy, occupational therapy, social work). Referral to physiotherapy and occupational therapy was associated with greater injury severity, functional dependence, hospitalisation and older age. Referral to nursing, psychology and social work was associated with more post-concussion symptoms, younger age, anxiety, depression and assault-related injury. The large number of referrals to psychology strengthens the case for including it as a core rehabilitation discipline.

Characteristics and functional outcomes of brain injury caused by physical assault in Canada: a population-based study from an inpatient rehabilitation setting

PURPOSE

To investigate the characteristics and inpatient rehabilitation outcomes of persons who sustained a traumatic brain injury (TBI) resulting from physical assault - a form of intentional TBI - and compare these outcomes to those of persons with TBI resulting from other aetiologies.

METHOD

A prospective population-based cohort study using inpatient rehabilitation data from Canadian population-based administrative databases for the fiscal years 2001-2006. Outcome measures were measures of functional independence (motor and cognitive), as measured by the FIM™ Instrument, and discharge destinations.

RESULTS

Characteristics associated with intentional TBI were being male, younger in age and unemployed; living alone and having a greater likelihood of alcohol/drug abuse prior to admission. The intentional TBI group showed poorer total functional gains at discharge from inpatient rehabilitation. Multivariate regression analyses showed that persons with intentional injury were less likely to be discharged home.

CONCLUSIONS

Persons with TBI from physical assault are a distinct clinical group in Canadian inpatient rehabilitation settings. These findings can support clinicians in determining proper assessment, management, discharge planning and post-rehabilitation care that target specific needs of persons with TBI resulting from physical assault.

IMPLICATIONS FOR REHABILITATION

Clinicians should have appropriate training to properly assess the mental health status of this patient group. Inpatient rehabilitation facilities should be prepared to provide services targeting psychosocial, substance abuse and interpersonal relationship issues to persons with a TBI from physical assault while patients are still within a hospital setting. Follow-up clinical care and community support services are warranted for those with intentional TBIs, including provision of occupational rehabilitation services, such as vocational rehabilitation. The discharge team should be responsible for ensuring appropriate discharge to community in the absence of family or other advocates on behalf of the patient.

A Systematic Review of Early Prognostic Factors for Return to Work After Traumatic Brain Injury

This article presents a systematic review identifying variables and their prognostic value for return to work (RTW) after traumatic brain injury (TBI). RTW has been identified as being a key goal following TBI, with estimates ranging from 10% to 70%. Prediction of postinjury employment is important for planning rehabilitation and structuring individualised vocational services. Studies examining prognostic factors were identified by searching four electronic databases, until June 2006. Searches yielded 1948 studies of which 55 met inclusion criteria and were subsequently rated for methodological quality. Mean methodological score for included studies was 3.9/6 (SD0.9, range 1–6). Analysis focused on a subset of 27 studies which provided sampling from all three domains of preinjury, injury and early postinjury variables. Few studies considered preinjury variables, apart from simple demographics. Only five studies considered preinjury employment, which was a significant predictor in each case. Severity of injury variables were invariably examined, but were significant predictors in only 8/27 studies (30%). For early postinjury variables, 14/27 studies entered cognitive variables with 12/14 (86%) identifying them as significant predictors; 3/27 studies examined neurophysical variables, with 2/3 (67%) studies finding them significant; and 12/27 studies examined multidimensional/participation variables which were statistically significant individual predictors in 8/12 (67%) cases. The results are discussed in the context of methodological issues encountered during the course of the review that require addressing in future studies.

Global outcome in acute phase of treatment following moderate-to-severe traumatic brain injury from motor vehicle collisions vs assaults

PRIMARY OBJECTIVE

To compare socio-demographic, medical characteristics and acute outcomes between patients with traumatic brain injuries (TBIs) from motor vehicle collision (MVC) or assault in an acute care setting.

RESEARCH DESIGN

This descriptive, comparative retrospective cohort study included 415 patients with moderate and severe TBI secondary to an assault (n¼91) vs a motor vehicle collision (n=324).

METHODS AND PROCEDURES

Outcome measures were length of stay (LOS) in the intensive care unit and in hospital, Extended Glasgow Outcome Scale (GOS-E), FIM® instrument (‘FIM’) and discharge destination.

MAIN OUTCOMES AND RESULTS

Patients with TBI from MVC had a higher percentage of polytrauma, higher injury severity scores, required more orthopaedic surgeries and thoracic drain insertions. Patients with TBI from assault were more often non-Caucasian, young single men, less educated with higher unemployment rates and criminal records, with a history of alcohol and drug abuse and were more often intoxicated on admission. There was no significant group difference in the LOS and FIM ratings, but patients with assault-related TBI were more often discharged home and had a more favourable GOS-E.

CONCLUSION

Variables such as injury severity, age, level of intoxication on admission and presence of surgeries should be considered when determining acute outcome.

Predictors of extended rehabilitation length of stay after traumatic brain injury

OBJECTIVE

To develop a prediction rule for acutely identifying patients at risk for extended rehabilitation length of stay (LOS) after traumatic brain injury (TBI) by using demographic and injury characteristics.

DESIGN

Retrospective cohort study.

SETTING

Traumatic Brain Injury Model Systems.

PARTICIPANTS

Sample of TBI survivors (N=7284) with injuries occurring between 1999 and 2009.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Extended rehabilitation LOS defined as 67 days or longer.

RESULTS

A multivariable model was built containing FIM motor and cognitive scores at admission, preinjury level of education, cause of injury, punctate/petechial hemorrhage, acute-care LOS, and primary payor source. The model had good calibration, excellent discrimination (area under the receiver operating characteristic curve = .875), and validated well. Based on this model, a formula for determining the probability of extended rehabilitation LOS and a prediction rule that classifies patients with predicted probabilities greater than 4.9% as at risk for extended rehabilitation LOS were developed.

CONCLUSIONS

The current predictor model for TBI survivors who require extended inpatient rehabilitation may allow for enhanced rehabilitation team planning, improved patient and family education, and better use of health care resources. Cross-validation of this model with other TBI populations is recommended.

Self-inflicted traumatic brain injury: Characteristics and outcomes

OBJECTIVE

To characterize the population of those receiving inpatient rehabilitation who sustained a traumatic brain injury (TBI) secondary to a suicide attempt and identify differences between such individuals and a demographically-matched control group (n = 230) of those whose TBIs were of an unintentional aetiology.

METHOD

Analysed cases were identified from the TBI Model Systems National Database. Based on ICD-9-CM external cause-of-injury codes, 79 participants incurred a TBI secondary to a suicide attempt. An approximate 1 : 3 matched case-control (age, gender, race, injury year) design was chosen to make statistical comparisons.

RESULTS

Those who sustained a TBI secondary to a suicide attempt had greater pre-existing psychiatric and psychosocial problems (substance use problems (p = 0.01) prior suicide attempt (p < 0.0001), psychiatric hospitalization (p = 0.014) and non-productive activity (p = 0.014)), required more resources during acute and rehabilitative hospitalizations (i.e. charges per day; p = 0.024, p = 0.047) and had greater disability at the time of discharge, even after controlling for injury severity (p = 0.022).

CONCLUSION

Individuals who sustained TBIs secondary to a suicide attempt had increased pre-injury psychiatric and psychosocial problems and poorer outcomes at discharge than those who incurred unintentional injuries. For these individuals, acute and rehabilitation charges per day were higher and could not be accounted for by injury severity.

Establishing a prognosis for functional outcome during coma recovery

PRIMARY OBJECTIVE

One of the most challenging tasks for clinicians caring for survivors of severe brain injury (BI) is establishing a prognosis, for long-term functional outcome, while the patient is unconscious. The objective of this article is to report findings regarding the prediction of functional outcomes 1-year after severe BI using data available when the patient is unconscious.

RESEARCH DESIGN

Longitudinal prognostication study.

METHODS AND PROCEDURES

Persons unconscious after severe BI who present to inpatient (IP) rehabilitation hospitals in the Midwestern US are enrolled in an ongoing study. Each subject is followed for 1-year and the final outcome interview includes approximately 70 questions; 32 of these questions are from the Craig Handicap Assessment and Reporting Technique (CHART). A sample of 63 persons was abstracted from the study database to examine the predictability of 42 independent variables and 16 dichotomous outcomes.

MAIN OUTCOMES AND RESULTS

Twelve of the 16 dichotomous outcomes were found to be significantly predictable (p < 0.05). These involve activity, participation, environment and quality of life outcomes. Ten predictors were found to be significant (p < 0.05): aetiology (Closed Head Injury vs. Other BI), presence of urinary tract infection (UTI), seizure, hypertension during IP rehabilitation, veteran benefit eligibility, health insurance, marital status at injury, whether or not recovery of consciousness occurred within 1 year, the number of days between injury and admission to acute rehabilitation and the average length of IP rehabilitation stay. Eight of the 10 variables are available early after injury or when the patient is unconscious.

Intentional traumatic brain injury in Ontario, Canada

BACKGROUND

Violence and traumatic brain injury (TBI) are two major public health concerns. This violence-related TBI, however, has not been studied in Canada and there is little literature on a profile of risk factors and injury severity regarding TBI because of self-inflicted/suicidal and assault/homicidal injury compared with unintentional TBI.

METHODS

Cross-sectional study using the comprehensive data set (CDS) of Ontario trauma registry (OTR) from 1993 to 2001.

SETTING

Data from a large trauma registry were used to assess demographic and injury-related characteristics, injury severity and incident time associated with TBI that were either caused unintentionally, were self-inflicted or resulted from an assault.

RESULTS

This study identified 1,409 (8.0%) intentional TBIs and 16,211 (92.0%) unintentional TBIs. Of the intentional TBIs, 389 (27.6%) was self-inflicted TBI (Si-TBI) and 1,020 (72.4%) was other-inflicted TBI (Oi-TBI). The most common cause of Si-TBI was "jumping from high places" (32.1%), followed by "firearms" (30.6%). About half of Oi-TBI was because of "fight and brawl" (48.3%), followed by "struck by objects" (26.1%). Si-TBI was associated with younger age, female gender, and having more alcohol/drug abuse history. For Oi-TBI, younger age, male gender, having more alcohol/drug abuse history were independently associated.

CONCLUSION

This research provides the first comprehensive overview of intentional TBI based on Canadian data. The CDS of the OTR provided the ability to identify who is at risk for intentional TBI. Prevention programs and more targeted rehabilitation services should be designed for this vulnerable population.

Comparing functional status and community integration in severe penetrating and motor vehicle-related brain injuries

OBJECTIVE

To examine the functional status of persons surviving a severe penetrating traumatic brain injury (TBI) resulting from a gunshot wound who require inpatient rehabilitation.

DESIGN

Data were collected prospectively at 4 different time periods: rehabilitation admission and discharge and year 1 and year 2 postinjury.

SETTING

Rehabilitation hospital within a Traumatic Brain Injury Model System.

PARTICIPANTS

Forty-five persons with severe penetrating brain injury and 45 persons involved in a motor vehicle crash (MVC).

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Disability Rating Scale (DRS), FIM instrument, and Community Integration Questionnaire (CIQ).

RESULTS

Results indicated functional improvements for both the penetrating and motor vehicle severe TBI groups on the DRS and the FIM from rehabilitation admission to discharge. Follow-up data at 1 and 2 years postinjury revealed continued improvements on the DRS and FIM measures for both groups, with the greatest improvement in recovery during the first year. In addition, improved community reintegration emerged between 1 and 2 years postinjury for both groups, as measured by the CIQ. There was a small significant difference on the outcome measures between the 2 groups in the course of their recovery.

CONCLUSIONS

Persons who survive severe penetrating brain injuries and who require inpatient rehabilitation may show continuing improvement in functioning over time. For persons receiving inpatient rehabilitation services, initial improvement is most likely to occur during the hospital stay and continue postinjury, with the largest improvement in the first year after injury. Community reintegration can also be expected over time. One can expect similar outcomes for individuals who sustain a severe penetrating brain injury and a severe brain injury ensuing from an MVC.

Prognostic factors of long-term functioning and productivity after traumatic brain injury: a systematic review of prospective cohort studies

OBJECTIVE

To systematically review prospective cohort studies that investigated prognostic factors associated with long-term activity limitations or participation restrictions and productivity after a traumatic brain injury.

DATA SOURCES

PubMed and Psychinfo were searched from 1995 to April 2005, and references were checked.

REVIEW METHODS

Publications were selected if the study assessed prognostic factors for activity limitations or participation restrictions at least one year post injury; outcome was measured with another or additional measure besides the Glasgow Outcome Scale; the design was a prospective cohort study of adult traumatic brain injury patients; the article was a full-text article written in English, French, German or Dutch. Two reviewers independently assessed methodological quality. A study was considered as 'high quality' if it satisfied at least half of the maximum available quality score.

RESULTS

Thirty-five articles reporting on 14 cohorts were included. Due to heterogeneity in prognostic factors and outcome measures, a best-evidence synthesis was performed. All cohorts were of high quality. Strong evidence for predicting disability was found for older age, pre-injury unemployment, pre-injury substance abuse, and more disability at rehabilitation discharge. Strong prognostic factors for being non-productive were pre-injury unemployment, longer post-traumatic amnesia, more disability at rehabilitation admission, and pre-injury substance abuse.

CONCLUSION

Older age, pre-injury unemployment, pre-injury substance abuse and more disability at rehabilitation discharge are important predictors of long-term disability. Pre-injury unemployment, longer post-traumatic amnesia, more disability at rehabilitation admission and pre-injury substance abuse are important predictors of being non-productive.

Prognostic value of demographic characteristics in traumatic brain injury: results from the IMPACT study

Outcome following traumatic brain injury (TBI) is not only dependent on the nature and severity of injury and subsequent treatment, but also on constituent characteristics of injured individuals. We aimed to describe and quantify the relationship between demographic characteristics and six month outcome assessed by the Glasgow Outcome Scale (GOS) after TBI. Individual patient data on age (n = 8719), gender (n = 8720), race (n = 5320), and education (n = 2201) were extracted from eight therapeutic Phase III randomized clinical trials and three surveys in moderate or severe TBI, contained in the IMPACT database. The strength of prognostic effects was analyzed with binary and proportional odds regression analysis and expressed as an odds ratio. Age was analyzed as a continuous variable with spline functions, and the odds ratio calculated over the difference between the 75 th and 25 th percentiles. Associations with other predictors were explored. Increasing age was strongly related to poorer outcome (OR 2.14; 95% CI 2.00-2.28) in a continuous fashion that could be approximated by a linear function. No gender differences in outcome were found (OR: 1.01; CI 0.92-1.11), and exploratory analysis failed to show any gender/age interaction. The studies included predominantly Caucasians (83%); outcome in black patients was poorer relative to this group (OR 1.30; CI 1.09-1.56). This relationship was sustained on adjusted analyses, and requires further study into mediating factors. Higher levels of education were weakly related to a better outcome (OR: 0.70; CI 0.52-0.94). On multivariable analysis adjusting for age, motor score, and pupils, the prognostic effect of race and education were sustained. We conclude that outcome following TBI is dependent on age, race, to a lesser extent on education, but not on gender.

Outcomes in TBI with violent versus nonviolent etiology in a predominantly rural setting

OBJECTIVE

To evaluate differences in outcome in persons with violent versus nonviolent traumatic brain injury (TBI) etiology.

DESIGN

Two-group (violent vs nonviolent) 1-year follow-up study.

SETTING

Midwestern medical center TBI Model System serving a predominantly rural catchment area.

PARTICIPANTS

Forty-five (n = 19 violent TBI etiology; n = 26 nonviolent TBI etiology) inpatients with primary diagnosis of TBI followed up as outpatients 1 year after injury.

MAIN OUTCOME MEASURES

Substance use, income source, employment status, Wechsler Adult Intelligence Scale--Revised (abbreviated version), Logical Memory I and II from the Wechsler Memory Scale--Revised, Wide Range Achievement Test--Third Edition Reading subtest, Trail-Making Tests A and B, Rey Auditory Verbal Learning Test, Community Integration Questionnaire, Neurobehavioral Functioning Inventory.

RESULTS

Members of the violent group were more likely to be men, of a racial minority, unemployed, and have low income. Substance abuse was common among both groups prior to injury, with significant declines at 1 year. Follow-up also revealed significant group differences in verbal intelligence, social integration, productivity, and source of income, but nonsignificant difference in employment. In all comparisons, more favorable outcomes were found for the nonviolent group.

CONCLUSIONS

Persons with violent injury etiology have poorer premorbid functioning and are likely to have less favorable outcomes than the general population with TBI. Therefore, persons with violent TBI etiology may require more intensive aftercare programming to promote improved rehabilitation outcomes.

Appraising evidence on community integration following brain injury: a systematic review

A systematic review of the community integration (CI) literature for persons with traumatic brain injury was undertaken to evaluate: (1) How do we best measure CI? (2) Can we predict CI following rehabilitation? (3) Does social and activity participation have an effect on CI? (4) Does CI have an effect on quality of life/life satisfaction? Seventy-two articles were analysed. The results demonstrated: (1) strong evidence supporting the use of the Community Integration Questionnaire (CIQ), (2) mixed evidence supporting the ability to predict CI, with the prominent predictive variables being severity of injury, age, gender, education, prior work, living environment, cognition, emotional status, functional performance and disability. The literature search was restricted to articles published in English and the heterogeneity in the outcomes, methods, participants and other characteristics not reported. Further research is needed to examine the complex relationship of person, environment and CI.

Access to inpatient rehabilitation after violence-related traumatic brain injury11No commercial party having a direct financial interest in the results of the research supporting this article has or will confer a benefit on the author(s) or on any organization with which the author(s) is/are associated

OBJECTIVES

To examine injury characteristics, demographics, and discharge disposition after traumatic brain injury of violent or nonviolent cause.

DESIGN

Cohort study.

SETTING

Level I trauma center.

PARTICIPANTS

Patients (N=1807) admitted with a Head Abbreviated Injury Score (AIS) of 2 or more over a 2-year period.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Injury cause was classified as violent or nonviolent. Discharge disposition was classified as home, inpatient rehabilitation, skilled nursing facility (SNF), and other.

RESULTS

The violence group was more likely to be male, to include individuals from diverse racial groups, to have an alcohol level above the legal limit, to have a more severe Head AIS, and to have Medicaid funding and equal access to inpatient rehabilitation compared with the nonviolence group. The violence group, though, was more likely to be discharged to home than to inpatient rehabilitation and more likely to be discharged to inpatient rehabilitation than to an SNF. The nonviolence group had a longer acute care length of stay and a higher rate of injuries to other body systems.

CONCLUSIONS

People with violence-related injuries often present unique rehabilitation challenges. After accounting for injury severity and demographics, there was no evidence of bias against the violently injured in gaining access to inpatient rehabilitation services.

Violence-Related Traumatic Brain Injury: A Population-Based Study

BACKGROUND

Most studies of traumatic brain injury (TBI) and violence are small, focus on one violent mechanism only, and are nonrepresentative. This large, population-based effort examines characteristics, circumstances of injury, treatment pathways, and outcomes of persons with TBI as a result of all types of violence, compares them with other TBI survivors, identifies a risk profile, and examines how a violent cause impacts later outcomes.

METHODS

This study involved medical record abstraction and telephone survey at 1 year postinjury of a weighted sample of 2,771 Coloradans hospitalized with TBI between January 1, 1996, and June 30, 1999.

RESULTS

People with violently incurred TBI are more likely to be young, male, members of minority groups, single, and premorbid alcohol abusers than other TBI survivors. At 1 year postinjury, they report less community integration and more headaches, confusion, and sensory and attentional disturbances. Predictors of these outcomes included age, gender, injury severity, and employment status.

CONCLUSION

It appears that essentially the same factors that increase risk of sustaining a violent TBI negatively impact later outcomes as well.

Race and productivity outcome after traumatic brain injury: influence of confounding factors

OBJECTIVE

Investigate the impact of race on productivity outcome after traumatic brain injury (TBI) and evaluate the influence of confounding factors on this relationship.

DESIGN

Inception cohort of 1083 adults with TBI for whom 1-year productivity follow-up data were available.

RESULTS

Univariable logistic regression indicated that race was a significant predictor of productivity outcome after TBI. African Americans were 2.76 times more likely to be nonproductive than whites and other racial minorities were 1.92 times more likely to be nonproductive than whites. Multivariable logistic regression analyses revealed that the effect of race on employability was influenced by confounds with preinjury productivity, education level, and cause of injury. After adjustment for other predictors, African Americans were 2.00 times more likely to be nonproductive than whites and other racial minorities were 2.08 times more likely to be nonproductive than whites. The multivariable logistic regression model with all predictors except race accounted for 39% of the variability in productivity outcome (R2-Nagelkerke=0.39), whereas the full logistic regression model including race accounted for 41% of the variability in productivity outcome (R2-Nagelkerke=0.41); a difference of only 2%.

CONCLUSION

Any effect of race on productivity is significantly influenced by confounding with preinjury productivity, education level, and cause of injury.

Neurobehavioral outcome in persons with violent or nonviolent traumatic brain injury

OBJECTIVE

To broaden the investigation of those injured violently by examining neuropsychological and psychosocial outcomes in relation to circumstances of traumatic brain injury and preinjury factors.

DESIGN

A prospective, longitudinal study.

PARTICIPANTS

A total of 752 adults with traumatic brain injury was grouped into those injured by violent or nonviolent circumstances and followed to 1-year post injury.

MAIN OUTCOME MEASURES

Circumstance groups were compared on demographics, preexisting conditions, brain injury severity, and neuropsychological and psychosocial outcomes.

RESULTS

The results indicate significant differences between the groups on demographics, preexisting conditions, and head injury severity. Neuropsychological and psychosocial outcome did not differ between the circumstance groups when all other factors were taken into account.

CONCLUSIONS

Injury severity and characteristics of the person that predate the injury were important to outcome rather than the circumstances of the injury itself.

Early identification of mild traumatic brain injury in female victims of domestic violence

BACKGROUND

Domestic violence and traumatic brain injuries (TBIs) are major societal problems with public health implications. The inter-relationship between this specific form of violence and TBI has not been explored. However, a clinically relevant relationship is suggested by recent outcome data showing that TBI survivors who are victims of assault are more prone to a suboptimal outcome.

METHODS

This observational study screened women who presented to 3 metropolitan emergency departments for health issues associated with domestic violence for a possible secondary mild TBI.

RESULTS

Over a 7- to 9-month survey period, a total of 169 women with health issues directly attributable to domestic violence and who were referred to sexual assault-domestic violence health staff were identified. Thirty percent (n = 51) agreed to participate in this survey. A positive loss of consciousness on at least one occasion was reported in 30% of the respondents, and 67% of women reported residual problems that were potentially head-injury related.

CONCLUSION

These data argue for greater vigilance in screening domestic violence victims for mild TBI because earlier identification and treatment of any postconcussive syndrome symptoms seems to diminish their adverse impact on outcome.

[Content validity of an information system used for head injury rehabilitation based on an analysis of medical records]

OBJECTIVE

This study examines the content validity of the TCC-Québec Information System based on an analysis of rehabilitation medical records. The goal was to determine the agreement between the variables of the TCC-Québec Information System identified by experts and based on an extensive literature review and those found in medical records.

METHOD

The medical records of 82 adults with a head injury were reviewed. The individuals had been hospitalized from 1997 to 1998 at three different acute care facilities or three rehabilitation centers. The abstractor determined if the information pertaining to a variable (e.g. personal history, impairments, or disabilities relating to sensori-motor function) was present in the record. A standardized and reliable procedure was used to ensure the quality of data extraction. The percentage of variables found in the medical records and the number of records in which each variable was documented were calculated for each clinical setting (acute care or rehabilitation) and for the different geographical regions.

RESULTS

The results suggest that a large discrepancy exists between what experts desired to be included in the information system and what is really documented clinically. No discrepancy exists between the different regions. Only 23% of variables were found in more than 70% of records.

CONCLUSION

This study provides recommendations about the most relevant variables to be included in an information system based on clinicians'information needs and the clinical reality. As such, these results should facilitate the use and implementation of the information system under study.

Long-term recovery course after traumatic brain injury: a comparison of the functional independence measure and disability rating scale

OBJECTIVES

To study group changes over time after traumatic brain injury (TBI).

DESIGN

Prospective cohort.

SETTING AND PARTICIPANTS

TBI Model System Database with 1160 subjects using cohort with complete data.

MAIN OUTCOME MEASURES

Functional Independence Measure (FIM) and Disability Rating Scale (DRS) at rehabilitation discharge and annually after injury.

RESULTS

Statistically significant differences existed between FIM-total, FIM-Motor, FIM-Cognitive subscales, and DRS at rehabilitation discharge and year 1. Comparisons of year-to-year intervals, years 1 and 3, 1 and 5, and 3 and 5, revealed no statistically significant differences except between years 1 and 3 and 1 and 5 with DRS, and years 1 and 5 with FIM. Including only those more dependent at year 1 revealed statistically significant differences between years 1 and 2 and 1 and 5 on FIM-Cognitive and DRS, but not the FIM-Motor. The proportion of change for FIM and DRS items from year 1 to years 2 and 5 revealed DRS Level of Functioning and Employability items accounted for most DRS change, whereas FIM change was more spread across its components.

CONCLUSIONS

DRS is more sensitive to changes during a shorter time period than FIM and seems to be more appropriate for detecting long-term deficits. However, research studies aimed at detecting meaningful changes year to year after TBI may need to use other tools or consider changes among individuals instead of group changes. DRS Level of Function and Employability Items represent complex functions expected to recover later than the more basic DRS items. Sole use of these two DRS items might provide an efficient means of measuring long-term recovery when resources are limited, whereas expansion of these two items might allow greater sensitivity and detail.

A comparison of substance abuse and violence in the prediction of long-term rehabilitation outcomes after traumatic brain injury

OBJECTIVE

To determine the relative contributions of substance abuse history and violent etiology to the prediction of outcomes for individuals who sustained a traumatic brain injury (TBI) requiring inpatient rehabilitation.

DESIGN

Longitudinal study of outcomes 1 year postdischarge from rehabilitation.

SETTING

Specialized TBI acute rehabilitation unit.

PARTICIPANTS

Three hundred fifty-one individuals consecutively admitted for rehabilitation.

INTERVENTIONS

Gathered data from patients' medical records (including etiology of injury, initial Glasgow Coma Scale scores, and FIMtrade mark instrument scores at discharge), demographic details, and history of substance abuse; phone and mail survey data from individuals (Satisfaction with Life Scale [SWLS]; Community Integration Questionnaire [CIQ]).

MAIN OUTCOME MEASURES

CIQ and SWLS; relative contributions of injury etiology, demographic and injury-related dependent variables, and substance abuse history to predictive model.

RESULTS

Almost 80% of persons with injuries from violence-related causes had a history of substance abuse. Substance abuse was found to contribute to the prediction of life satisfacton and productivity, while violent etiology was not a significant contributor to predictive models.

CONCLUSION

Substance abuse history proved to be a strong predictor of long-term outcomes, while violent etiology of injury was less influential. The results of this study emphasize the need to include substance abuse history in all studies of outcomes after TBI, and to increase prevention efforts to limit the effects of such a history.

Severe penetrating head injury: a study of outcomes

OBJECTIVE

To determine and describe the demographics and functional outcomes of persons who require inpatient rehabilitation for severe penetrating head injury resulting from a gunshot wound to the head.

DESIGN

Data were collected prospectively from the time of admission to acute care through discharge from inpatient rehabilitation.

SETTING

Two sites: an urban, level I, acute care, trauma center and an inpatient rehabilitation hospital with a specialized brain injury unit.

PARTICIPANTS

Twenty-seven persons with severe penetrating head injury.

MAIN OUTCOME MEASURES

The FIM instrument, the Disability Rating Scale (DRS), and the length of stay (LOS).

RESULTS

Demographic data showed our population to be similar to other groups of persons at high risk for violent injury. Eighty-five percent of the subjects were men with a mean age of 34 years. The majority were African American (93%), reflective of our general patient population. Average acute care LOS was 31 days and average rehabilitation LOS was 44 days. Average FIM gain was 40.2 and, on average, DRS scores improved 7.6 points from rehabilitation admission to discharge. All study participants made enough progress to be discharged to private residences.

CONCLUSION

Although the mortality rate is high among patients with penetrating head injury, those who survive to receive inpatient rehabilitation can achieve functional improvement.

Do women fare worse: a metaanalysis of gender differences in traumatic brain injury outcome

OBJECT

The purpose of this metaanalysis was to investigate possible gender differences in traumatic brain injury (TBI) sequelae. The case fatality rates in patients after TBI have previously been shown to be significantly higher in women as compared with men.

METHODS

A quantitative review of published studies of TBI outcome revealed eight studies (20 outcome variables) of TBI, in which outcome was reported separately for men and women.

CONCLUSIONS

Outcome was worse in women than in men for 85% of the measured variables, with an average effect size of -0.15. Although clinical opinion is often that women tend to experience better outcomes than men after TBI, the opposite pattern was suggested in the results of this metaanalysis. However, this conclusion is limited by the fact that, in only a small percentage of the total published reports on TBI outcome, was outcome described separately for each sex. A careful, prospective study of sex differences in TBI outcome is clearly needed.

Use of injury severity variables in determining disability and community integration after traumatic brain injury

BACKGROUND

Long-term outcome is important in managing traumatic brain injury (TBI), an epidemic in the United States. Many injury severity variables have been shown to predict major morbidity and mortality. Less is known about their relationship with specific long-term outcomes.

METHODS

Glasgow Coma Scale, Revised Trauma Score, Injury Severity Score, and Trauma and Injury Severity Score, along with other demographic and premorbid values, were obtained for 378 consecutive patients hospitalized after TBI at a Level I trauma center between September 1997 and May 1998. Of this cohort, 120 patients were contacted for 1-year follow-up assessment with the Disability Rating Scale, Community Integration Questionnaire, and employment data.

RESULTS

Univariate analyses showed these to be significant single predictors of 1-year outcome. Multivariate analyses revealed that the Revised Trauma Score and Glasgow Coma Scale had significant additive value in predicting injury variables Disability Rating Scale scores when combined with other demographic and premorbid variables studied. Predictive models of 1-year outcome were developed.

CONCLUSION

Injury severity variables are significant single outcome predictors and, in combination with premorbid and demographic variables, help predict long-term disability and community integration for individuals hospitalized with TBI.

Intentional traumatic brain injury: epidemiology, risk factors, and associations with injury severity and mortality

BACKGROUND

Intentional injury is associated with significant morbidity and mortality and has been associated with certain demographic and socioeconomic groups. Less is known about the relationship of intentional traumatic brain injury (TBI) to injury severity, mortality, and demographic and socioeconomic profile. The objective of this study was to delineate demographic and event-related factors associated with intentional TBI and to evaluate the predictive value of intentional TBI on injury severity and mortality.

METHODS

Prospective data were obtained for 2,637 adults sustaining TBIs between January 1994 and September 1998. Descriptive, univariate, and multivariate analyses were conducted to determine the predictive value of intentional TBI on injury severity and mortality.

RESULTS

Gender, minority status, age, substance abuse, and residence in a zipcode with low average income were associated with intentional TBI. Multivariate analysis found minority status and substance abuse to be predictive of intentional injury after adjusting for other demographic variables studied. Intentional TBI was predictive of mortality and anatomic severity of injury to the head. Penetrating intentional TBI was predictive of injury severity with all injury severity markers studied.

CONCLUSION

Many demographic variables are risk factors for intentional TBI, and such injury is a risk factor for both injury severity and mortality. Future studies are needed to definitively link intentional TBI to disability and functional outcome.

Neurobehavioural outcomes of penetrating and tangential gunshot wounds to the head

OBJECTIVE

The objective of this study was to compare penetrating and tangential gunshot wounds to the head with regards to demographic, neurobehavioural and clinical outcome measures.

METHODS

Twenty-nine patients with penetrating gunshot wounds (P-GSW) and 11 patients with tangential gunshot wound (T-GSW) to the head admitted to an acute neurotrauma service were compared using standardized neurobehavioural and clinical outcome measures.

RESULTS

The mean GCS was 10.5 +/- 0.79 for the P-GSW group and 13.4 +/- 0.72 for the T-GSW group. The mean AIS-CNS for the P-GSW group was 5.00 +/- 0 and for the T-GSW group was 3.7 +/- 0.27. Significance was found on Digit Span (p < 0.05) and Block Design (p < 0.009) subtests. Outcomes between the two groups were similar, except for significant differences were found for acute length of stay (LOS) (P-GSW was 47.72 +/- 13.2 and T-GSW group was 13.0 +/- 1.3, p = 0.005) and for acute care charges (P-GSW group was $150,533 +/- 23,834 and T-GSW group was $70,712 +/- 16,587, p = 0.05).

CONCLUSIONS

Initially, a penetrating gunshot wound is a more severe and costly injury than a tangential gunshot wound to the head, however T-GSW possess significant deficits and, if the patient survives past the acute phase of recovery, the two groups have similar functional outcomes. Future standard classification, neuropsychological, and clinical outcome measures.

Do women fare worse? A metaanalysis of gender differences in outcome after traumatic brain injury

The purpose of this metaanalysis was to investigate possible gender differences in TBI sequelae. The case fatality rates in patients after TBI have previously been shown to be significantly higher in women as compared with men. A quantitative review of published studies of TBI outcome revealed eight studies (20 outcome variables) of TBI in which outcome was reported separately for men and women. Outcome was worse in women than in men for 85% of the measured variables, with an average effect size of −0.15. Although clinical opinion is often that women tend to experience better outcomes than do men after TBI, the opposite pattern was suggested in the results of this metaanalysis. However, this conclusion is limited by the fact that in only a small percentage of the total published reports on TBI outcome was outcome described separately for each sex. A careful, prospective study of sex differences in TBI outcome is clearly needed.