Traumatic brain injury: influence of blood alcohol level on post-acute cognitive function

Alcohol-related brain damage: an umbrella (term) for the approaching post-COVID monsoon

Individuals with alcohol-related brain damage (ARBD) represent a population whose healthcare needs often go unmet. This is the result of a lack of not only an awareness surrounding the condition by healthcare professionals, but also healthcare service inclusion and delivery, more broadly. The Coronavirus 2019 (COVID-19) pandemic and the associated lockdowns dramatically affected the accessibility and availability of addiction services globally, while also driving changes in alcohol consumption among the most vulnerable. In the absence of change, this culmination of increased high-risk drinking behaviour, lack of awareness by healthcare professionals and severely limited service delivery for individuals living with ARBD post COVID-19, represents a perfect storm that is rapidly approaching our health and care services world-wide. Collectively, this will reduce positive health outcomes in an already at-risk group.

The negative influence of chronic alcohol abuse on acute cognitive recovery after a traumatic brain injury

OBJECTIVE

Cognitive recovery after a traumatic brain injury (TBI) may be negatively affected by a prior alcohol use disorder (AUD). This study aims to compare the cognitive recovery of patients who had comorbid TBI and AUD relative to TBI alone and investigate the influence of blood alcohol level (BAL) at hospital admission on this recovery.

METHOD

The sample consisted of 42 patients who had sustained a TBI (mild or moderate) and had an AUD diagnosis (TBI+AUD), and 42 patients who had sustained a TBI alone (TBI). The Brief Cognitive Exam in Traumatology (EXACT), designed to evaluate cognitive functions in the acute phase of TBI was administered (± 2 weeks post-injury).

RESULTS

After controlling for BAL at admission, the TBI+AUD group had a lower EXACT total score compared to the TBI group. The negative influence of age on the results was more pronounced in the TBI+AUD group. The number of intoxicated patients at admission was also higher in this group, although there was no correlation between BAL at admission and cognitive outcome.

CONCLUSION

The presence of an AUD diagnosis seems to exert a greater negative influence on cognitive recovery following a mild/moderate TBI than BAL at admission, especially in older patients.

Application of multiple testing procedures for identifying relevant comorbidities, from a large set, in traumatic brain injury for research applications utilizing big health-administrative data

Background

Multiple testing procedures (MTP) are gaining increasing popularity in various fields of biostatistics, especially in statistical genetics. However, in injury surveillance research utilizing the growing amount and complexity of health-administrative data encoded in the International Statistical Classification of Diseases and Related Health Problems 10th Revision (ICD-10), few studies involve MTP and discuss their applications and challenges.

Objective

We aimed to apply MTP in the population-wide context of comorbidity preceding traumatic brain injury (TBI), one of the most disabling injuries, to find a subset of comorbidity that can be targeted in primary injury prevention.

Methods

In total, 2,600 ICD-10 codes were used to assess the associations between TBI and comorbidity, with 235,003 TBI patients, on a matched data set of patients without TBI. McNemar tests were conducted on each 2,600 ICD-10 code, and appropriate multiple testing adjustments were applied using the Benjamini-Yekutieli procedure. To study the magnitude and direction of associations, odds ratios with 95% confidence intervals were constructed.

Results

Benjamini-Yekutieli procedure captured 684 ICD-10 codes, out of 2,600, as codes positively associated with a TBI event, reducing the effective number of codes for subsequent analysis and comprehension.

Conclusion

Our results illustrate the utility of MTP for data mining and dimension reduction in TBI research utilizing big health-administrative data to support injury surveillance research and generate ideas for injury prevention.

Traumatic brain injury and the misuse of alcohol, opioids, and cannabis

Traumatic brain injury (TBI), most often classified as concussion, is caused by biomechanical forces to the brain resulting in short- or long-term impairment in brain function. TBI resulting from military combat, sports, violence, falls, and vehicular accidents is a major cause of long-term physical, cognitive, and psychiatric dysfunction. Psychiatric disorders associated with TBI include depression, anxiety, and substance use disorder, all having significant implications for post-TBI recovery and rehabilitation. This chapter reviews the current preclinical and clinical literature describing the bidirectional relationship between TBI and misuse of three commonly abused drugs: alcohol, opioids, and cannabis. We highlight the influence of each of these drugs on the incidence of TBI, as well as trends in their use after TBI. Furthermore, we discuss factors that may underlie post-injury substance use. Understanding the complex relationship between TBI and substance misuse will enhance the clinical treatment of individuals suffering from these two highly comorbid conditions.

When Two Wrongs Make a Right: The Effect of Acute and Chronic Binge Drinking on Traumatic Brain Injury Outcomes in Young Adult Female Rats

Alcohol is the most commonly abused drug by young adults across North America. Although alcohol consumption itself incurs a risk of neurological damage, it is also a significant risk factor for traumatic brain injury (TBI). TBI among young adults is described as a modern healthcare epidemic. The drastic changes occurring within their neurological networks put young adults at greater risk for developing long-term post-traumatic deficits. Contradictory findings have been indicated regarding the effects of alcohol consumption on TBI outcomes in adults, with some studies demonstrating detrimental effects, whereas others suggest neuroprotective abilities. However, little is known about the effects of alcohol consumption on TBI outcomes during the sensitive stage of early adulthood. Young adult female Sprague-Dawley rats were randomly assigned to one of six experimental conditions: Pre-injury alcohol+TBI; Pre-injury alcohol+Sham; Pre- and Post-injury alcohol+TBI; Pre- and Post-injury alcohol+Sham; No alcohol+TBI; No alcohol+Sham. Alcohol consumption groups received an amount of 10% v/v ethanol solution based on the animals' weight. Following the injury, the rats were subjected to a behavioral test battery to assess post-concussive symptomology. Overall, chronic binge drinking significantly improved TBI outcomes related to motor coordination and balance, whereas binge drinking in general significantly decreased anxiety-like behaviors. Additionally, in many cases, chronic binge drinking appears to return the TBI animal's behavioral outcomes to levels comparable to those of the no alcohol sham animals. Thus, the results suggest that alcohol may exhibit neuroprotective abilities in the context of early adulthood TBI.

Impact of day-of-injury alcohol consumption on outcomes after traumatic brain injury: A meta-analysis

Although a known risk factor for traumatic brain injury (TBI), alcohol has been found to both promote and protect against secondary brain damage. However, it is presently unclear whether the cognitive, psychological and medical/functional outcomes of adults who have consumed alcohol prior to sustaining a TBI differ from those who have not. This meta-analysis examined the outcomes of groups that differed in terms of their day-of-injury (DOI) blood alcohol levels (BALs) by comparing positive with zero BAL (BAL⁺/BAL^-) and high with low BAL (BAL^high/BAL^low) samples. The PubMed, PsycINFO, EMBASE, and Scopus databases were searched from inception until the end of March 2015. Hedge's g effects (continuous data) and odds ratios (categorical data) were calculated for 27 studies that compared either the outcomes of BAL⁺ and BAL^- groups or BAL^high and BAL^low groups. BAL⁺ was associated with significantly poorer cognitive outcomes (overall and on general tests) and higher levels of disability, and BAL^high was associated with shorter stays in intensive care. More generally, however, most effect sizes were small to low-moderate in size, non-significant and inconsistent in their direction. Although DOI alcohol consumption increases the risk of sustaining a TBI, it is not consistently associated with better or worse outcomes, other than subtle cognitive deficits; the source of which remains to be determined.

Alcohol Consumption Does not Impede Recovery from Mild to Moderate Traumatic Brain Injury

OBJECTIVES

To examine the effect of pre-injury alcohol use, acute alcohol intoxication, and post-injury alcohol use on outcome from mild to moderate traumatic brain injury (TBI).

METHODS

Prospective inception cohort of patients who presented to the Emergency Department with mild to moderate TBI and had a blood alcohol level (BAL) taken for clinical purposes. Those who completed the 1-year outcome assessment were eligible for this study (N=91). Outcomes of interest were the count of post-concussion symptoms (British Columbia Post-Concussion Symptom Inventory), low neuropsychological test scores (Neuropsychological Assessment Battery), and abnormal regions of interest on diffusion tensor imaging (low fractional anisotropy). The main predictors were pre-injury alcohol consumption (Cognitive Lifetime Drinking History interview), BAL, and post-injury alcohol use.

RESULTS

The alcohol use variables were moderately to strongly inter-correlated. None of the alcohol use variables (whether continuous or categorical) were related to 1-year TBI outcomes in generalized linear modeling. Participants in this cohort generally had a good clinical outcome, regardless of their pre-, peri-, and post-injury alcohol use.

CONCLUSIONS

Alcohol may not significantly alter long-term outcome from mild to moderate TBI. (JINS, 2016, 22, 816-827).

The effect of blood alcohol level and preinjury chronic alcohol use on outcome from severe traumatic brain injury in Hispanics, anglo-Caucasians, and African-americans

OBJECTIVE

To examine (a) ethnic differences in blood alcohol level (BAL) and preinjury chronic alcohol use (PI-ETOH) within a severe closed head injury (CHI) sample and (b) the main and interaction effects of BAL, PI-ETOH, and ethnicity on functional outcome following severe CHI.

PARTICIPANTS

A total of 434 Hispanic, Anglo-Caucasian, and African-American individuals with severe CHI.

DESIGN

Retrospective cohort study.

SETTING

Consecutive admissions to a level 1 trauma center.

MAIN MEASURES

After admission to the trauma center, BAL was collected for each patient. Additional information regarding PI-ETOH was collected in a subset of patients (N = 116). Functional outcome was measured using the Disability Rating Scale (DRS) at 6 months after injury.

RESULTS

A one-way analysis of variance revealed ethnic differences in mean BAL. Hierarchical multiple regression indicated that BAL did not predict DRS outcomes after controlling for pertinent covariates. An interaction effect between PI-ETOH and ethnicity was observed, such that presence of chronic alcohol use predicted worse functional outcome for Anglo-Caucasians and African-Americans, but more favorable outcome for Hispanics.

CONCLUSIONS

Ethnic differences in BALs within our severe traumatic brain injury sample mirrored ethnic drinking patterns observed in the general population, with Hispanics having the highest BALs. A paradoxical relationship between PI-ETOH and functional outcome was observed for Hispanics.

Substance use and mild traumatic brain injury risk reduction and prevention: a novel model for treatment

Traumatic brain injury (TBI) and substance use disorders (SUDs) frequently co-occur. Individuals with histories of alcohol or other drug use are at greater risk for sustaining TBI, and individuals with TBI frequently misuse substances before and after injury. Further, a growing body of literature supports the relationship between comorbid histories of mild TBI (mTBI) and SUDs and negative outcomes. Alcohol and other drug use are strongly associated with risk taking. Disinhibition, impaired executive function, and/or impulsivity as a result of mTBI also contribute to an individual's proclivity towards risk-taking. Risk-taking behavior may therefore, be a direct result of SUD and/or history of mTBI, and risky behaviors may predispose individuals for subsequent injury or continued use of substances. Based on these findings, evaluation of risk-taking behavior associated with the co-occurrence of SUD and mTBI should be a standard clinical practice. Interventions aimed at reducing risky behavior among members of this population may assist in decreasing negative outcomes. A novel intervention (Substance Use and Traumatic Brain Injury Risk Reduction and Prevention (STRRP)) for reducing and preventing risky behaviors among individuals with co-occurring mTBI and SUD is presented. Areas for further research are discussed.

Outcome prediction in mild traumatic brain injury: age and clinical variables are stronger predictors than CT abnormalities

Mild traumatic brain injury (mTBI) is a common heterogeneous neurological disorder with a wide range of possible clinical outcomes. Accurate prediction of outcome is desirable for optimal treatment. This study aimed both to identify the demographic, clinical, and computed tomographic (CT) characteristics associated with unfavorable outcome at 6 months after mTBI, and to design a prediction model for application in daily practice. All consecutive mTBI patients (Glasgow Coma Scale [GCS] score: 13-15) admitted to our hospital who were age 16 or older were included during an 8-year period as part of the prospective Radboud University Brain Injury Cohort Study (RUBICS). Outcome was assessed at 6 months post-trauma using the Glasgow Outcome Scale-Extended (GOSE), dichotomized into unfavorable (GOSE score 1-6) and favorable (GOSE score 7-8) outcome groups. The predictive value of several variables was determined using multivariate binary logistic regression analysis. We included 2784 mTBI patients and found CT abnormalities in 20.7% of the 1999 patients that underwent a head CT. Age, extracranial injuries, and day-of-injury alcohol intoxication proved to be the strongest outcome predictors. The presence of facial fractures and the number of hemorrhagic contusions emerged as CT predictors. Furthermore, we showed that the predictive value of a scheme based on a modified Injury Severity Score (ISS), alcohol intoxication, and age equalled the value of one that also included CT characteristics. In fact, it exceeded one that was based on CT characteristics alone. We conclude that, although valuable for the identification of the individual mTBI patient at risk for deterioration and eventual neurosurgical intervention, CT characteristics are imperfect predictors of outcome after mTBI.

Isolated severe traumatic brain injuries: association of blood alcohol levels with the severity of injuries and outcomes

BACKGROUND

Traumatic brain injury is a common cause of death after traumatic insults. Alcohol intoxication is a recognized contributor to the occurrence of these injuries. The specific effects of alcohol exposure on injury severity and subsequent outcomes, however, remain controversial. The aim of this study was to investigate the relationship between blood alcohol levels (BAL) and outcomes in patients with isolated severe traumatic brain injuries (sTBI).

METHODS

During the calendar year 2003, as part of a pilot project, the Los Angeles County Department of Health Services obtained routine BAL on all patients transported to any of its 13 trauma centers. This study analyzes the effect of BAL on outcomes in patients with isolated sTBI (head Abbreviated Injury Scale (AIS) score >or=3; extracranial AIS score <3). The Low/No ethanol (ETOH) group included patients with negative or low (<0.08 mg/dL) BAL. Patients with BAL >or=0.08 mg/dL constituted the high ETOH group. Logistic regression was performed to determine whether alcohol levels had an independent association with outcomes.

RESULTS

There were 815 patients with isolated severe head injuries. Overall, 468 patients (57%) constituted the Low/No ETOH group, and 347 (43%) the high ETOH group. Alcohol levels were not significantly associated with severity of injury, hypotension at admission, Glasgow Coma Scale score, incidence of major complications, and intensive care unit or hospital length of stay. However, adjusted mortality was significantly lower in the high ETOH group when compared with the Low/No ETOH (8.9% vs. 17.1%; adjusted odds ratio: 0.60, 95% confidence interval: 0.37-0.96, p = 0.037). In the subgroup of patients with Injury Severity Score >15 the relative risk for mortality in the high ETOH group was significantly lower than in patients with Low/No ETOH. There was also an increased survival with high ETOH in patients with Injury Severity Score >25, but this was not statistically significant.

CONCLUSIONS

Among patients with isolated sTBI, BAL do not seem to be associated with overall injury severity, head injury severity, or the occurrence of major morbidities. Similarly, hospital and intensive care unit lengths are not affected by high admission BAL level. The adjusted overall in-hospital mortality, however, is significantly lower in patients presenting with the high BAL (>or=0.08 g/dL) after isolated sTBI.

Incidence of self-reported brain injury and the relationship with substance abuse: findings from a longitudinal community survey

BACKGROUND

Traumatic or serious brain injury (BI) has persistent and well documented adverse outcomes, yet 'mild' or 'moderate' BI, which often does not result in hospital treatment, accounts for half the total days of disability attributed to BI. There are currently few data available from community samples on the incidence and correlates of these injuries. Therefore, the study aimed to assess the 1) incidence of self-reported mild (not requiring hospital admission) and moderate (admitted to hospital)) brain injury (BI), 2) causes of injury 3) physical health scores and 4) relationship between BI and problematic alcohol or marijuana use.

METHODS

An Australian community sequential-cohort study (cohorts aged 20-24, 40-44 and 60-64 years at wave one) used a survey methodology to assess BI and substance use at baseline and four years later.

RESULTS

Of the 7485 wave one participants, 89.7% were re-interviewed at wave two. There were 56 mild (230.8/100000 person-years) and 44 moderate BI (180.5/100000 person-years) reported between waves one and two. Males and those in the 20-24 year cohort had increased risk of BI. Sports injury was the most frequent cause of BI (40/100) with traffic accidents being a greater proportion of moderate (27%) than mild (7%) BI. Neither alcohol nor marijuana problems at wave one were predictors of BI. BI was not a predictor of developing substance use problems by wave two.

CONCLUSIONS

BI were prevalent in this community sample, though the incidence declined with age. Factors associated with BI in community samples differ from those reported in clinical samples (e.g. typically traumatic brain injury with traffic accidents the predominate cause). Further, detailed evaluation of the health consequences of these injuries is warranted.

Serum ethanol levels: predictor of survival after severe traumatic brain injury

BACKGROUND

Recent studies have suggested that moderate doses of ethanol (ETOH) before traumatic brain injury (TBI) may have a neuroprotective role.

OBJECTIVE

: The objective of this study is to investigate the effects of serum ETOH levels on outcomes after TBI. Our hypothesis was that ETOH exposure is associated with improved survival in severe TBI patients and that the serum ETOH levels on admission correlate with survival.

METHODS

All patients sustaining severe TBI (head abbreviated injury score >or=3) admitted to the Surgical Intensive Care Unit at the Los Angeles County + University of Southern California Medical Center from January 2000 to December 2005 who had a serum ETOH level measured on admission were analyzed. Patients were classified into ETOH-positive and ETOH-negative groups, according to the serum ETOH levels and compared for differences in outcomes using logistic regression to adjust for clinically and statistically relevant confounding factors.

RESULTS

During the 5-year study period, 482 severe TBI patients admitted to the Surgical Intensive Care Unit at Los Angeles County + University of Southern California Medical Center had a serum ETOH level measured on admission. A total of 47% of severe TBI patients were tested for ETOH. ETOH levels were positive in 37% (179) and negative in 63% (303) of the TBI patients. The ETOH-positive group had a higher percentage of males (91% vs. 79%, p = 0.001), lower percentage of penetrating injuries (9% vs. 20%, p = 0.002), and lower injury severity score (25.7 +/- 11.5 vs. 28.4 +/- 14.1, p = 0.05). Overall mortality was significantly lower in the ETOH-positive group at 27% versus 40% (odds ratio = 0.55, 95% confidence interval: 0.37-0.82; p = 0.004). This survival benefit remained significant after multivariable analysis (adjusted odds ratio = 0.54, 95% confidence interval: 0.31-0.92; adjusted p = 0.02). The mean serum ETOH level was significantly higher for survivors than for nonsurvivors (0.11 +/- 0.21 vs. 0.05 +/- 0.10, p < 0.001). The serum ETOH levels significantly correlated with the probability of survival (r = 0.21, p < 0.001), but this correlation was not strong as shown by the low r value.

CONCLUSION

The results of this study suggest that elevated ETOH serum levels are independently associated with higher survival in patients with severe traumatic brain injuries. Additional research is required to further investigate the mechanism and potential therapeutic implications of this association.

Elevated Blood Alcohol Level May be Protective of Trauma Patient Mortality

To determine whether a positive blood alcohol level (BAL) affects morbidity and mortality at a Level I trauma center, a retrospective review of trauma patients 18 years of age and older was performed. There were 7985 trauma patients and 8 per cent (645) had a positive BAL. BAL(+) patients had lower Injury Severity Score (ISS) (8 vs 11, P < 0.01), lower rate of penetrating injury (9 vs 25%, P < 0.01), and were older (38 vs 32 years, P = 0.01). Overall there were 559 deaths (7%); (1% mortality in BAL(+) patients and 7% in BAL(-) patients; P < 0.0001). There were 352 (4.4%) complications with similar rates among BAL(-) and (+) patients. On univariate analysis, a positive BAL was inversely associated with death (OR, 0.17) as was blunt trauma (OR, 0.29), whereas older age (OR 1.009) and increased ISS (OR 1.13) were associated with death. On multivariable analysis, after adjusting for age, ISS, and mechanism of injury, a positive BAL remained protective against death (OR 0.35) as did blunt trauma (OR 0.2). Age (OR 1.04) and increased ISS (OR 1.19) were associated with mortality. In conclusion, a positive BAL was associated with a decreased mortality risk in trauma patients, which persisted after adjusting for multiple confounding variables.

Alcohol and drug use following traumatic brain injury: a prospective study

PRIMARY OBJECTIVES

To establish pre-morbid alcohol and drug use in persons with TBI, relative to controls, investigate how patterns of substance use change over time following TBI and identify factors associated with heavy post-injury substance use.

METHODS AND PROCEDURES

The Alcohol Use Disorders Identification test (AUDIT) and Drug Abuse Screening Test (DAST) was completed by 121 hospital inpatients with TBI, documenting pre-injury alcohol and drug use, and 133 demographically similar controls. Participants with TBI completed these measures and the Hospital Anxiety and Depression Scale (HADS) again 1 and 2 years post-injury and 76 also completed them at 3 years.

RESULTS

Participants with TBI showed similar levels of drug and alcohol use to controls pre-injury, with 31.4% of the TBI group and 29.3% of controls drinking at hazardous levels. Alcohol and drug use declined in the first year post-injury, but increased by 2 years post-injury, with only 21.4% of participants with TBI reporting abstinence from alcohol and 25.4% drinking at hazardous levels. Only 9% showed a drug problem, but 24% had returned to some drug use. Those showing heavy alcohol use post-injury were young, male and heavy drinkers pre-injury. Drug and alcohol use was similar at 3 years post-injury.

CONCLUSIONS

More active intervention is needed to reduce alcohol and drug use following TBI.

Relationships among premorbid alcohol use, acute intoxication, and early functional status after traumatic brain injury

OBJECTIVE

To investigate the relationships among intoxication at time of injury, preinjury history of problem drinking, and early functional status in patients with traumatic brain injury (TBI).

DESIGN

Prospective cohort study.

SETTING

Acute inpatient TBI rehabilitation.

PARTICIPANTS

Participants were 1748 persons with TBI.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Blood alcohol levels (BALs) were obtained at admission to the emergency department, and a history of problem drinking was obtained through interview. Study outcomes, Disability Rating Scale (DRS), and FIM instrument scores were gathered at admission to inpatient rehabilitation.

RESULTS

Multivariate regression analysis revealed that BAL and a history of binge drinking were predictive of DRS, but not FIM, scores. A higher BAL was associated with poorer functional status on the DRS. Paradoxically, a history of binge drinking was associated with more intact functional status on the DRS.

CONCLUSIONS

The relationships among intoxication at time of injury, history of problem drinking, and early outcome after TBI were modest. Injury severity had a more significant association with TBI functional status.

Traumatic brain injury in intoxicated patients

BACKGROUND

We sought to evaluate the effect alcohol intoxication may have had in nonsurgically treated patients with severe traumatic brain injury.

METHODS

The Montreal General Hospital Traumatic Brain Injury Registry was used to identify all adult patients with a Glasgow Coma Scale score < or =8 at admission, within a 15-month period. All charts were retrospectively reviewed.

RESULTS

Twenty-three patients had toxic blood alcohol levels (BAL > or =21.7 mmol/L), 24 were alcohol negative (BAL <3 mmol/L), and 10 were alcohol-influenced or had unknown BAL. Patients were more likely to have intracranial pressure monitoring if they had multiple intracranial hemorrhages, sustained multiple injuries, or had a post-resuscitative Glasgow Coma Scale score < or =8. Intoxicated patients had a mean delay of 151 minutes more in the insertion time of an intracranial pressure monitoring device, compared with alcohol-negative patients.

CONCLUSIONS

Alcohol was a confounding factor in the treatment of some of our patients.

Traumatic brain injury and substance misuse: a systematic review of prevalence and outcomes research (1994-2004)

A systematic review of the evidence on substance misuse prevalence in patients with traumatic brain injury (TBI) and outcomes associated with this population is presented. Building upon an earlier review of the area by Corigan (1995), this review is limited to research published between 1994 and 2004. Psycinfo and Medline abstract databases were searched for English-language publications citing research from Western countries on the epidemiology and outcomes of adult TBI patients (aged 15 years or older). The majority of reviewed studies were undertaken in the USA and the investigation foci and methods used were multifarious, constraining the generalisation of the review findings. Prevalence for alcohol intoxication at time of injury in the review was found to be almost identical to that in Corrigan's review: 37-51% and 36-51%, respectively. Pre-TBI history of alcohol misuse was found to be less prevalent in the present as opposed to Corrigan's review: 37-51% and 55-66%, respectively. Outcome findings were mixed (also found by Corrigan), but mainly in the expected direction of poorer outcomes (neurological, medical, neuropsychological, and functional) in patients with pre-TBI substance misuse. Further research and implications for services are outlined.

Alcohol related falls: an interesting pattern of injuries

OBJECTIVE

To discover if there is a significant difference in the pattern and severity of injury sustained during falls in patients who have consumed alcohol and those who have not. To determine how pattern and severity of injury correlates with blood alcohol concentration.

METHOD

A prospective quasi-randomised controlled study between November 2001 and July 2002. All healthy adults between 16 and 60 years who had fallen from standing height were included. A systematic history and examination permitted calculation of injury severity scores as per abbreviated injury scale update 1998. Blood alcohol concentrations were obtained from intoxicated patients with consent.

RESULTS

351 healthy adult patients were included in the study, there were 238 in the no alcohol group, 113 had consumed alcohol and blood alcohol intake were obtained for 47. The alcohol group had a higher incidence of head injuries (46 (48%) versus 22 (9%)) with a lower incidence of limb injuries (39 (39%) versus 183 (76%)) than the no alcohol group. There was a significant difference in the pattern of injury between the alcohol and no alcohol groups (chi(2), p<0.001) and there was a significant difference in the injury severity scores (p<0.001, Z = -2.5). In the alcohol group severity and pattern correlated with alcohol concentration at the time of injury. Patients with an alcohol concentration<2 g/l had mostly soft tissue limb injuries (58%), 2-2.5 mostly significant limb fractures (55%), and >2.5 mostly significant head injuries (90%).

CONCLUSIONS

Alcohol related falls are more often associated with severe craniofacial injury. The severity of both limb and head injury is greater and correlates directly with blood alcohol concentration.

The Effects of Admission Alcohol Level on Cerebral Blood Flow and Outcomes after Severe Traumatic Brain Injury

This study examined the relationship between admission serum alcohol level (ETOH) and cerebral blood flow (CBF) and outcomes in the adult traumatic brain injured (TBI) population. We hypothesized that individuals with ETOH > 100 mg/dL will have decreased blood flow on admission and poorer outcomes. Eighty subjects, age 16-65, with severe TBI (Glasgow Coma Score [GCS] </= 8) were entered into the study. Correlational analysis assessed the relationship between ETOH and admission severity of injury scores as measured by Marshall and APACHE III scores, CBF, and outcomes. Comparison of CBF and outcomes between groups based on admission serum ETOH level was conducted with analysis of variance and post hoc Scheffé analyses as well as regression analysis. There was a significant relationship between serum ETOH level and GCS (p = 0.02), but not APACHE III scores (p = 0.12) or Marshall scores (p = 0.27). There was a significant correlation between global CBF and serum ETOH level (p = 0.02). There was no statistically significant association between serum ETOH level and GOS at 3 (p = 0.97), 6 (p= 0.56), or 12 (p = 0.73) months after injury. The data indicated that serum ETOH levels > 100 mg/dL at the time of admission after a TBI were associated with a decrease in global CBF. Elevated serum ETOH level at time of injury did not, however, impact outcomes.

Alcohol abuse and traumatic brain injury: quantitative magnetic resonance imaging and neuropsychological outcome

Prior or concurrent alcohol use at the time of traumatic brain injury (TBI) was examined in terms of post-injury atrophic changes measured by quantitative analysis of magnetic resonance imaging (MRI) and neuropsychological outcome. Two groups of TBI subjects were examined: those with a clinically significant blood alcohol level (BAL) present at the time of injury (TBI + BAL) and those without a significant BAL (TBI-only). To explore the potential impact of both acute and chronic alcohol use, subjects in both groups were further clustered into one of four subgroups (NONE, MILD, MODERATE or HEAVY) based upon available information regarding their pre-injury alcohol use. One-way analysis of covariance (ANCOVA) and multiple analysis of covariance (MANCOVA) were used with subject grouping as the main factor. Age, injury severity as measured by Glasgow Coma Scale (GCS) score, years of education, total intracranial volume (TICV), and the number of days post-injury were included as covariates where appropriate. Increased general atrophy was observed in patients with (a) a positive BAL and/or (b) a history of moderate to heavy pre-injury alcohol use. In addition, performance on neuropsychological outcome variables (WAIS-R and WMS-R Index scores) was generally worse in the subgroups of patients with positive BAL and a history of preinjury alcohol use, as compared to the other TBI groups though not statistically significant. Implications of alcohol use, at the time of brain injury, are discussed.

Brain and Spinal Cord Injury

Up to 50% of all trauma deaths in the United States involve significant injury to the brain or spinal cord. This chapter highlights the public health significance of traumatic brain and spinal cord injury and examines methodological issues in studies of the epidemiology of these injuries. It addresses methodological challenges in epidemiologic and clinical studies of brain and spinal cord injury, including difficulties in case ascertainment, differing approaches to brain injury classification, and measurement issues in brain injury severity and outcome scales. The chapter summarizes scientific literature addressing demographic and lifestyle risk factors for brain injury including age, sex, and alcohol consumption. External causes of traumatic brain and spinal cord injury are also discussed, including transportation-related injuries and increasingly recognized sports-related brain injuries.

Acute ethanol intake attenuates inflammatory cytokines after brain injury in rats: a possible role for corticosterone

It has been reported that acute ethanol intoxication exerts dose-dependent effects, both beneficial and detrimental, on the outcome of traumatic brain injury (TBI), although the mechanism(s) has not been determined. Given that pro-inflammatory cytokines are either neuroprotective or neurotoxic, depending on their tissue levels, ethanol-induced alterations in brain cytokine production may be involved in determining the recovery after TBI. The present study was undertaken to examine the effect of acute ethanol pretreatments (producing blood alcohol concentrations of 100+/-16 mg/dL, and 220+/-10 mg/dL, considered low and intoxicating doses, respectively) on interleukin-1beta (IL-1beta) and tumor necrosis factor-alpha (TNF-alpha) levels in discrete brain regions. In addition, serum corticosterone levels were also examined because the hormone is a modulator of cytokine production, its secretion is stimulated by ethanol, and it has been associated with the severity of post-injury neurologic dysfunction. The data presented in this report demonstrate that moderate cortical impact brain injury elicits a marked increase in IL-1beta and TNF-alpha in the injured cortex as well as in the hippocampus ipsilateral to the injury. Ethanol pretreatment lowered cytokine levels in the cortex, hippocampus and hypothalamus in a dose-dependent manner after TBI compared to the untreated injured rats. Serum corticosterone levels were markedly increased in the injured rats, and were further augmented in the ethanol-pretreated injured animals in a dose-dependent manner. Our findings suggest that ethanol-induced decrease in pro-inflammatory cytokine production may be linked to increased circulating corticosterone, both of which may contribute to the outcome of brain injury.

Effects of chronic ethanol administration on expression of BDNF and trkB mRNAs in rat hippocampus after experimental brain injury

Previous evidence indicates that both chronic alcohol treatment and traumatic brain injury modulate expression of certain neurotrophins and neurotrophin receptors in cortical tissue. However, the combined effects of chronic alcohol and brain trauma on expression of neurotrophins and their receptors have not been investigated. In the present study, we examined the effects of 6 weeks of chronic ethanol administration on lateral fluid percussion (FP) brain injury-induced alterations in expression of mRNAs for the neurotrophin brain-derived neurotrophic factor (BDNF) and its high affinity receptor, trkB, in rat hippocampus. In both the control- (pair-fed isocaloric sucrose) diet and the chronic ethanol-diet groups, unilateral FP brain injury induced a bilateral increase in levels of both BDNF and trkB mRNAs in the dentate gyrus granule cell layer, and of BDNF mRNA in hippocampal region CA3. However, no significant differences in expression were found between the control-diet and ethanol-diet groups, in either the sham-injured or FP-injured animals. These findings suggest that 6 weeks of chronic ethanol administration does not alter the plasticity of hippocampal BDNF/trkB expression in response to experimental brain injury.