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Shahim P, Pham DL, van der Merwe AJ, Moore B, Chou Y, Lippa SM, Kenney K, Diaz‐Arrastia R, Chan L. Serum NfL and GFAP as biomarkers of progressive neurodegeneration in TBI. Alzheimers Dement 2024; 20:4663-4676. [PMID: 38805359 PMCID: PMC11247683 DOI: 10.1002/alz.13898] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2023] [Revised: 04/01/2024] [Accepted: 04/12/2024] [Indexed: 05/30/2024]
Abstract
BACKGROUND We examined spatial patterns of brain atrophy after mild, moderate, and severe traumatic brain injury (TBI), the relationship between progression of brain atrophy with initial traumatic axonal injury (TAI), cognitive outcome, and with serum biomarkers of brain injury. METHODS A total of 143 patients with TBI and 43 controls were studied cross-sectionally and longitudinally up to 5 years with multiple assessments, which included brain magnetic resonance imaging, cognitive testing, and serum biomarkers. RESULTS TBI patients showed progressive volume loss regardless of injury severity over several years, and TAI was independently associated with accelerated brain atrophy. Cognitive performance improved over time. Higher baseline serum neurofilament light (NfL) and glial fibrillary acidic protein (GFAP) were associated with greater rate of brain atrophy over 5 years. DISCUSSSION Spatial patterns of atrophy differ by injury severity and TAI is associated with the progression of brain atrophy. Serum NfL and GFAP show promise as non-invasive prognostic biomarkers of progressive neurodegeneration in TBI. HIGHLIGHTS In this longitudinal study of patient with mild, moderate, and severe traumatic brain injury (TBI) who were assessed with paired magnetic resonance imaging (MRI), blood biomarkers, and cognitive assessments, we found that brain atrophy after TBI is progressive and continues for many years even after a mild head trauma without signs of brain injury on conventional MRI. We found that spatial pattern of brain atrophy differs between mild, moderate, and severe TBI, where in patients with mild TBI , atrophy is mainly seen in the gray matter, while in those with moderate to severe brain injury atrophy is predominantly seen in the subcortical gray matter and whiter matter. Cognitive performance improves over time after a TBI. Serum measures of neurofilament light or glial fibrillary acidic protein are associated with progression of brain atrophy after TBI.
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Affiliation(s)
- Pashtun Shahim
- Rehabilitation Medicine DepartmentNational Institutes of Health (NIH) Clinical CenterBethesdaMarylandUSA
- National Institutes of Neurological Disorders and Stroke, NIHBethesdaMarylandUSA
- Department of NeurologyMedStar Georgetown University Hospital, Pasquerilla Healthcare CenterWashingtonDistrict of ColumbiaUSA
- The Military Traumatic Brain Injury Initiative (MTBI2)BethesdaMarylandUSA
- The Henry M. Jackson Foundation for the Advancement of Military MedicineBethesdaMarylandUSA
| | - Dzung L. Pham
- The Military Traumatic Brain Injury Initiative (MTBI2)BethesdaMarylandUSA
- Uniformed Services University of the Health SciencesBethesdaMarylandUSA
| | - Andre J. van der Merwe
- Rehabilitation Medicine DepartmentNational Institutes of Health (NIH) Clinical CenterBethesdaMarylandUSA
- The Military Traumatic Brain Injury Initiative (MTBI2)BethesdaMarylandUSA
- The Henry M. Jackson Foundation for the Advancement of Military MedicineBethesdaMarylandUSA
| | - Brian Moore
- Rehabilitation Medicine DepartmentNational Institutes of Health (NIH) Clinical CenterBethesdaMarylandUSA
- The Military Traumatic Brain Injury Initiative (MTBI2)BethesdaMarylandUSA
- The Henry M. Jackson Foundation for the Advancement of Military MedicineBethesdaMarylandUSA
| | - Yi‐Yu Chou
- The Military Traumatic Brain Injury Initiative (MTBI2)BethesdaMarylandUSA
- The Henry M. Jackson Foundation for the Advancement of Military MedicineBethesdaMarylandUSA
| | - Sara M. Lippa
- Uniformed Services University of the Health SciencesBethesdaMarylandUSA
- National Intrepid Center of Excellence, Walter Reed National Military Medical CenterBethesdaMarylandUSA
| | - Kimbra Kenney
- Uniformed Services University of the Health SciencesBethesdaMarylandUSA
- National Intrepid Center of Excellence, Walter Reed National Military Medical CenterBethesdaMarylandUSA
| | - Ramon Diaz‐Arrastia
- Department of NeurologyUniversity of Pennsylvania Perelman School of MedicinePhiladelphiaPennsylvaniaUSA
| | - Leighton Chan
- Rehabilitation Medicine DepartmentNational Institutes of Health (NIH) Clinical CenterBethesdaMarylandUSA
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Hume CH, Mitra B, Wright BJ, Kinsella GJ. Quality of life and psychological health after mild traumatic brain injury in older people: Three- and six-month follow up. Brain Inj 2023; 37:1262-1271. [PMID: 37470460 DOI: 10.1080/02699052.2023.2237882] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2022] [Revised: 06/03/2023] [Accepted: 07/06/2023] [Indexed: 07/21/2023]
Abstract
OBJECTIVES Examine quality of life (QoL) and psychological health after mild traumatic brain injury (mTBI) in older people (65+ years) at 3- and 6-month follow-up and explore which injury factors predicted QoL. METHODS mTBI patients were compared to trauma comparison (TC) and community comparison (CC) groups. QoL and psychological health were measured at both timepoints. After accounting for 3-month psychological health, injury severity, neuroimaging, and 3-month neuropsychological performance were assessed as predictors of 6-month QoL. RESULTS Overall 3-month QoL was lower for mTBI (Cohen's d = 0.938) and TC (Cohen's d = 0.485) groups compared to CCs, but by 6 months only mTBI patients continued to report poorer overall QoL (Cohen's d = 0.577) and physical QoL (Cohen's d = 0.656). Despite group differences, QoL for most (~92%) was within normative limits. 3-month psychological health predicted QoL 6-months postinjury (β = -.377, 95% CI -.614, -.140) but other proposed risk factors (GCS <15, neuroimaging, 3-month neuropsychological performance) did not uniquely predict QoL. CONCLUSIONS Older adults following mTBI reported lower QoL up to 6-months postinjury compared to non-injured peers, indicating that mTBI patients were particularly susceptible to ongoing differences in QoL 6-months postinjury.
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Affiliation(s)
- Camilla H Hume
- School of Psychology and Public Health, La Trobe University, Melbourne, Australia
| | - Biswadev Mitra
- Emergency and Trauma Centre, The Alfred Hospital, Melbourne, Australia
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
- National Trauma Research Institute, The Alfred, Melbourne, Victoria, Australia
| | - Bradley J Wright
- School of Psychology and Public Health, La Trobe University, Melbourne, Australia
| | - Glynda J Kinsella
- School of Psychology and Public Health, La Trobe University, Melbourne, Australia
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Kim N, Jamison K, Jaywant A, Garetti J, Blunt E, RoyChoudhury A, Butler T, Dams-O'Connor K, Khedr S, Chen CC, Shetty T, Winchell R, Hill NJ, Schiff ND, Kuceyeski A, Shah SA. Comparisons of electrophysiological markers of impaired executive attention after traumatic brain injury and in healthy aging. Neuroimage 2023; 274:120126. [PMID: 37191655 PMCID: PMC10286242 DOI: 10.1016/j.neuroimage.2023.120126] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2023] [Revised: 04/10/2023] [Accepted: 04/19/2023] [Indexed: 05/17/2023] Open
Abstract
Executive attention impairments are a persistent and debilitating consequence of traumatic brain injury (TBI). To make headway towards treating and predicting outcomes following heterogeneous TBI, cognitive impairment specific pathophysiology first needs to be characterized. In a prospective observational study, we measured EEG during the attention network test aimed at detecting alerting, orienting, executive attention and processing speed. The sample (N = 110) of subjects aged 18-86 included those with and without traumatic brain injury: n = 27, complicated mild TBI; n = 5, moderate TBI; n = 10, severe TBI; n = 63, non-brain-injured controls. Subjects with TBI had impairments in processing speed and executive attention. Electrophysiological markers of executive attention processing in the midline frontal regions reveal that, as a group, those with TBI and elderly non-brain-injured controls have reduced responses. We also note that those with TBI and elderly controls have responses that are similar for both low and high-demand trials. In subjects with moderate-severe TBI, reductions in frontal cortical activation and performance profiles are both similar to that of controls who are ∼4 to 7 years older. Our specific observations of frontal response reductions in subjects with TBI and in older adults is consistent with the suggested role of the anterior forebrain mesocircuit as underlying cognitive impairments. Our results provide novel correlative data linking specific pathophysiological mechanisms underlying domain-specific cognitive deficits following TBI and with normal aging. Collectively, our findings provide biomarkers that may serve to track therapeutic interventions and guide development of targeted therapeutics following brain injuries.
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Affiliation(s)
- Nayoung Kim
- Department of Radiology, Weill Cornell Medicine, New York, NY 10065, United States
| | - Keith Jamison
- Department of Radiology, Weill Cornell Medicine, New York, NY 10065, United States
| | - Abhishek Jaywant
- Department of Psychiatry, Weill Cornell Medicine, New York, NY 10065, United States; Department of Rehabilitation Medicine, Weill Cornell Medicine, New York, NY 10065, United States; NewYork-Presbyterian Hospital, New York, NY 10065, United States
| | - Jacob Garetti
- Department of Radiology, Weill Cornell Medicine, New York, NY 10065, United States
| | - Emily Blunt
- Department of Rehabilitation and Human Performance, Icahn School of Medicine at Mount Sinai, New York, NY 10029, United States
| | - Arindam RoyChoudhury
- Division of Biostatistics, Department of Population Health Sciences, Weill Cornell Medicine, New York, NY 10065, United States
| | - Tracy Butler
- Department of Radiology, Weill Cornell Medicine, New York, NY 10065, United States
| | - Kristen Dams-O'Connor
- Department of Rehabilitation and Human Performance, Icahn School of Medicine at Mount Sinai, New York, NY 10029, United States; Department of Neurology, Icahn School of Medicine at Mount Sinai, New York, NY 10029, United States
| | - Shahenda Khedr
- Department of Surgery, NewYork-Presbyterian Queens Hospital, Queens, NY 11355, United States
| | - Chun-Cheng Chen
- Department of Surgery, NewYork-Presbyterian Queens Hospital, Queens, NY 11355, United States; Department of Surgery, Weill Cornell Medicine, New York, NY 10065, United States
| | - Teena Shetty
- Department of Neurology, Hospital for Special Surgery, New York, NY, 10021 United States
| | - Robert Winchell
- Department of Surgery, Weill Cornell Medicine, New York, NY 10065, United States
| | - N Jeremy Hill
- National Center for Adaptive Neurotechnologies, Stratton VA Medical Center, Albany, NY 12208, United States; Electrical & Computer Engineering Department, State University of New York at Albany, NY 12226, United States
| | - Nicholas D Schiff
- Department of BMRI & Neurology, Weill Cornell Medicine, New York, NY 10065, United States
| | - Amy Kuceyeski
- Department of Radiology, Weill Cornell Medicine, New York, NY 10065, United States
| | - Sudhin A Shah
- Department of Radiology, Weill Cornell Medicine, New York, NY 10065, United States; Department of BMRI & Neurology, Weill Cornell Medicine, New York, NY 10065, United States.
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Hume CH, Mitra B, Wright BJ, Kinsella GJ. Mild Traumatic Brain Injury and Functional Outcome in Older Adults: Pain Interference But Not Cognition Mediates the Relationship Between Traumatic Injury and Functional Difficulties. J Head Trauma Rehabil 2023; 38:E278-E288. [PMID: 36602271 DOI: 10.1097/htr.0000000000000846] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
OBJECTIVE To examine functional status of older people 3 months after mild traumatic brain injury (mTBI) and identify whether pain interference or cognition mediates any relationship found between injury status and functional outcomes. SETTING Patients admitted to a Melbourne-based emergency department. PARTICIPANTS Older adults 65 years and older: 40 with mTBI, 66 with orthopedic injury without mTBI (TC), and 47 healthy controls (CC) without injury. DESIGN Observational cohort study. MAIN MEASURES Functional outcome was measured using the World Health Organization Disability Assessment Schedule (WHODAS 2.0) and single- and dual-task conditions of the Timed-Up-and-Go task. Pain interference and cognitive performance at 3 months post-injury were examined as mediators of the relationship between injury status (injured vs noninjured) and functional outcome. RESULTS Patients with mTBI and/or orthopedic injury reported greater difficulties in overall functioning, including community participation, compared with noninjured older people (CC group). Both trauma groups walked slower than the CC group on the mobility task, but all groups were similar on the dual-task condition. Pain interference mediated the relationship between injury status and overall functioning [ b = 0.284; 95% CI = 0.057, 0.536), community participation ( b = 0.259; 95% CI = 0.051, 0.485), and mobility ( b = 0.116; 95% CI = 0.019, 0.247). However, cognition did not mediate the relationship between injury status and functional outcomes. CONCLUSIONS Three months after mild traumatic injury (with and without mTBI), patients 65 years and older had greater functional difficulties compared with noninjured peers. Pain interference, but not cognition, partially explained the impact of traumatic injury on functional outcomes. This highlights the importance of reducing pain interference for older patients after injury (including mTBI) to support better functional recovery.
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Affiliation(s)
- Camilla H Hume
- Melbourne Campus, La Trobe University, Bundoora, Australia (Ms Hume); Emergency and Trauma Centre, The Alfred Hospital, Melbourne, Australia, and School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia, and National Trauma Research Institute, The Alfred Hospital, Melbourne, Australia (Dr Mitra); and School of Psychology and Public Health, La Trobe University, Melbourne, Australia (Ms Hume and Drs Wright and Kinsella)
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Jaywant A, Blunt E, Jamison K, Kim N, RoyChoudhury A, Schiff ND, Kuceyeski A, Dams-O'Connor K, Shah S. Association Between the Attention Network Test, Neuropsychological Measures, and Disability in Post-Acute Traumatic Brain Injury. Neurotrauma Rep 2023; 4:318-329. [PMID: 37771426 PMCID: PMC10523404 DOI: 10.1089/neur.2022.0068] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/30/2023] Open
Abstract
Cognitive impairment after traumatic brain injury (TBI) is persistent and disabling. Assessing cognitive function in a reliable and valid manner, using measures that are sensitive to the integrity of underlying neural substrates, is crucial in clinical research. The Attention Network Test (ANT) is one such assessment measure that has demonstrated associations with neural regions involved in attention; however, clinical utility of the ANT is limited because its relationship with neuropsychological measures of cognitive function (i.e., its construct validity) has not yet been established in TBI. We evaluated the association between the ANT and 1) a neuropsychological battery assessing executive function and memory and 2) global function assessed by the Glasgow Outcome Scale-Extended (GOSE). Forty-eight adults with complicated mild-severe TBI were evaluated ∼5 months post-injury. Using principal component analysis and multi-variate linear regression adjusted for age, gender, education, and cause of injury, we found that ANT reaction time and executive network scores predicted a principal component assessing processing speed and executive function. Conversely, the ANT did not predict a principal component assessing memory. The ANT was weakly associated with the GOSE. Among persons with TBI during the post-acute phase of recovery, the ANT has good construct validity as evidenced by its associations with neuropsychological measures of processing speed and executive function, but not memory. Given that ANT networks are known to relate to specific neuroanatomical regions, the ANT may be a useful outcome measure for evaluating novel therapeutics targeting attention and executive functions after TBI.
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Affiliation(s)
- Abhishek Jaywant
- Department of Psychiatry, Weill Cornell Medicine, New York, New York, USA
- Department of Rehabilitation Medicine, Weill Cornell Medicine, New York, New York, USA
- NewYork-Presbyterian Hospital, New York, New York, USA
| | - Emily Blunt
- Brain Injury Research Center, Icahn School of Medicine at Mount Sinai, New York, New York, USA
- Department of Rehabilitation and Human Performance, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Keith Jamison
- Department of Radiology, Weill Cornell Medicine, New York, New York, USA
| | - Nayoung Kim
- Department of Radiology, Weill Cornell Medicine, New York, New York, USA
| | - Arindam RoyChoudhury
- Department of Population Health Sciences, Weill Cornell Medicine, New York, New York, USA
| | - Nicholas D. Schiff
- Brain and Mind Research Institute, Weill Cornell Medicine, New York, New York, USA
- Department of Neurology, Weill Cornell Medicine, New York, New York, USA
| | - Amy Kuceyeski
- Department of Radiology, Weill Cornell Medicine, New York, New York, USA
- Brain and Mind Research Institute, Weill Cornell Medicine, New York, New York, USA
| | - Kristen Dams-O'Connor
- Brain Injury Research Center, Icahn School of Medicine at Mount Sinai, New York, New York, USA
- Department of Rehabilitation and Human Performance, Icahn School of Medicine at Mount Sinai, New York, New York, USA
- Department of Neurology, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Sudhin Shah
- Department of Radiology, Weill Cornell Medicine, New York, New York, USA
- Brain and Mind Research Institute, Weill Cornell Medicine, New York, New York, USA
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Maas AIR, Menon DK, Manley GT, Abrams M, Åkerlund C, Andelic N, Aries M, Bashford T, Bell MJ, Bodien YG, Brett BL, Büki A, Chesnut RM, Citerio G, Clark D, Clasby B, Cooper DJ, Czeiter E, Czosnyka M, Dams-O’Connor K, De Keyser V, Diaz-Arrastia R, Ercole A, van Essen TA, Falvey É, Ferguson AR, Figaji A, Fitzgerald M, Foreman B, Gantner D, Gao G, Giacino J, Gravesteijn B, Guiza F, Gupta D, Gurnell M, Haagsma JA, Hammond FM, Hawryluk G, Hutchinson P, van der Jagt M, Jain S, Jain S, Jiang JY, Kent H, Kolias A, Kompanje EJO, Lecky F, Lingsma HF, Maegele M, Majdan M, Markowitz A, McCrea M, Meyfroidt G, Mikolić A, Mondello S, Mukherjee P, Nelson D, Nelson LD, Newcombe V, Okonkwo D, Orešič M, Peul W, Pisică D, Polinder S, Ponsford J, Puybasset L, Raj R, Robba C, Røe C, Rosand J, Schueler P, Sharp DJ, Smielewski P, Stein MB, von Steinbüchel N, Stewart W, Steyerberg EW, Stocchetti N, Temkin N, Tenovuo O, Theadom A, Thomas I, Espin AT, Turgeon AF, Unterberg A, Van Praag D, van Veen E, Verheyden J, Vyvere TV, Wang KKW, Wiegers EJA, Williams WH, Wilson L, Wisniewski SR, Younsi A, Yue JK, Yuh EL, Zeiler FA, Zeldovich M, Zemek R. Traumatic brain injury: progress and challenges in prevention, clinical care, and research. Lancet Neurol 2022; 21:1004-1060. [PMID: 36183712 PMCID: PMC10427240 DOI: 10.1016/s1474-4422(22)00309-x] [Citation(s) in RCA: 255] [Impact Index Per Article: 127.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2022] [Accepted: 07/22/2022] [Indexed: 02/06/2023]
Abstract
Traumatic brain injury (TBI) has the highest incidence of all common neurological disorders, and poses a substantial public health burden. TBI is increasingly documented not only as an acute condition but also as a chronic disease with long-term consequences, including an increased risk of late-onset neurodegeneration. The first Lancet Neurology Commission on TBI, published in 2017, called for a concerted effort to tackle the global health problem posed by TBI. Since then, funding agencies have supported research both in high-income countries (HICs) and in low-income and middle-income countries (LMICs). In November 2020, the World Health Assembly, the decision-making body of WHO, passed resolution WHA73.10 for global actions on epilepsy and other neurological disorders, and WHO launched the Decade for Action on Road Safety plan in 2021. New knowledge has been generated by large observational studies, including those conducted under the umbrella of the International Traumatic Brain Injury Research (InTBIR) initiative, established as a collaboration of funding agencies in 2011. InTBIR has also provided a huge stimulus to collaborative research in TBI and has facilitated participation of global partners. The return on investment has been high, but many needs of patients with TBI remain unaddressed. This update to the 2017 Commission presents advances and discusses persisting and new challenges in prevention, clinical care, and research. In LMICs, the occurrence of TBI is driven by road traffic incidents, often involving vulnerable road users such as motorcyclists and pedestrians. In HICs, most TBI is caused by falls, particularly in older people (aged ≥65 years), who often have comorbidities. Risk factors such as frailty and alcohol misuse provide opportunities for targeted prevention actions. Little evidence exists to inform treatment of older patients, who have been commonly excluded from past clinical trials—consequently, appropriate evidence is urgently required. Although increasing age is associated with worse outcomes from TBI, age should not dictate limitations in therapy. However, patients injured by low-energy falls (who are mostly older people) are about 50% less likely to receive critical care or emergency interventions, compared with those injured by high-energy mechanisms, such as road traffic incidents. Mild TBI, defined as a Glasgow Coma sum score of 13–15, comprises most of the TBI cases (over 90%) presenting to hospital. Around 50% of adult patients with mild TBI presenting to hospital do not recover to pre-TBI levels of health by 6 months after their injury. Fewer than 10% of patients discharged after presenting to an emergency department for TBI in Europe currently receive follow-up. Structured follow-up after mild TBI should be considered good practice, and urgent research is needed to identify which patients with mild TBI are at risk for incomplete recovery. The selection of patients for CT is an important triage decision in mild TBI since it allows early identification of lesions that can trigger hospital admission or life-saving surgery. Current decision making for deciding on CT is inefficient, with 90–95% of scanned patients showing no intracranial injury but being subjected to radiation risks. InTBIR studies have shown that measurement of blood-based biomarkers adds value to previously proposed clinical decision rules, holding the potential to improve efficiency while reducing radiation exposure. Increased concentrations of biomarkers in the blood of patients with a normal presentation CT scan suggest structural brain damage, which is seen on MR scanning in up to 30% of patients with mild TBI. Advanced MRI, including diffusion tensor imaging and volumetric analyses, can identify additional injuries not detectable by visual inspection of standard clinical MR images. Thus, the absence of CT abnormalities does not exclude structural damage—an observation relevant to litigation procedures, to management of mild TBI, and when CT scans are insufficient to explain the severity of the clinical condition. Although blood-based protein biomarkers have been shown to have important roles in the evaluation of TBI, most available assays are for research use only. To date, there is only one vendor of such assays with regulatory clearance in Europe and the USA with an indication to rule out the need for CT imaging for patients with suspected TBI. Regulatory clearance is provided for a combination of biomarkers, although evidence is accumulating that a single biomarker can perform as well as a combination. Additional biomarkers and more clinical-use platforms are on the horizon, but cross-platform harmonisation of results is needed. Health-care efficiency would benefit from diversity in providers. In the intensive care setting, automated analysis of blood pressure and intracranial pressure with calculation of derived parameters can help individualise management of TBI. Interest in the identification of subgroups of patients who might benefit more from some specific therapeutic approaches than others represents a welcome shift towards precision medicine. Comparative-effectiveness research to identify best practice has delivered on expectations for providing evidence in support of best practices, both in adult and paediatric patients with TBI. Progress has also been made in improving outcome assessment after TBI. Key instruments have been translated into up to 20 languages and linguistically validated, and are now internationally available for clinical and research use. TBI affects multiple domains of functioning, and outcomes are affected by personal characteristics and life-course events, consistent with a multifactorial bio-psycho-socio-ecological model of TBI, as presented in the US National Academies of Sciences, Engineering, and Medicine (NASEM) 2022 report. Multidimensional assessment is desirable and might be best based on measurement of global functional impairment. More work is required to develop and implement recommendations for multidimensional assessment. Prediction of outcome is relevant to patients and their families, and can facilitate the benchmarking of quality of care. InTBIR studies have identified new building blocks (eg, blood biomarkers and quantitative CT analysis) to refine existing prognostic models. Further improvement in prognostication could come from MRI, genetics, and the integration of dynamic changes in patient status after presentation. Neurotrauma researchers traditionally seek translation of their research findings through publications, clinical guidelines, and industry collaborations. However, to effectively impact clinical care and outcome, interactions are also needed with research funders, regulators, and policy makers, and partnership with patient organisations. Such interactions are increasingly taking place, with exemplars including interactions with the All Party Parliamentary Group on Acquired Brain Injury in the UK, the production of the NASEM report in the USA, and interactions with the US Food and Drug Administration. More interactions should be encouraged, and future discussions with regulators should include debates around consent from patients with acute mental incapacity and data sharing. Data sharing is strongly advocated by funding agencies. From January 2023, the US National Institutes of Health will require upload of research data into public repositories, but the EU requires data controllers to safeguard data security and privacy regulation. The tension between open data-sharing and adherence to privacy regulation could be resolved by cross-dataset analyses on federated platforms, with the data remaining at their original safe location. Tools already exist for conventional statistical analyses on federated platforms, however federated machine learning requires further development. Support for further development of federated platforms, and neuroinformatics more generally, should be a priority. This update to the 2017 Commission presents new insights and challenges across a range of topics around TBI: epidemiology and prevention (section 1 ); system of care (section 2 ); clinical management (section 3 ); characterisation of TBI (section 4 ); outcome assessment (section 5 ); prognosis (Section 6 ); and new directions for acquiring and implementing evidence (section 7 ). Table 1 summarises key messages from this Commission and proposes recommendations for the way forward to advance research and clinical management of TBI.
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Affiliation(s)
- Andrew I R Maas
- Department of Neurosurgery, Antwerp University Hospital and University of Antwerp, Edegem, Belgium
| | - David K Menon
- Division of Anaesthesia, University of Cambridge, Addenbrooke’s Hospital, Cambridge, UK
| | - Geoffrey T Manley
- Department of Neurological Surgery, University of California, San Francisco, CA, USA
| | - Mathew Abrams
- International Neuroinformatics Coordinating Facility, Karolinska Institutet, Stockholm, Sweden
| | - Cecilia Åkerlund
- Department of Physiology and Pharmacology, Section of Perioperative Medicine and Intensive Care, Karolinska Institutet, Stockholm, Sweden
| | - Nada Andelic
- Division of Clinical Neuroscience, Department of Physical Medicine and Rehabilitation, Oslo University Hospital and University of Oslo, Oslo, Norway
| | - Marcel Aries
- Department of Intensive Care, Maastricht UMC, Maastricht, Netherlands
| | - Tom Bashford
- Division of Anaesthesia, University of Cambridge, Addenbrooke’s Hospital, Cambridge, UK
| | - Michael J Bell
- Critical Care Medicine, Neurological Surgery and Pediatrics, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Yelena G Bodien
- Department of Neurology and Department of Physical Medicine and Rehabilitation, Harvard Medical School, Boston, MA, USA
| | - Benjamin L Brett
- Department of Neurosurgery, Medical College of Wisconsin, Milwaukee, WI, USA
| | - András Büki
- Department of Neurosurgery, Faculty of Medicine and Health Örebro University, Örebro, Sweden
- Department of Neurosurgery, Medical School; ELKH-PTE Clinical Neuroscience MR Research Group; and Neurotrauma Research Group, Janos Szentagothai Research Centre, University of Pecs, Pecs, Hungary
| | - Randall M Chesnut
- Department of Neurological Surgery and Department of Orthopaedics and Sports Medicine, University of Washington, Harborview Medical Center, Seattle, WA, USA
| | - Giuseppe Citerio
- School of Medicine and Surgery, Universita Milano Bicocca, Milan, Italy
- NeuroIntensive Care, San Gerardo Hospital, Azienda Socio Sanitaria Territoriale (ASST) Monza, Monza, Italy
| | - David Clark
- Brain Physics Lab, Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, Addenbrooke’s Hospital, Cambridge, UK
| | - Betony Clasby
- Department of Sociological Studies, University of Sheffield, Sheffield, UK
| | - D Jamie Cooper
- School of Public Health and Preventive Medicine, Monash University and The Alfred Hospital, Melbourne, VIC, Australia
| | - Endre Czeiter
- Department of Neurosurgery, Medical School; ELKH-PTE Clinical Neuroscience MR Research Group; and Neurotrauma Research Group, Janos Szentagothai Research Centre, University of Pecs, Pecs, Hungary
| | - Marek Czosnyka
- Brain Physics Lab, Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, Addenbrooke’s Hospital, Cambridge, UK
| | - Kristen Dams-O’Connor
- Department of Rehabilitation and Human Performance and Department of Neurology, Brain Injury Research Center, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Véronique De Keyser
- Department of Neurosurgery, Antwerp University Hospital and University of Antwerp, Edegem, Belgium
| | - Ramon Diaz-Arrastia
- Department of Neurology and Center for Brain Injury and Repair, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Ari Ercole
- Division of Anaesthesia, University of Cambridge, Addenbrooke’s Hospital, Cambridge, UK
| | - Thomas A van Essen
- Department of Neurosurgery, Leiden University Medical Center, Leiden, Netherlands
- Department of Neurosurgery, Medical Center Haaglanden, The Hague, Netherlands
| | - Éanna Falvey
- College of Medicine and Health, University College Cork, Cork, Ireland
| | - Adam R Ferguson
- Brain and Spinal Injury Center, Department of Neurological Surgery, Weill Institute for Neurosciences, University of California San Francisco and San Francisco Veterans Affairs Healthcare System, San Francisco, CA, USA
| | - Anthony Figaji
- Division of Neurosurgery and Neuroscience Institute, University of Cape Town, Cape Town, South Africa
| | - Melinda Fitzgerald
- Curtin Health Innovation Research Institute, Curtin University, Bentley, WA, Australia
- Perron Institute for Neurological and Translational Sciences, Nedlands, WA, Australia
| | - Brandon Foreman
- Department of Neurology and Rehabilitation Medicine, University of Cincinnati Gardner Neuroscience Institute, University of Cincinnati, Cincinnati, OH, USA
| | - Dashiell Gantner
- School of Public Health and Preventive Medicine, Monash University and The Alfred Hospital, Melbourne, VIC, Australia
| | - Guoyi Gao
- Department of Neurosurgery, Shanghai General Hospital, Shanghai Jiaotong University School of Medicine
| | - Joseph Giacino
- Department of Physical Medicine and Rehabilitation, Harvard Medical School and Spaulding Rehabilitation Hospital, Charlestown, MA, USA
| | - Benjamin Gravesteijn
- Department of Public Health, Erasmus MC University Medical Center Rotterdam, Rotterdam, Netherlands
| | - Fabian Guiza
- Department and Laboratory of Intensive Care Medicine, University Hospitals Leuven and KU Leuven, Leuven, Belgium
| | - Deepak Gupta
- Department of Neurosurgery, Neurosciences Centre and JPN Apex Trauma Centre, All India Institute of Medical Sciences, New Delhi, India
| | - Mark Gurnell
- Metabolic Research Laboratories, Institute of Metabolic Science, University of Cambridge, Cambridge, UK
| | - Juanita A Haagsma
- Department of Public Health, Erasmus MC University Medical Center Rotterdam, Rotterdam, Netherlands
| | - Flora M Hammond
- Department of Physical Medicine and Rehabilitation, Indiana University School of Medicine, Rehabilitation Hospital of Indiana, Indianapolis, IN, USA
| | - Gregory Hawryluk
- Section of Neurosurgery, GB1, Health Sciences Centre, University of Manitoba, Winnipeg, MB, Canada
| | - Peter Hutchinson
- Brain Physics Lab, Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, Addenbrooke’s Hospital, Cambridge, UK
| | - Mathieu van der Jagt
- Department of Intensive Care, Erasmus MC University Medical Center Rotterdam, Rotterdam, Netherlands
| | - Sonia Jain
- Biostatistics Research Center, Herbert Wertheim School of Public Health, University of California, San Diego, CA, USA
| | - Swati Jain
- Brain Physics Lab, Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, Addenbrooke’s Hospital, Cambridge, UK
| | - Ji-yao Jiang
- Department of Neurosurgery, Shanghai Renji Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Hope Kent
- Department of Psychology, University of Exeter, Exeter, UK
| | - Angelos Kolias
- Brain Physics Lab, Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, Addenbrooke’s Hospital, Cambridge, UK
| | - Erwin J O Kompanje
- Department of Intensive Care, Erasmus MC University Medical Center Rotterdam, Rotterdam, Netherlands
| | - Fiona Lecky
- Centre for Urgent and Emergency Care Research, Health Services Research Section, School of Health and Related Research, University of Sheffield, Sheffield, UK
| | - Hester F Lingsma
- Department of Public Health, Erasmus MC University Medical Center Rotterdam, Rotterdam, Netherlands
| | - Marc Maegele
- Cologne-Merheim Medical Center, Department of Trauma and Orthopedic Surgery, Witten/Herdecke University, Cologne, Germany
| | - Marek Majdan
- Institute for Global Health and Epidemiology, Department of Public Health, Faculty of Health Sciences and Social Work, Trnava University, Trnava, Slovakia
| | - Amy Markowitz
- Department of Neurological Surgery, University of California, San Francisco, CA, USA
| | - Michael McCrea
- Department of Neurosurgery and Neurology, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Geert Meyfroidt
- Department and Laboratory of Intensive Care Medicine, University Hospitals Leuven and KU Leuven, Leuven, Belgium
| | - Ana Mikolić
- Department of Public Health, Erasmus MC University Medical Center Rotterdam, Rotterdam, Netherlands
| | - Stefania Mondello
- Department of Biomedical and Dental Sciences and Morphofunctional Imaging, University of Messina, Messina, Italy
| | - Pratik Mukherjee
- Department of Radiology and Biomedical Imaging, University of California San Francisco, San Francisco, CA, USA
| | - David Nelson
- Section for Anesthesiology and Intensive Care, Department of Physiology and Pharmacology, Karolinska Institutet, Stockholm, Sweden
| | - Lindsay D Nelson
- Department of Neurosurgery and Neurology, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Virginia Newcombe
- Division of Anaesthesia, University of Cambridge, Addenbrooke’s Hospital, Cambridge, UK
| | - David Okonkwo
- Department of Neurological Surgery, University of Pittsburgh, Pittsburgh, PA, USA
| | - Matej Orešič
- School of Medical Sciences, Örebro University, Örebro, Sweden
| | - Wilco Peul
- Department of Neurosurgery, Leiden University Medical Center, Leiden, Netherlands
| | - Dana Pisică
- Department of Public Health, Erasmus MC University Medical Center Rotterdam, Rotterdam, Netherlands
- Department of Neurosurgery, Erasmus MC University Medical Center Rotterdam, Rotterdam, Netherlands
| | - Suzanne Polinder
- Department of Public Health, Erasmus MC University Medical Center Rotterdam, Rotterdam, Netherlands
| | - Jennie Ponsford
- Monash-Epworth Rehabilitation Research Centre, Turner Institute for Brain and Mental Health, School of Psychological Sciences, Monash University, Melbourne, VIC, Australia
| | - Louis Puybasset
- Department of Anesthesiology and Intensive Care, APHP, Sorbonne Université, Hôpital Pitié-Salpêtrière, Paris, France
| | - Rahul Raj
- Department of Neurosurgery, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Chiara Robba
- Department of Anaesthesia and Intensive Care, Policlinico San Martino IRCCS for Oncology and Neuroscience, Genova, Italy, and Dipartimento di Scienze Chirurgiche e Diagnostiche, University of Genoa, Italy
| | - Cecilie Røe
- Division of Clinical Neuroscience, Department of Physical Medicine and Rehabilitation, Oslo University Hospital and University of Oslo, Oslo, Norway
| | - Jonathan Rosand
- Center for Genomic Medicine, Massachusetts General Hospital, Boston, MA, USA
| | | | - David J Sharp
- Department of Brain Sciences, Imperial College London, London, UK
| | - Peter Smielewski
- Brain Physics Lab, Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, Addenbrooke’s Hospital, Cambridge, UK
| | - Murray B Stein
- Department of Psychiatry and Department of Family Medicine and Public Health, UCSD School of Medicine, La Jolla, CA, USA
| | - Nicole von Steinbüchel
- Institute of Medical Psychology and Medical Sociology, University Medical Center Goettingen, Goettingen, Germany
| | - William Stewart
- Department of Neuropathology, Queen Elizabeth University Hospital and University of Glasgow, Glasgow, UK
| | - Ewout W Steyerberg
- Department of Biomedical Data Sciences Leiden University Medical Center, Leiden, Netherlands
| | - Nino Stocchetti
- Department of Pathophysiology and Transplantation, Milan University, and Neuroscience ICU, Fondazione IRCCS Ca Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Nancy Temkin
- Departments of Neurological Surgery, and Biostatistics, University of Washington, Seattle, WA, USA
| | - Olli Tenovuo
- Department of Rehabilitation and Brain Trauma, Turku University Hospital, and Department of Neurology, University of Turku, Turku, Finland
| | - Alice Theadom
- National Institute for Stroke and Applied Neurosciences, Faculty of Health and Environmental Studies, Auckland University of Technology, Auckland, New Zealand
| | - Ilias Thomas
- School of Medical Sciences, Örebro University, Örebro, Sweden
| | - Abel Torres Espin
- Department of Neurological Surgery, University of California, San Francisco, CA, USA
| | - Alexis F Turgeon
- Department of Anesthesiology and Critical Care Medicine, Division of Critical Care Medicine, Université Laval, CHU de Québec-Université Laval Research Center, Québec City, QC, Canada
| | - Andreas Unterberg
- Department of Neurosurgery, Heidelberg University Hospital, Heidelberg, Germany
| | - Dominique Van Praag
- Departments of Clinical Psychology and Neurosurgery, Antwerp University Hospital, and University of Antwerp, Edegem, Belgium
| | - Ernest van Veen
- Department of Public Health, Erasmus MC University Medical Center Rotterdam, Rotterdam, Netherlands
| | | | - Thijs Vande Vyvere
- Department of Radiology, Faculty of Medicine and Health Sciences, Department of Rehabilitation Sciences (MOVANT), Antwerp University Hospital, and University of Antwerp, Edegem, Belgium
| | - Kevin K W Wang
- Department of Psychiatry, University of Florida, Gainesville, FL, USA
| | - Eveline J A Wiegers
- Department of Public Health, Erasmus MC University Medical Center Rotterdam, Rotterdam, Netherlands
| | - W Huw Williams
- Centre for Clinical Neuropsychology Research, Department of Psychology, University of Exeter, Exeter, UK
| | - Lindsay Wilson
- Division of Psychology, University of Stirling, Stirling, UK
| | - Stephen R Wisniewski
- University of Pittsburgh Graduate School of Public Health, Pittsburgh, Pennsylvania, USA
| | - Alexander Younsi
- Department of Neurosurgery, Heidelberg University Hospital, Heidelberg, Germany
| | - John K Yue
- Department of Neurological Surgery, University of California, San Francisco, CA, USA
| | - Esther L Yuh
- Department of Radiology and Biomedical Imaging, University of California San Francisco, San Francisco, CA, USA
| | - Frederick A Zeiler
- Departments of Surgery, Human Anatomy and Cell Science, and Biomedical Engineering, Rady Faculty of Health Sciences and Price Faculty of Engineering, University of Manitoba, Winnipeg, MB, Canada
| | - Marina Zeldovich
- Institute of Medical Psychology and Medical Sociology, University Medical Center Goettingen, Goettingen, Germany
| | - Roger Zemek
- Departments of Pediatrics and Emergency Medicine, University of Ottawa, Children’s Hospital of Eastern Ontario, ON, Canada
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Cairncross M, Gindwani H, Rita Egbert A, Torres IJ, Hutchison JS, Dams O'Connor K, Panenka WJ, Brubacher JR, Meddings L, Kwan L, Yeates KO, Green R, Silverberg ND. Criterion validity of the brief test of adult cognition by telephone (BTACT) for mild traumatic brain injury. Brain Inj 2022; 36:1228-1236. [PMID: 36099151 DOI: 10.1080/02699052.2022.2109744] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
OBJECTIVES There is a growing demand for remote assessment options for measuring cognition after mild traumatic brain injury (mTBI). The current study evaluated the criterion validity of the Brief Test of Adult Cognition by Telephone (BTACT) in distinguishing between adults with mTBI and trauma controls (TC) who sustained injuries not involving the head or neck. METHODS The BTACT was administered to the mTBI (n = 46) and TC (n = 35) groups at 1-2 weeks post-injury. Participants also completed the Rivermead Post Concussion Symptoms Questionnaire. RESULTS The BTACT global composite score did not significantly differ between the groups (t(79) = -1.04, p = 0.30); the effect size was small (d = 0.23). In receiver operating characteristic curve analyses, the BTACT demonstrated poor accuracy in differentiating between the groups (AUC = 0.567, SE = 0.065, 95% CI [0.44, 0.69]). The BTACT's ability to discriminate between mTBI and TCs did not improve after excluding mTBI participants (n = 15) who denied ongoing cognitive symptoms (AUC = 0.567, SE = 0.072, 95% CI [0.43, 0.71]). CONCLUSIONS The BTACT may lack sensitivity to subacute cognitive impairment attributable to mTBI (i.e., not explained by bodily pain, post-traumatic stress, and other nonspecific effects of injury).
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Affiliation(s)
- Molly Cairncross
- Rehabilitation Research Program, Vancouver Coastal Health Research Institute, Vancouver, Canada.,Department of Psychology, University of British Columbia, Vancouver, Canada.,Department of Psychology, Simon Fraser University, Vancouver, Canada
| | - Hiresh Gindwani
- Rehabilitation Research Program, Vancouver Coastal Health Research Institute, Vancouver, Canada.,Division of Physical Medicine & Rehabilitation, University of British Columbia, Vancouver, Canada
| | - Anna Rita Egbert
- Faculty of Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Ivan J Torres
- Department of Psychiatry, University of British Columbia, Vancouver, Canada.,British Columbia Mental Health and Substance Use Services Research Institute; Vancouver, Canada
| | - James S Hutchison
- Department of Critical Care and Neuroscience and Mental Health Research Program, The Hospital for Sick Children, the Institute for Medical Science and the Interdepartmental Division of Critical Care, University of Toronto, Toronto, Canada
| | - Kristen Dams O'Connor
- Department of Rehabilitation Medicine, Department of Neurology, Icahn School of Medicine at Mount Sinai
| | - William J Panenka
- Department of Psychiatry, University of British Columbia, Vancouver, Canada.,British Columbia Mental Health and Substance Use Services Research Institute; Vancouver, Canada
| | - Jeffrey R Brubacher
- Department of Emergency Medicine, Faculty of Medicine, The University of British Columbia, Vancouver, Canada
| | - Louise Meddings
- Faculty of Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Lexynn Kwan
- Division of Physical Medicine & Rehabilitation, University of British Columbia, Vancouver, Canada
| | - Keith O Yeates
- Department of Psychology, Alberta Children's Hospital Research Institute, and Hotchkiss Brain Institute, University of Calgary, Calgary, AB, Canada
| | - Robin Green
- KITE, Toronto Rehabilitation Institute, University Health Network, Toronto, Canada.,Department of Psychiatry, University of Toronto, Toronto, Canada
| | - Noah D Silverberg
- Rehabilitation Research Program, Vancouver Coastal Health Research Institute, Vancouver, Canada.,Department of Psychology, University of British Columbia, Vancouver, Canada.,Division of Physical Medicine & Rehabilitation, University of British Columbia, Vancouver, Canada
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Cognitive performance in older people after mild traumatic brain injury: Trauma effects and other risk factors. J Int Neuropsychol Soc 2022:1-11. [PMID: 36102332 DOI: 10.1017/s1355617722000674] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Cognitive symptoms are common in the initial weeks after mTBI, but recovery is generally expected within three months. However, there is limited information about recovery specifically in older age cohorts. Therefore, this study investigated cognitive outcome three months after mTBI in older adults (≥ 65 years) compared to trauma and community age-matched controls and explored risk factors for outcome after traumatic injury. METHODS Older mTBI patients (n = 40) and older adults with mild traumatic injury but without head injury (n = 66) were compared to a noninjured community control group (n = 47). Cognitive assessment included neuropsychological and computerized tests. Group differences were compared on individual tasks and overall cognitive performances using composite scores. Regression analyses identified predictors of outcome for trauma patients and moderator analyses explored possible interactions of mTBI severity with age and cognition. RESULTS As well as lower performances in processing speed and memory, both trauma groups had significantly lower performance on composite neuropsychological (d = .557 and .670) and computerized tasks (d = .783 and .824) compared to noninjured controls. Age, education, and history of depression were direct predictors of cognitive performance after mild traumatic injury (with or without head injury). Further moderation analysis demonstrated that mTBI severity (Glasgow Coma Scale < 15) moderated the impact of older age on computerized assessment (β = -.138). CONCLUSIONS Three months after mild trauma (regardless of head injury), older people demonstrate lower cognition compared to noninjured peers. However, severity of mTBI (Glasgow Coma Scale < 15) can interact with older age to predict poorer cognitive outcomes.
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Abstract
OBJECTIVE Older age is often identified as a risk factor for poor outcome from traumatic brain injury (TBI). However, this relates predominantly to mortality following moderate-severe TBI. It remains unclear whether increasing age exerts risk on the expected recovery from mild TBI (mTBI). In this systematic review of mTBI in older age (60+ years), a focus was to identify outcome through several domains - cognition, psychological health, and life participation. METHODS Fourteen studies were identified for review, using PRISMA guidelines. Narrative synthesis is provided for all outcomes, from acute to long-term time points, and a meta-analysis was conducted for data investigating life participation. RESULTS By 3-month follow-up, preliminary findings indicate that older adults continue to experience selective cognitive difficulties, but given the data it is possible these difficulties are due to generalised trauma or preexisting cognitive impairment. In contrast, there is stronger evidence across time points that older adults do not experience elevated levels of psychological distress following injury and endorse fewer psychological symptoms than younger adults. Meta-analysis, based on the Glasgow Outcome Scale at 6 months+ post-injury, indicates that a large proportion (67%; 95% CI 0.569, 0.761) of older adults can achieve good functional recovery, similar to younger adults. Nevertheless, individual studies using alternative life participation measures suggest more mixed rates of recovery. CONCLUSIONS Although our initial review suggests some optimism in recovery from mTBI in older age, there is an urgent need for more investigations in this under-researched but growing demographic. This is critical for ensuring adequate health service provision, if needed.
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Hood AM, Crosby LE, Stotesbury H, Kölbel M, Kirkham FJ. Considerations for Selecting Cognitive Endpoints and Psychological Patient-Reported Outcomes for Clinical Trials in Pediatric Patients With Sickle Cell Disease. Front Neurol 2022; 13:835823. [PMID: 35800079 PMCID: PMC9253275 DOI: 10.3389/fneur.2022.835823] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2021] [Accepted: 05/20/2022] [Indexed: 12/04/2022] Open
Abstract
Pediatric patients with sickle cell disease (SCD) experience a range of medical complications that result in significant morbidity and mortality. Recent advances in prophylactic and curative treatment approaches have highlighted the need for sensitive and clinically-meaningful trial endpoints. The detrimental effects of cognitive and psychological difficulties on social and economic mobility are well described. Although numerous reviews have assessed cognitive outcomes in other rare genetic disorders, SCD has not received the same focus. This review describes the cognitive (i.e., executive function and processing speed) and psychological domains (i.e., depression and anxiety) that are consistently associated with SCD pathology and, therefore, may be of particular interest as clinical trial endpoints. We then discuss corresponding well-validated and reliable cognitive tests and patient-reported outcomes (PROs) that may be appropriate for clinical trials given their robust psychometric properties, ease of administration, and previous use in the SCD population. Further, we provide a discussion of potential pitfalls and considerations to guide endpoint selection. In line with the move toward patient-centered medicine, we identify specific tests (e.g., NIH Toolbox Cognition Module, Wechsler Cancellation Test) and psychological PROs (e.g., PROMIS depression and anxiety scales) that are sensitive to SCD morbidity and have the potential to capture changes that are clinically meaningful in the context of patients' day to day lives. In particularly vulnerable cognitive domains, such as executive function, we highlight the advantages of composite over single-test scores within the context of trials. We also identify general (i.e., practice effects, disease heterogeneity) and SCD-specific considerations (i.e., genotype, treatment course, and disease course, including degree of neurologic, pain, and sleep morbidity) for trial measures. Executive function composites hold particular promise as trial endpoints that are clinically meaningful, amenable to change, relatively easy to collect, and can be incorporated into the routine care of patients with SCD in various settings and countries.
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Affiliation(s)
- Anna M. Hood
- Division of Psychology and Mental Health, Manchester Centre for Health Psychology, University of Manchester, Manchester, United Kingdom
| | - Lori E. Crosby
- Division of Behavioral Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, United States
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, United States
- James M. Anderson Center for Health Systems Excellence, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, United States
| | - Hanne Stotesbury
- Developmental Neurosciences Unit and Biomedical Research Centre, University College London Great Ormond Street Institute of Child Health, London, United Kingdom
| | - Melanie Kölbel
- Developmental Neurosciences Unit and Biomedical Research Centre, University College London Great Ormond Street Institute of Child Health, London, United Kingdom
| | - Fenella J. Kirkham
- Developmental Neurosciences Unit and Biomedical Research Centre, University College London Great Ormond Street Institute of Child Health, London, United Kingdom
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11
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Schneider ALC, Huie JR, Boscardin WJ, Nelson L, Barber JK, Yaffe K, Diaz-Arrastia R, Ferguson AR, Kramer J, Jain S, Temkin N, Yuh E, Manley GT, Gardner RC. Cognitive Outcome 1 Year After Mild Traumatic Brain Injury: Results From the TRACK-TBI Study. Neurology 2022; 98:e1248-e1261. [PMID: 35173018 PMCID: PMC8967334 DOI: 10.1212/wnl.0000000000200041] [Citation(s) in RCA: 29] [Impact Index Per Article: 14.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2021] [Accepted: 01/03/2022] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND AND OBJECTIVES The objectives of this study were to develop and establish concurrent validity of a clinically relevant definition of poor cognitive outcome 1 year after mild traumatic brain injury (mTBI), to compare baseline characteristics across cognitive outcome groups, and to determine whether poor 1-year cognitive outcome can be predicted by routinely available baseline clinical variables. METHODS Prospective cohort study included 656 participants ≥17 years of age presenting to level 1 trauma centers within 24 hours of mTBI (Glasgow Coma Scale score 13-15) and 156 demographically similar healthy controls enrolled in the Transforming Research and Clinical Knowledge in TBI (TRACK-TBI) study. Poor 1-year cognitive outcome was defined as cognitive impairment (below the ninth percentile of normative data on ≥2 cognitive tests), cognitive decline (change score [1-year score minus best 2-week or 6-month score] exceeding the 90% reliable change index on ≥2 cognitive tests), or both. Associations of poor 1-year cognitive outcome with 1-year neurobehavioral outcomes were performed to establish concurrent validity. Baseline characteristics were compared across cognitive outcome groups, and backward elimination logistic regression was used to build a prediction model. RESULTS Mean age of participants with mTBI was 40.2 years; 36.6% were female; 76.6% were White. Poor 1-year cognitive outcome was associated with worse 1-year functional outcome, more neurobehavioral symptoms, greater psychological distress, and lower satisfaction with life (all p < 0.05), establishing concurrent validity. At 1 year, 13.5% of participants with mTBI had a poor cognitive outcome vs 4.5% of controls (p = 0.003). In univariable analyses, poor 1-year cognitive outcome was associated with non-White race, lower education, lower income, lack of health insurance, hyperglycemia, preinjury depression, and greater injury severity (all p < 0.05). The final multivariable prediction model included education, health insurance, preinjury depression, hyperglycemia, and Rotterdam CT score ≥3 and achieved an area under the curve of 0.69 (95% CI 0.62-0.75) for the prediction of a poor 1-year cognitive outcome, with each variable associated with >2-fold increased odds of poor 1-year cognitive outcome. DISCUSSION Poor 1-year cognitive outcome is common, affecting 13.5% of patients with mTBI vs 4.5% of controls. These results highlight the need for better understanding of mechanisms underlying poor cognitive outcome after mTBI to inform interventions to optimize cognitive recovery.
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Affiliation(s)
- Andrea L C Schneider
- From the Department of Neurology (A.L.C.S., R.D.-A.), University of Pennsylvania Perelman School of Medicine, Philadelphia; Departments of Neurosurgery (J.R.H., A.R.F., G.T.M.), Epidemiology and Biostatistics (W.J.B., K.Y.), Neurology (K.Y., J.K., R.C.G.), Psychiatry (K.Y.), and Radiology and Biomedical Imaging (E.Y.), University of California San Francisco; Department of Neurosurgery (L.N.), Medical College of Wisconsin, Madison; Departments of Neurological Surgery (J.K.B., N.T.) and Biostatistics (N.T.), University of Washington, Seattle; and Biostatistics Research Center (S.J.), Herbert Wertheim School of Public Health and Human Longevity Science, University of California San Diego, La Jolla
| | - J Russell Huie
- From the Department of Neurology (A.L.C.S., R.D.-A.), University of Pennsylvania Perelman School of Medicine, Philadelphia; Departments of Neurosurgery (J.R.H., A.R.F., G.T.M.), Epidemiology and Biostatistics (W.J.B., K.Y.), Neurology (K.Y., J.K., R.C.G.), Psychiatry (K.Y.), and Radiology and Biomedical Imaging (E.Y.), University of California San Francisco; Department of Neurosurgery (L.N.), Medical College of Wisconsin, Madison; Departments of Neurological Surgery (J.K.B., N.T.) and Biostatistics (N.T.), University of Washington, Seattle; and Biostatistics Research Center (S.J.), Herbert Wertheim School of Public Health and Human Longevity Science, University of California San Diego, La Jolla
| | - W John Boscardin
- From the Department of Neurology (A.L.C.S., R.D.-A.), University of Pennsylvania Perelman School of Medicine, Philadelphia; Departments of Neurosurgery (J.R.H., A.R.F., G.T.M.), Epidemiology and Biostatistics (W.J.B., K.Y.), Neurology (K.Y., J.K., R.C.G.), Psychiatry (K.Y.), and Radiology and Biomedical Imaging (E.Y.), University of California San Francisco; Department of Neurosurgery (L.N.), Medical College of Wisconsin, Madison; Departments of Neurological Surgery (J.K.B., N.T.) and Biostatistics (N.T.), University of Washington, Seattle; and Biostatistics Research Center (S.J.), Herbert Wertheim School of Public Health and Human Longevity Science, University of California San Diego, La Jolla
| | - Lindsay Nelson
- From the Department of Neurology (A.L.C.S., R.D.-A.), University of Pennsylvania Perelman School of Medicine, Philadelphia; Departments of Neurosurgery (J.R.H., A.R.F., G.T.M.), Epidemiology and Biostatistics (W.J.B., K.Y.), Neurology (K.Y., J.K., R.C.G.), Psychiatry (K.Y.), and Radiology and Biomedical Imaging (E.Y.), University of California San Francisco; Department of Neurosurgery (L.N.), Medical College of Wisconsin, Madison; Departments of Neurological Surgery (J.K.B., N.T.) and Biostatistics (N.T.), University of Washington, Seattle; and Biostatistics Research Center (S.J.), Herbert Wertheim School of Public Health and Human Longevity Science, University of California San Diego, La Jolla
| | - Jason K Barber
- From the Department of Neurology (A.L.C.S., R.D.-A.), University of Pennsylvania Perelman School of Medicine, Philadelphia; Departments of Neurosurgery (J.R.H., A.R.F., G.T.M.), Epidemiology and Biostatistics (W.J.B., K.Y.), Neurology (K.Y., J.K., R.C.G.), Psychiatry (K.Y.), and Radiology and Biomedical Imaging (E.Y.), University of California San Francisco; Department of Neurosurgery (L.N.), Medical College of Wisconsin, Madison; Departments of Neurological Surgery (J.K.B., N.T.) and Biostatistics (N.T.), University of Washington, Seattle; and Biostatistics Research Center (S.J.), Herbert Wertheim School of Public Health and Human Longevity Science, University of California San Diego, La Jolla
| | - Kristine Yaffe
- From the Department of Neurology (A.L.C.S., R.D.-A.), University of Pennsylvania Perelman School of Medicine, Philadelphia; Departments of Neurosurgery (J.R.H., A.R.F., G.T.M.), Epidemiology and Biostatistics (W.J.B., K.Y.), Neurology (K.Y., J.K., R.C.G.), Psychiatry (K.Y.), and Radiology and Biomedical Imaging (E.Y.), University of California San Francisco; Department of Neurosurgery (L.N.), Medical College of Wisconsin, Madison; Departments of Neurological Surgery (J.K.B., N.T.) and Biostatistics (N.T.), University of Washington, Seattle; and Biostatistics Research Center (S.J.), Herbert Wertheim School of Public Health and Human Longevity Science, University of California San Diego, La Jolla
| | - Ramon Diaz-Arrastia
- From the Department of Neurology (A.L.C.S., R.D.-A.), University of Pennsylvania Perelman School of Medicine, Philadelphia; Departments of Neurosurgery (J.R.H., A.R.F., G.T.M.), Epidemiology and Biostatistics (W.J.B., K.Y.), Neurology (K.Y., J.K., R.C.G.), Psychiatry (K.Y.), and Radiology and Biomedical Imaging (E.Y.), University of California San Francisco; Department of Neurosurgery (L.N.), Medical College of Wisconsin, Madison; Departments of Neurological Surgery (J.K.B., N.T.) and Biostatistics (N.T.), University of Washington, Seattle; and Biostatistics Research Center (S.J.), Herbert Wertheim School of Public Health and Human Longevity Science, University of California San Diego, La Jolla
| | - Adam R Ferguson
- From the Department of Neurology (A.L.C.S., R.D.-A.), University of Pennsylvania Perelman School of Medicine, Philadelphia; Departments of Neurosurgery (J.R.H., A.R.F., G.T.M.), Epidemiology and Biostatistics (W.J.B., K.Y.), Neurology (K.Y., J.K., R.C.G.), Psychiatry (K.Y.), and Radiology and Biomedical Imaging (E.Y.), University of California San Francisco; Department of Neurosurgery (L.N.), Medical College of Wisconsin, Madison; Departments of Neurological Surgery (J.K.B., N.T.) and Biostatistics (N.T.), University of Washington, Seattle; and Biostatistics Research Center (S.J.), Herbert Wertheim School of Public Health and Human Longevity Science, University of California San Diego, La Jolla
| | - Joel Kramer
- From the Department of Neurology (A.L.C.S., R.D.-A.), University of Pennsylvania Perelman School of Medicine, Philadelphia; Departments of Neurosurgery (J.R.H., A.R.F., G.T.M.), Epidemiology and Biostatistics (W.J.B., K.Y.), Neurology (K.Y., J.K., R.C.G.), Psychiatry (K.Y.), and Radiology and Biomedical Imaging (E.Y.), University of California San Francisco; Department of Neurosurgery (L.N.), Medical College of Wisconsin, Madison; Departments of Neurological Surgery (J.K.B., N.T.) and Biostatistics (N.T.), University of Washington, Seattle; and Biostatistics Research Center (S.J.), Herbert Wertheim School of Public Health and Human Longevity Science, University of California San Diego, La Jolla
| | - Sonia Jain
- From the Department of Neurology (A.L.C.S., R.D.-A.), University of Pennsylvania Perelman School of Medicine, Philadelphia; Departments of Neurosurgery (J.R.H., A.R.F., G.T.M.), Epidemiology and Biostatistics (W.J.B., K.Y.), Neurology (K.Y., J.K., R.C.G.), Psychiatry (K.Y.), and Radiology and Biomedical Imaging (E.Y.), University of California San Francisco; Department of Neurosurgery (L.N.), Medical College of Wisconsin, Madison; Departments of Neurological Surgery (J.K.B., N.T.) and Biostatistics (N.T.), University of Washington, Seattle; and Biostatistics Research Center (S.J.), Herbert Wertheim School of Public Health and Human Longevity Science, University of California San Diego, La Jolla
| | - Nancy Temkin
- From the Department of Neurology (A.L.C.S., R.D.-A.), University of Pennsylvania Perelman School of Medicine, Philadelphia; Departments of Neurosurgery (J.R.H., A.R.F., G.T.M.), Epidemiology and Biostatistics (W.J.B., K.Y.), Neurology (K.Y., J.K., R.C.G.), Psychiatry (K.Y.), and Radiology and Biomedical Imaging (E.Y.), University of California San Francisco; Department of Neurosurgery (L.N.), Medical College of Wisconsin, Madison; Departments of Neurological Surgery (J.K.B., N.T.) and Biostatistics (N.T.), University of Washington, Seattle; and Biostatistics Research Center (S.J.), Herbert Wertheim School of Public Health and Human Longevity Science, University of California San Diego, La Jolla
| | - Esther Yuh
- From the Department of Neurology (A.L.C.S., R.D.-A.), University of Pennsylvania Perelman School of Medicine, Philadelphia; Departments of Neurosurgery (J.R.H., A.R.F., G.T.M.), Epidemiology and Biostatistics (W.J.B., K.Y.), Neurology (K.Y., J.K., R.C.G.), Psychiatry (K.Y.), and Radiology and Biomedical Imaging (E.Y.), University of California San Francisco; Department of Neurosurgery (L.N.), Medical College of Wisconsin, Madison; Departments of Neurological Surgery (J.K.B., N.T.) and Biostatistics (N.T.), University of Washington, Seattle; and Biostatistics Research Center (S.J.), Herbert Wertheim School of Public Health and Human Longevity Science, University of California San Diego, La Jolla
| | - Geoffrey T Manley
- From the Department of Neurology (A.L.C.S., R.D.-A.), University of Pennsylvania Perelman School of Medicine, Philadelphia; Departments of Neurosurgery (J.R.H., A.R.F., G.T.M.), Epidemiology and Biostatistics (W.J.B., K.Y.), Neurology (K.Y., J.K., R.C.G.), Psychiatry (K.Y.), and Radiology and Biomedical Imaging (E.Y.), University of California San Francisco; Department of Neurosurgery (L.N.), Medical College of Wisconsin, Madison; Departments of Neurological Surgery (J.K.B., N.T.) and Biostatistics (N.T.), University of Washington, Seattle; and Biostatistics Research Center (S.J.), Herbert Wertheim School of Public Health and Human Longevity Science, University of California San Diego, La Jolla
| | - Raquel C Gardner
- From the Department of Neurology (A.L.C.S., R.D.-A.), University of Pennsylvania Perelman School of Medicine, Philadelphia; Departments of Neurosurgery (J.R.H., A.R.F., G.T.M.), Epidemiology and Biostatistics (W.J.B., K.Y.), Neurology (K.Y., J.K., R.C.G.), Psychiatry (K.Y.), and Radiology and Biomedical Imaging (E.Y.), University of California San Francisco; Department of Neurosurgery (L.N.), Medical College of Wisconsin, Madison; Departments of Neurological Surgery (J.K.B., N.T.) and Biostatistics (N.T.), University of Washington, Seattle; and Biostatistics Research Center (S.J.), Herbert Wertheim School of Public Health and Human Longevity Science, University of California San Diego, La Jolla.
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12
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Cruz Navarro J, Ponce Mejia LL, Robertson C. A Precision Medicine Agenda in Traumatic Brain Injury. Front Pharmacol 2022; 13:713100. [PMID: 35370671 PMCID: PMC8966615 DOI: 10.3389/fphar.2022.713100] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2021] [Accepted: 02/25/2022] [Indexed: 11/13/2022] Open
Abstract
Traumatic brain injury remains a leading cause of death and disability across the globe. Substantial uncertainty in outcome prediction continues to be the rule notwithstanding the existing prediction models. Additionally, despite very promising preclinical data, randomized clinical trials (RCTs) of neuroprotective strategies in moderate and severe TBI have failed to demonstrate significant treatment effects. Better predictive models are needed, as the existing validated ones are more useful in prognosticating poor outcome and do not include biomarkers, genomics, proteonomics, metabolomics, etc. Invasive neuromonitoring long believed to be a "game changer" in the care of TBI patients have shown mixed results, and the level of evidence to support its widespread use remains insufficient. This is due in part to the extremely heterogenous nature of the disease regarding its etiology, pathology and severity. Currently, the diagnosis of traumatic brain injury (TBI) in the acute setting is centered on neurological examination and neuroimaging tools such as CT scanning and MRI, and its treatment has been largely confronted using a "one-size-fits-all" approach, that has left us with many unanswered questions. Precision medicine is an innovative approach for TBI treatment that considers individual variability in genes, environment, and lifestyle and has expanded across the medical fields. In this article, we briefly explore the field of precision medicine in TBI including biomarkers for therapeutic decision-making, multimodal neuromonitoring, and genomics.
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Affiliation(s)
- Jovany Cruz Navarro
- Departments of Anesthesiology and Neurosurgery, Baylor College of Medicine, Houston, TX, United States
| | - Lucido L. Ponce Mejia
- Departments of Neurosurgery and Neurology, LSU Health Science Center, New Orleans, LA, United States
| | - Claudia Robertson
- Department of Neurosurgery, Baylor College of Medicine, Houston, TX, United States
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13
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Dennis EL, Baron D, Bartnik‐Olson B, Caeyenberghs K, Esopenko C, Hillary FG, Kenney K, Koerte IK, Lin AP, Mayer AR, Mondello S, Olsen A, Thompson PM, Tate DF, Wilde EA. ENIGMA brain injury: Framework, challenges, and opportunities. Hum Brain Mapp 2022; 43:149-166. [PMID: 32476212 PMCID: PMC8675432 DOI: 10.1002/hbm.25046] [Citation(s) in RCA: 28] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2019] [Revised: 04/23/2020] [Accepted: 05/03/2020] [Indexed: 12/19/2022] Open
Abstract
Traumatic brain injury (TBI) is a major cause of disability worldwide, but the heterogeneous nature of TBI with respect to injury severity and health comorbidities make patient outcome difficult to predict. Injury severity accounts for only some of this variance, and a wide range of preinjury, injury-related, and postinjury factors may influence outcome, such as sex, socioeconomic status, injury mechanism, and social support. Neuroimaging research in this area has generally been limited by insufficient sample sizes. Additionally, development of reliable biomarkers of mild TBI or repeated subconcussive impacts has been slow, likely due, in part, to subtle effects of injury and the aforementioned variability. The ENIGMA Consortium has established a framework for global collaboration that has resulted in the largest-ever neuroimaging studies of multiple psychiatric and neurological disorders. Here we describe the organization, recent progress, and future goals of the Brain Injury working group.
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Affiliation(s)
- Emily L. Dennis
- Department of NeurologyUniversity of Utah School of MedicineSalt Lake CityUtahUSA
- George E. Wahlen Veterans Affairs Medical CenterSalt Lake CityUtahUSA
- Imaging Genetics CenterStevens Neuroimaging & Informatics Institute, Keck School of Medicine of USCMarina del ReyCaliforniaUSA
| | - David Baron
- Western University of Health SciencesPomonaCaliforniaUSA
| | - Brenda Bartnik‐Olson
- Department of RadiologyLoma Linda University Medical CenterLoma LindaCaliforniaUSA
| | - Karen Caeyenberghs
- Cognitive Neuroscience Unit, School of PsychologyDeakin UniversityBurwoodVictoriaAustralia
| | - Carrie Esopenko
- Department of Rehabilitation and Movement SciencesRutgers Biomedical Health SciencesNewarkNew JerseyUSA
| | - Frank G. Hillary
- Department of PsychologyPennsylvania State UniversityUniversity ParkPennsylvaniaUSA
- Social Life and Engineering Sciences Imaging CenterUniversity ParkPennsylvaniaUSA
| | - Kimbra Kenney
- Department of NeurologyUniformed Services University of the Health SciencesBethesdaMarylandUSA
- National Intrepid Center of ExcellenceWalter Reed National Military Medical CenterBethesdaMarylandUSA
| | - Inga K. Koerte
- Psychiatry Neuroimaging LaboratoryBrigham and Women's HospitalBostonMassachusettsUSA
- Department of Child and Adolescent Psychiatry, Psychosomatics and PsychotherapyLudwig‐Maximilians‐UniversitätMunichGermany
| | - Alexander P. Lin
- Center for Clinical SpectroscopyBrigham and Women's Hospital, Harvard Medical SchoolBostonMassachusettsUSA
| | - Andrew R. Mayer
- Mind Research NetworkAlbuquerqueNew MexicoUSA
- Department of Neurology and PsychiatryUniversity of New Mexico School of MedicineAlbuquerqueNew MexicoUSA
| | - Stefania Mondello
- Department of Biomedical and Dental Sciences and Morphofunctional ImagingUniversity of MessinaMessinaItaly
| | - Alexander Olsen
- Department of PsychologyNorwegian University of Science and TechnologyTrondheimNorway
- Department of Physical Medicine and RehabilitationSt. Olavs Hospital, Trondheim University HospitalTrondheimNorway
| | - Paul M. Thompson
- Imaging Genetics CenterStevens Neuroimaging & Informatics Institute, Keck School of Medicine of USCMarina del ReyCaliforniaUSA
- Department of Neurology, Pediatrics, Psychiatry, Radiology, Engineering, and OphthalmologyUniversity of Southern California (USC)Los AngelesCaliforniaUSA
| | - David F. Tate
- Department of NeurologyUniversity of Utah School of MedicineSalt Lake CityUtahUSA
- George E. Wahlen Veterans Affairs Medical CenterSalt Lake CityUtahUSA
| | - Elisabeth A. Wilde
- Department of NeurologyUniversity of Utah School of MedicineSalt Lake CityUtahUSA
- George E. Wahlen Veterans Affairs Medical CenterSalt Lake CityUtahUSA
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14
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Psychoeducation as Precision Health in Military-Related Mild Traumatic Brain Injury. Arch Phys Med Rehabil 2021; 103:1222-1232. [PMID: 34516996 DOI: 10.1016/j.apmr.2021.08.012] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2021] [Revised: 07/13/2021] [Accepted: 08/17/2021] [Indexed: 11/21/2022]
Abstract
A significant proportion of Service Members and Veterans (SMVs) experience at least 1 mild traumatic brain injury during military activities (mil-mTBI), which can result in enduring cognitive symptoms. Although multiple cognitive rehabilitation (CR) interventions have been developed for this population, patient psychoeducation focusing on biopsychosocial relationships and health behaviors is often cited as the first line of defense for mil-mTBI sequelae. However, theoretical and conceptual foundations of these psychoeducational techniques are not well articulated. This raises questions about the potency of attempts to boost health literacy in affected SMVs, who represent a highly heterogeneous patient population within a special cultural milieu. To elucidate the significance of this problem and identify opportunities for improvement, we view the psychoeducation of SMVs through the lens of educational principles described in serious mental illness, where "psychoeducation" was first formally defined, as well as contextual and phenomenological aspects of mil-mTBI that may complicate treatment efforts. To advance psychoeducation research and practice in mil-mTBI, we discuss how treatment theory, which seeks to link active treatment ingredients with specific therapeutic targets, and an associated conceptual framework for medical rehabilitation-the Rehabilitation Treatment Specification System-can be leveraged to personalize educational content, integrate it into multicomponent CR interventions, and evaluate its effectiveness.
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15
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Mahncke HW, DeGutis J, Levin H, Newsome MR, Bell MD, Grills C, French LM, Sullivan KW, Kim SJ, Rose A, Stasio C, Merzenich MM. A randomized clinical trial of plasticity-based cognitive training in mild traumatic brain injury. Brain 2021; 144:1994-2008. [PMID: 34312662 PMCID: PMC8370402 DOI: 10.1093/brain/awab202] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2020] [Revised: 02/04/2021] [Accepted: 03/09/2021] [Indexed: 11/14/2022] Open
Abstract
Clinical practice guidelines support cognitive rehabilitation for people with a history of mild traumatic brain injury (mTBI) and cognitive impairment, but no class I randomized clinical trials have evaluated the efficacy of self-administered computerized cognitive training. The goal of this study was to evaluate the efficacy of a self-administered computerized plasticity-based cognitive training programmes in primarily military/veteran participants with a history of mTBI and cognitive impairment. A multisite randomized double-blind clinical trial of a behavioural intervention with an active control was conducted from September 2013 to February 2017 including assessments at baseline, post-training, and after a 3-month follow-up period. Participants self-administered cognitive training (experimental and active control) programmes at home, remotely supervised by a healthcare coach, with an intended training schedule of 5 days per week, 1 h per day, for 13 weeks. Participants (149 contacted, 83 intent-to-treat) were confirmed to have a history of mTBI (mean of 7.2 years post-injury) through medical history/clinician interview and persistent cognitive impairment through neuropsychological testing and/or quantitative participant reported measure. The experimental intervention was a brain plasticity-based computerized cognitive training programme targeting speed/accuracy of information processing, and the active control was composed of computer games. The primary cognitive function measure was a composite of nine standardized neuropsychological assessments, and the primary directly observed functional measure a timed instrumental activities of daily living assessment. Secondary outcome measures included participant-reported assessments of cognitive and mental health. The treatment group showed an improvement in the composite cognitive measure significantly larger than that of the active control group at both the post-training [+6.9 points, confidence interval (CI) +1.0 to +12.7, P = 0.025, d = 0.555] and the follow-up visit (+7.4 points, CI +0.6 to +14.3, P = 0.039, d = 0.591). Both large and small cognitive function improvements were seen twice as frequently in the treatment group than in the active control group. No significant between-group effects were seen on other measures, including the directly-observed functional and symptom measures. Statistically equivalent improvements in both groups were seen in depressive and cognitive symptoms.
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Affiliation(s)
| | - Joseph DeGutis
- VA Boston Healthcare System, and Harvard Medical School, Boston, MA, USA
| | - Harvey Levin
- Michael E. DeBakey VA Medical Center, and Baylor College of Medicine, Houston, TX, USA
| | - Mary R Newsome
- Michael E. DeBakey VA Medical Center, and Baylor College of Medicine, Houston, TX, USA
| | - Morris D Bell
- VA Connecticut Healthcare System, and Yale University School of Medicine, West Haven, CT, USA
| | - Chad Grills
- Desmond T. Doss Health Clinic, Schofield Barracks, Oahu, HI, USA
| | - Louis M French
- Defense and Veterans Brain Injury Center, Walter Reed National Military Medical Center, Bethesda, MD, USA
- National Intrepid Center of Excellence, Walter Reed National Military Medical Center, Bethesda, MD, USA
- Uniformed Services University of the Health Sciences, Bethesda, MD, USA
| | - Katherine W Sullivan
- National Intrepid Center of Excellence, Walter Reed National Military Medical Center, Bethesda, MD, USA
| | | | - Annika Rose
- Posit Science Corporation, San Francisco, CA, USA
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16
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Wilde EA, Dennis EL, Tate DF. The ENIGMA Brain Injury working group: approach, challenges, and potential benefits. Brain Imaging Behav 2021; 15:465-474. [PMID: 33506440 PMCID: PMC8035294 DOI: 10.1007/s11682-021-00450-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2019] [Revised: 12/29/2020] [Accepted: 01/03/2021] [Indexed: 12/26/2022]
Abstract
The Enhancing NeuroImaging Genetics through Meta-Analysis (ENIGMA) consortium brings together researchers from around the world to try to identify the genetic underpinnings of brain structure and function, along with robust, generalizable effects of neurological and psychiatric disorders. The recently-formed ENIGMA Brain Injury working group includes 10 subgroups, based largely on injury mechanism and patient population. This introduction to the special issue summarizes the history, organization, and objectives of ENIGMA Brain Injury, and includes a discussion of strategies, challenges, opportunities and goals common across 6 of the subgroups under the umbrella of ENIGMA Brain Injury. The following articles in this special issue, including 6 articles from different subgroups, will detail the challenges and opportunities specific to each subgroup.
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Affiliation(s)
- Elisabeth A Wilde
- TBICC, Department of Neurology, University of Utah School of Medicine, Salt Lake City, UT, USA
- George E. Wahlen VA Medical Center, Salt Lake City, UT, USA
- H. Ben Taub Department of Physical Medicine and Rehabilitation, Baylor College of Medicine, Houston, TX, USA
| | - Emily L Dennis
- TBICC, Department of Neurology, University of Utah School of Medicine, Salt Lake City, UT, USA.
- George E. Wahlen VA Medical Center, Salt Lake City, UT, USA.
- Psychiatry Neuroimaging Laboratory, Brigham & Women's Hospital, Harvard Medical School, Boston, MA, USA.
- Imaging Genetics Center, Stevens Neuroimaging & Informatics Institute, Keck School of Medicine of USC, Marina del Rey, Los Angeles, CA, USA.
| | - David F Tate
- TBICC, Department of Neurology, University of Utah School of Medicine, Salt Lake City, UT, USA
- George E. Wahlen VA Medical Center, Salt Lake City, UT, USA
- Missouri Institute of Mental Health, University of Missouri, St. Louis, MO, USA
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17
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Wilson L, Horton L, Kunzmann K, Sahakian BJ, Newcombe VF, Stamatakis EA, von Steinbuechel N, Cunitz K, Covic A, Maas A, Van Praag D, Menon D. Understanding the relationship between cognitive performance and function in daily life after traumatic brain injury. J Neurol Neurosurg Psychiatry 2020; 92:jnnp-2020-324492. [PMID: 33268472 DOI: 10.1136/jnnp-2020-324492] [Citation(s) in RCA: 35] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/04/2020] [Revised: 10/03/2020] [Accepted: 10/19/2020] [Indexed: 01/28/2023]
Abstract
OBJECTIVE Cognitive impairment is a key cause of disability after traumatic brain injury (TBI) but relationships with overall functioning in daily life are often modest. The aim is to examine cognition at different levels of function and identify domains associated with disability. METHODS 1554 patients with mild-to-severe TBI were assessed at 6 months post injury on the Glasgow Outcome Scale-Extended (GOSE), the Short Form-12v2 and a battery of cognitive tests. Outcomes across GOSE categories were compared using analysis of covariance adjusting for age, sex and education. RESULTS Overall effect sizes were small to medium, and greatest for tests involving processing speed (ηp 2 0.057-0.067) and learning and memory (ηp 2 0.048-0.052). Deficits in cognitive performance were particularly evident in patients who were dependent (GOSE 3 or 4) or who were unable to participate in one or more major life activities (GOSE 5). At higher levels of function (GOSE 6-8), cognitive performance was surprisingly similar across categories. There were decreases in performance even in patients reporting complete recovery without significant symptoms. Medium to large effect sizes were present for summary measures of cognition (ηp 2 0.111), mental health (ηp 2 0.131) and physical health (ηp 2 0.252). CONCLUSIONS This large-scale study provides novel insights into cognitive performance at different levels of disability and highlights the importance of processing speed in function in daily life. At upper levels of outcome, any influence of cognition on overall function is markedly attenuated and differences in mental health are salient.
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Affiliation(s)
- Lindsay Wilson
- Division of Psychology, University of Stirling, Stirling, UK
| | - Lindsay Horton
- Division of Psychology, University of Stirling, Stirling, UK
| | - Kevin Kunzmann
- MRC Biostatistics Unit, University of Cambridge, Cambridge, UK
| | | | - Virginia Fj Newcombe
- Division of Anaesthesia, University of Cambridge, Addenbrooke's Hospital, Cambridge, UK
| | - Emmanuel A Stamatakis
- Division of Anaesthesia, University of Cambridge, Addenbrooke's Hospital, Cambridge, UK
| | - Nicole von Steinbuechel
- Institute of Medical Psychology and Medical Sociology, University Medical Center Goettingen and Georg-August-University, Goettingen, Germany
| | - Katrin Cunitz
- Institute of Medical Psychology and Medical Sociology, University Medical Center Goettingen and Georg-August-University, Goettingen, Germany
| | - Amra Covic
- Institute of Medical Psychology and Medical Sociology, University Medical Center Goettingen and Georg-August-University, Goettingen, Germany
| | - Andrew Maas
- Department of Neurosurgery, Antwerp University Hospital and University of Antwerp, Edegem, Belgium
| | - Dominique Van Praag
- Department of Psychology, Antwerp University Hospital and University of Antwerp, Edegem, Belgium
| | - David Menon
- Division of Anaesthesia, University of Cambridge, Addenbrooke's Hospital, Cambridge, UK
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18
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Stenberg J, Karr JE, Karlsen RH, Skandsen T, Silverberg ND, Iverson GL. Examining Test-Retest Reliability and Reliable Change for Cognition Endpoints for the CENTER-TBI Neuropsychological Test Battery. Front Neurol 2020; 11:541533. [PMID: 33192971 PMCID: PMC7606629 DOI: 10.3389/fneur.2020.541533] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2020] [Accepted: 09/22/2020] [Indexed: 12/01/2022] Open
Abstract
Objective: Seven candidate cognition composite scores have been developed and evaluated as part of a research program designed to validate a cognition endpoint for traumatic brain injury (TBI) research and clinical trials, but these composites have yet to be examined longitudinally. This study examined test-retest reliability and methods for determining reliable change for these seven candidate composite scores, using the neuropsychological test battery from the Collaborative European NeuroTrauma Effectiveness Research in Traumatic Brain Injury (CENTER-TBI). Methods: Participants (18–59 years-old) with mild TBI (n = 124), orthopedic trauma without head injury (n = 67), and healthy community controls (n = 63) from the Trondheim MTBI follow-up study completed the CENTER-TBI neuropsychological test battery at 2 weeks and 3 months after injury. The battery included both traditional paper-and-pencil tests and computerized tests from the Cambridge Neuropsychological Test Automated Battery (CANTAB). Seven composite scores were calculated for the paper-and-pencil tests, the CANTAB tests, and all tests combined (i.e., 21 composites in total on each assessment): the overall test battery mean (OTBM); global deficit score (GDS); neuropsychological deficit score-weighted (NDS-W); low score composite (LSC); and the number of scores ≤5th percentile, ≤16th percentile, or <50th percentile. The OTBM was calculated by averaging T scores for all tests. The other composite scores were deficit-based scores, assigning different weights to low scores. Results: All composites revealed better cognitive performance at the 3-month assessment compared to the 2-week assessment and the magnitude of improvement was similar across groups. Differences, in terms of effect sizes, were largest on the OTBMs. In the combined composites, the test-retest correlation was highest for the OTBM (Spearman's rho = 0.87, in the community control group) and lowest for the number of scores ≤5th percentile (rho = 0.41). Conclusion: The high test-retest reliability of the OTBM appears to favor its use in TBI research; however, future studies are needed to examine these candidate composite scores in participants with more severe TBIs and cognitive deficits and the association of the composites with functional outcomes.
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Affiliation(s)
- Jonas Stenberg
- Department of Neuromedicine and Movement Science, Norwegian University of Science and Technology (NTNU), Trondheim, Norway.,Department of Neurosurgery, St. Olavs Hospital, Trondheim University Hospital, Trondheim, Norway
| | - Justin E Karr
- Department of Physical Medicine and Rehabilitation, Harvard Medical School, Boston, MA, United States.,Department of Psychiatry, Harvard Medical School, Boston, MA, United States.,Spaulding Rehabilitation Hospital, Charlestown, MA, United States.,Home Base, A Red Sox Foundation and Massachusetts General Hospital Program, Charlestown, MA, United States.,Spaulding Research Institute, Charlestown, MA, United States
| | - Rune H Karlsen
- Department of Neuromedicine and Movement Science, Norwegian University of Science and Technology (NTNU), Trondheim, Norway
| | - Toril Skandsen
- Department of Neuromedicine and Movement Science, Norwegian University of Science and Technology (NTNU), Trondheim, Norway.,Department of Physical Medicine and Rehabilitation, St. Olavs Hospital, Trondheim University Hospital, Trondheim, Norway
| | - Noah D Silverberg
- Department of Psychology, University of British Columbia, Vancouver, BC, Canada.,Division of Physical Medicine and Rehabilitation, University of British Columbia, Vancouver, BC, Canada.,Rehabilitation Research Program, GF Strong Rehabilitation Centre, Vancouver, BC, Canada
| | - Grant L Iverson
- Department of Physical Medicine and Rehabilitation, Harvard Medical School, Boston, MA, United States.,Spaulding Rehabilitation Hospital, Charlestown, MA, United States.,Home Base, A Red Sox Foundation and Massachusetts General Hospital Program, Charlestown, MA, United States.,Spaulding Research Institute, Charlestown, MA, United States
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19
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Patient and clinician experiences of a computerised cognitive battery for use after concussion: a preliminary qualitative study. BRAIN IMPAIR 2020. [DOI: 10.1017/brimp.2020.14] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
AbstractObjective:The Cognition Battery of the National Institute of Health (NIH) Toolbox for Assessment of Neurological and Behavioural Function is a computerised neuropsychological battery recommended for clinical practice, neurological research and clinical trials. We investigated the utility of the NIH Toolbox Cognition Battery (NIHTB-CB) for people with concussion.Methods:In this small qualitative study, semi-structured interviews were conducted with five adults with concussion who were participating in a larger study using the NIHTB-CB. Three clinician participants and two cultural advisors familiar with the tool were also interviewed. Interview transcripts were analysed using a general thematic approach and qualitative description.Results:Participants described both positive and negative experiences with the NIHTB-CB and using qualitative description, their experiences were organised into three broad themes: (1) using technology for cognitive testing made sense, (2) there were some cultural relevance questions and (3) cognitive testing after concussion could have challenges. They were positive about the computerised format and range of domains assessed for the concussion context but identified the contextual relevance of some content as having potential to impact on performances.Conclusion:This was a small study examining the experiences of a select group of participants, but nevertheless does suggest a need for future research validating the NIHTB-CB for use in different cultural and clinical contexts.
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20
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Stenberg J, Karr JE, Terry DP, Saksvik SB, Vik A, Skandsen T, Silverberg ND, Iverson GL. Developing Cognition Endpoints for the CENTER-TBI Neuropsychological Test Battery. Front Neurol 2020; 11:670. [PMID: 32765400 PMCID: PMC7379151 DOI: 10.3389/fneur.2020.00670] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2020] [Accepted: 06/05/2020] [Indexed: 12/18/2022] Open
Abstract
Background: Measuring cognitive functioning is common in traumatic brain injury (TBI) research, but no universally accepted method for combining several neuropsychological test scores into composite, or summary, scores exists. This study examined several possible composite scores for the test battery used in the large-scale study Collaborative European NeuroTrauma Effectiveness Research in Traumatic Brain Injury (CENTER-TBI). Methods: Participants with mild traumatic brain injury (MTBI; n = 140), orthopedic trauma (n = 72), and healthy community controls (n = 70) from the Trondheim MTBI follow-up study completed the CENTER-TBI test battery at 2 weeks after injury, which includes both traditional paper-and-pencil tests and tests from the Cambridge Neuropsychological Test Automated Battery (CANTAB). Seven composite scores were calculated for the paper and pencil tests, the CANTAB tests, and all tests combined (i.e., 21 composites): the overall test battery mean (OTBM); global deficit score (GDS); neuropsychological deficit score-weighted (NDS-W); low score composite (LSC); and the number of scores ≤5th percentile, ≤16th percentile, or <50th percentile. Results: The OTBM and the number of scores <50th percentile composites had distributional characteristics approaching a normal distribution. The other composites were in general highly skewed and zero-inflated. When the MTBI group, the trauma control group, and the community control group were compared, effect sizes were negligible to small for all composites. Subgroups with vs. without loss of consciousness at the time of injury did not differ on the composite scores and neither did subgroups with complicated vs. uncomplicated MTBIs. Intercorrelations were high within the paper-and-pencil composites, the CANTAB composites, and the combined composites and lower between the paper-and-pencil composites and the CANTAB composites. Conclusion: None of the composites revealed significant differences between participants with MTBI and the two control groups. Some of the composite scores were highly correlated and may be redundant. Additional research on patients with moderate to severe TBIs is needed to determine which scores are most appropriate for TBI clinical trials.
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Affiliation(s)
- Jonas Stenberg
- Department of Neuromedicine and Movement Science, Norwegian University of Science and Technology (NTNU), Trondheim, Norway.,Department of Neurosurgery, St. Olavs Hospital, Trondheim University Hospital, Trondheim, Norway
| | - Justin E Karr
- Department of Physical Medicine and Rehabilitation, Harvard Medical School, Boston, MA, United States.,Department of Psychiatry, Harvard Medical School, Boston, MA, United States.,Spaulding Rehabilitation Hospital, Charlestown, MA, United States.,Home Base, A Red Sox Foundation and Massachusetts General Hospital Program, Charlestown, MA, United States.,Spaulding Research Institute, Charlestown, MA, United States
| | - Douglas P Terry
- Department of Physical Medicine and Rehabilitation, Harvard Medical School, Boston, MA, United States.,Spaulding Rehabilitation Hospital, Charlestown, MA, United States.,Home Base, A Red Sox Foundation and Massachusetts General Hospital Program, Charlestown, MA, United States
| | - Simen B Saksvik
- Department of Psychology, Norwegian University of Science and Technology (NTNU), Trondheim, Norway.,Department of Physical Medicine and Rehabilitation, St. Olavs Hospital, Trondheim University Hospital, Trondheim, Norway
| | - Anne Vik
- Department of Neuromedicine and Movement Science, Norwegian University of Science and Technology (NTNU), Trondheim, Norway.,Department of Neurosurgery, St. Olavs Hospital, Trondheim University Hospital, Trondheim, Norway
| | - Toril Skandsen
- Department of Neuromedicine and Movement Science, Norwegian University of Science and Technology (NTNU), Trondheim, Norway.,Department of Physical Medicine and Rehabilitation, St. Olavs Hospital, Trondheim University Hospital, Trondheim, Norway
| | - Noah D Silverberg
- Department of Psychology, University of British Columbia, Vancouver, BC, Canada.,Division of Physical Medicine & Rehabilitation, University of British Columbia, Vancouver, BC, Canada.,Rehabilitation Research Program, GF Strong Rehabilitation Centre, Vancouver, BC, Canada
| | - Grant L Iverson
- Department of Physical Medicine and Rehabilitation, Harvard Medical School, Boston, MA, United States.,Spaulding Rehabilitation Hospital, Charlestown, MA, United States.,Home Base, A Red Sox Foundation and Massachusetts General Hospital Program, Charlestown, MA, United States.,Spaulding Research Institute, Charlestown, MA, United States
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21
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Yue JK, Satris GG, Dalle Ore CL, Huie JR, Deng H, Winkler EA, Lee YM, Vassar MJ, Taylor SR, Schnyer DM, Lingsma HF, Puccio AM, Yuh EL, Mukherjee P, Valadka AB, Ferguson AR, Markowitz AJ, Okonkwo DO, Manley GT. Polytrauma Is Associated with Increased Three- and Six-Month Disability after Traumatic Brain Injury: A TRACK-TBI Pilot Study. Neurotrauma Rep 2020; 1:32-41. [PMID: 34223528 PMCID: PMC8240880 DOI: 10.1089/neur.2020.0004] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
Polytrauma and traumatic brain injury (TBI) frequently co-occur and outcomes are routinely measured by the Glasgow Outcome Scale-Extended (GOSE). Polytrauma may confound GOSE measurement of TBI-specific outcomes. Adult patients with TBI from the prospective Transforming Research and Clinical Knowledge in Traumatic Brain Injury Pilot (TRACK-TBI Pilot) study had presented to a Level 1 trauma center after injury, received head computed tomography (CT) within 24 h, and completed the GOSE at 3 months and 6 months post-injury. Polytrauma was defined as an Abbreviated Injury Score (AIS) ≥3 in any extracranial region. Univariate regressions were performed using known GOSE clinical cutoffs. Multi-variable regressions were performed for the 3- and 6-month GOSE, controlling for known demographic and injury predictors. Of 361 subjects (age 44.9 ± 18.9 years, 69.8% male), 69 (19.1%) suffered polytrauma. By Glasgow Coma Scale (GCS) assessment, 80.1% had mild, 5.8% moderate, and 14.1% severe TBI. On univariate logistic regression, polytrauma was associated with increased odds of moderate disability or worse (GOSE ≤6; 3 month odds ratio [OR] = 2.57 [95% confidence interval (CI): 1.50-4.41; 6 month OR = 1.70 [95% CI: 1.01-2.88]) and death/severe disability (GOSE ≤4; 3 month OR = 3.80 [95% CI: 2.03-7.11]; 6 month OR = 3.33 [95% CI: 1.71-6.46]). Compared with patients with isolated TBI, more polytrauma patients experienced a decline in GOSE from 3 to 6 months (37.7 vs. 24.7%), and fewer improved (11.6 vs. 22.6%). Polytrauma was associated with greater univariate ordinal odds for poorer GOSE (3 month OR = 2.79 [95% CI: 1.73-4.49]; 6 month OR = 1.73 [95% CI: 1.07-2.79]), which was conserved on multi-variable ordinal regression (3 month OR = 3.05 [95% CI: 1.76-5.26]; 6 month OR = 2.04 [95% CI: 1.18-3.42]). Patients with TBI with polytrauma are at greater risk for 3- and 6-month disability compared with those with isolated TBI. Methodological improvements in assessing TBI-specific disability, versus disability attributable to all systemic injuries, will generate better TBI outcomes assessment tools.
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Affiliation(s)
- John K Yue
- Department of Neurological Surgery, University of California San Francisco, San Francisco, California, USA.,Brain and Spinal Injury Center, Zuckerberg San Francisco General Hospital, San Francisco, California, USA
| | - Gabriela G Satris
- Department of Neurological Surgery, University of California San Francisco, San Francisco, California, USA.,Brain and Spinal Injury Center, Zuckerberg San Francisco General Hospital, San Francisco, California, USA
| | - Cecilia L Dalle Ore
- Department of Neurological Surgery, University of California San Francisco, San Francisco, California, USA.,Brain and Spinal Injury Center, Zuckerberg San Francisco General Hospital, San Francisco, California, USA
| | - J Russell Huie
- Department of Neurological Surgery, University of California San Francisco, San Francisco, California, USA.,Brain and Spinal Injury Center, Zuckerberg San Francisco General Hospital, San Francisco, California, USA
| | - Hansen Deng
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Ethan A Winkler
- Department of Neurological Surgery, University of California San Francisco, San Francisco, California, USA.,Brain and Spinal Injury Center, Zuckerberg San Francisco General Hospital, San Francisco, California, USA
| | - Young M Lee
- Department of Neurological Surgery, University of California San Francisco, San Francisco, California, USA.,Brain and Spinal Injury Center, Zuckerberg San Francisco General Hospital, San Francisco, California, USA
| | - Mary J Vassar
- Department of Neurological Surgery, University of California San Francisco, San Francisco, California, USA.,Brain and Spinal Injury Center, Zuckerberg San Francisco General Hospital, San Francisco, California, USA
| | - Sabrina R Taylor
- Department of Neurological Surgery, University of California San Francisco, San Francisco, California, USA.,Brain and Spinal Injury Center, Zuckerberg San Francisco General Hospital, San Francisco, California, USA
| | - David M Schnyer
- Department of Psychology, University of Texas, Austin, Texas, USA
| | - Hester F Lingsma
- Department of Public Health, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Ava M Puccio
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Esther L Yuh
- Brain and Spinal Injury Center, Zuckerberg San Francisco General Hospital, San Francisco, California, USA.,Department of Radiology, University of California San Francisco, San Francisco, California, USA
| | - Pratik Mukherjee
- Brain and Spinal Injury Center, Zuckerberg San Francisco General Hospital, San Francisco, California, USA.,Department of Radiology, University of California San Francisco, San Francisco, California, USA
| | - Alex B Valadka
- Department of Neurological Surgery, Virginia Commonwealth University, Richmond, Virginia, USA
| | - Adam R Ferguson
- Department of Neurological Surgery, University of California San Francisco, San Francisco, California, USA.,Brain and Spinal Injury Center, Zuckerberg San Francisco General Hospital, San Francisco, California, USA
| | - Amy J Markowitz
- Brain and Spinal Injury Center, Zuckerberg San Francisco General Hospital, San Francisco, California, USA
| | - David O Okonkwo
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Geoffrey T Manley
- Department of Neurological Surgery, University of California San Francisco, San Francisco, California, USA.,Brain and Spinal Injury Center, Zuckerberg San Francisco General Hospital, San Francisco, California, USA
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22
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Iverson GL, Ivins BJ, Karr JE, Crane PK, Lange RT, Cole WR, Silverberg ND. Comparing Composite Scores for the ANAM4 TBI-MIL for Research in Mild Traumatic Brain Injury. Arch Clin Neuropsychol 2020; 35:56-69. [PMID: 31063188 DOI: 10.1093/arclin/acz021] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2018] [Revised: 02/26/2019] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVE The Automated Neuropsychological Assessment Metrics (Version 4) Traumatic Brain Injury Military (ANAM4 TBI-MIL) is commonly administered among U.S. service members both pre-deployment and following TBI. The current study used the ANAM4 TBI-MIL to develop a cognition summary score for TBI research and clinical trials, comparing eight composite scores based on their distributions and sensitivity/specificity when differentiating between service members with and without mild TBI (MTBI). METHOD Male service members with MTBI (n = 56; Mdn = 11 days-since-injury) or no self-reported TBI history (n = 733) completed eight ANAM4 TBI-MIL tests. Their throughput scores (correct responses/minute) were used to calculate eight composite scores: the overall test battery mean (OTBM); global deficit score (GDS); neuropsychological deficit score-weighted (NDS-W); low score composite (LSC); number of scores <50th, ≤16th percentile, or ≤5th percentile; and the ANAM Composite Score (ACS). RESULTS The OTBM and ACS were normally distributed. Other composites had skewed, zero-inflated distributions (62.9% had GDS = 0). All composites differed significantly between participants with and without MTBI (p < .001), with deficit scores showing the largest effect sizes (d = 1.32-1.47). The Area Under the Curve (AUC) was lowest for number of scores ≤5th percentile (AUC = 0.653) and highest for the LSC, OTBM, ACS, and NDS-W (AUC = 0.709-0.713). CONCLUSIONS The ANAM4 TBI-MIL has no well-validated composite score. The current study examined multiple candidate composite scores, finding that deficit scores showed larger group differences than the OTBM, but similar AUC values. The deficit scores were highly correlated. Future studies are needed to determine whether these scores show less redundancy among participants with more severe TBIs.
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Affiliation(s)
- Grant L Iverson
- Department of Physical Medicine and Rehabilitation, Harvard Medical School; Spaulding Rehabilitation Hospital; & Home Base, A Red Sox Foundation and Massachusetts General Hospital Program, Boston, MA, USA
| | - Brian J Ivins
- Defense and Veterans Brain Injury Center, Silver Spring, MD, USA
| | - Justin E Karr
- Departments of Psychiatry and Physical Medicine and Rehabilitation, Harvard Medical School; Spaulding Rehabilitation Hospital; & Home Base, A Red Sox Foundation and Massachusetts General Hospital Program, Boston, MA, USA
| | - Paul K Crane
- Department of Medicine, University of Washington, Seattle, WA, USA
| | - Rael T Lange
- Defense and Veterans Brain Injury Center, Walter Reed National Military Medical Center, Bethesda, MD, USA.,National Intrepid Center of Excellence, Walter Reed National Military Medical Center, Bethesda, MD, USA.,Department of Psychiatry, University of British Columbia, Vancouver, British Columbia, V6T 2A1, Canada
| | - Wesley R Cole
- Defense and Veterans Brain Injury Center; Intrepid Spirit; Womack Army Medical Center; Fort Bragg, NC, USA
| | - Noah D Silverberg
- Division of Physical Medicine and Rehabilitation, University of British Columbia; Rehabilitation Research Program, GF Strong Rehab Centre, Vancouver, British Columbia, V5Z 2G9, Canada
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23
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Iverson GL, Karr JE, Terry DP, Garcia-Barrera MA, Holdnack JA, Ivins BJ, Silverberg ND. Developing an Executive Functioning Composite Score for Research and Clinical Trials. Arch Clin Neuropsychol 2020; 35:312-325. [PMID: 31965141 DOI: 10.1093/arclin/acz070] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2019] [Revised: 09/30/2019] [Accepted: 10/20/2019] [Indexed: 12/31/2022] Open
Abstract
OBJECTIVE Executive functioning encompasses interactive cognitive processes such as planning, organization, set-shifting, inhibition, self-monitoring, working memory, and initiating and sustaining motor and mental activity. Researchers therefore typically assess executive functioning with multiple tests, each yielding multiple scores. A single composite score of executive functioning, which summarizes deficits across a battery of tests, would be useful in research and clinical trials. This study examines multiple candidate composite scores of executive functioning using tests from the Delis-Kaplan Executive Function System (D-KEFS). METHOD Participants were 875 adults between the ages of 20 and 89 years from the D-KEFS standardization sample. Seven Total Achievement scores were used from three tests (i.e., Trail Making, Verbal Fluency, and Color-Word Interference) to form eight composite scores that were compared based on their psychometric properties and association with intelligence (IQ). RESULTS The distributions of most composite scores were mildly to severely skewed, and some had a pronounced ceiling effect. The composite scores all showed a medium positive correlation with IQ. The composite scores were highly intercorrelated in the total sample and in four IQ subgroups (i.e., IQ <89, 90-99, 100-109, 110+), with some being so highly correlated that they appear redundant. CONCLUSIONS This study is part of a larger research program developing a cognition endpoint for research and clinical trials with sound psychometric properties and utility across discrepant test batteries. Future research is needed to examine the reliability and ecological validity of these composite scores.
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Affiliation(s)
- Grant L Iverson
- Department of Physical Medicine and Rehabilitation, Harvard Medical School, Spaulding Rehabilitation Hospital, Spaulding Research Institute, and Home Base, A Red Sox Foundation and Massachusetts General Hospital Program, Boston, MA 02129, USA
| | - Justin E Karr
- Department of Physical Medicine and Rehabilitation, Harvard Medical School, Spaulding Rehabilitation Hospital, Spaulding Research Institute, and Home Base, A Red Sox Foundation and Massachusetts General Hospital Program, Boston, MA 02129, USA
| | - Douglas P Terry
- Department of Physical Medicine and Rehabilitation, Harvard Medical School, Spaulding Rehabilitation Hospital, Spaulding Research Institute, and Home Base, A Red Sox Foundation and Massachusetts General Hospital Program, Boston, MA 02129, USA
| | | | | | - Brian J Ivins
- Defense and Veterans Brain Injury Center, Silver Spring, MD 20910, USA
| | - Noah D Silverberg
- Division of Physical Medicine and Rehabilitation, University of British Columbia; Rehabilitation Research Program, GF Strong Rehab Centre, Vancouver, British Columbia V5Z 2G9, Canada
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24
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Snell DL, Siegert RJ, Silverberg ND. Rasch analysis of the World Health Organization Disability Assessment Schedule 2.0 in a mild traumatic brain injury sample. Brain Inj 2020; 34:610-618. [PMID: 32078408 DOI: 10.1080/02699052.2020.1729417] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
In this study we examined the psychometric properties of the World Health Organization Disability Assessment Schedule (WHODAS 2.0 12-item version) in a mild traumatic brain injury (MTBI) sample.Materials and Methods: Treatment-seeking adults (n = 131) with MTBI recruited from outpatient clinics in Vancouver Canada, were assessed 1- and 3-months following clinic intake. Dimensionality, reliability, and differential item functioning of the WHODAS 2.0 were examined with Rasch analysis. Associations between change in WHODAS 2.0 scores and symptom, work and perceived improvement outcomes were examined.Results: Adequate fit to the Rasch model was achieved for 1-month follow-up assessment WHODAS 2.0 scores without altering the response format or item content [X2 (24, n = 130) = 21.2, p = .6]. The best model fit for 3-month follow-up assessment scores was achieved when two items (problems with dressing and washing) were combined [X2 (22, n = 115) = 20.9, p = .5]. Associations were evident between changes in WHODAS total Rasch scores and other outcome indicators such as return to productivity and percieved improvement.Conclusions: The WHODAS 2.0 (12-item version) is a psychometrically sound measure of functional outcome for adults seeking treatment following MTBI. Our table of ordinal to interval score conversions is recommended for future research examining MTBI outcomes.
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Affiliation(s)
- Deborah L Snell
- Concussion Clinic, Canterbury District Health Board, Christchurch, New Zealand.,Department of Orthopaedic Surgery and Musculoskeletal Medicine, University of Otago Christchurch, Christchurch, New Zealand
| | - Richard J Siegert
- Faculty of Health and Environmental Studies, AUT University, Auckland, New Zealand
| | - Noah D Silverberg
- Division of Physical Medicine & Rehabilitation, University of British Columbia, Vancouver, Canada.,Rehabilitation Research Program, GF Strong Rehab Centre, Vancouver, Canada.,Department of Physical Medicine and Rehabilitation, Harvard Medical School, Boston, Massachusetts, USA
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25
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Cognitive Reserve Moderates Cognitive Outcome After Mild Traumatic Brain Injury. Arch Phys Med Rehabil 2019; 101:72-80. [PMID: 31562876 DOI: 10.1016/j.apmr.2019.08.477] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2019] [Revised: 08/21/2019] [Accepted: 08/24/2019] [Indexed: 11/23/2022]
Abstract
OBJECTIVE To investigate whether cognitive reserve moderates differences in cognitive functioning between patients with mild traumatic brain injury (MTBI) and controls without MTBI and to examine whether patients with postconcussion syndrome have lower cognitive functioning than patients without postconcussion syndrome at 2 weeks and 3 months after injury. DESIGN Trondheim MTBI follow-up study is a longitudinal controlled cohort study with cognitive assessments 2 weeks and 3 months after injury. SETTING Recruitment at a level 1 trauma center and at a general practitioner-run, outpatient clinic. PARTICIPANTS Patients with MTBI (n=160) according to the World Health Organization criteria, trauma controls (n=71), and community controls (n=79) (N=310). MAIN OUTCOME MEASURES A cognitive composite score was used as outcome measure. The Vocabulary subtest was used as a proxy of cognitive reserve. Postconcussion syndrome diagnosis was assessed at 3 months with the British Columbia Postconcussion Symptom Inventory. RESULTS Linear mixed models demonstrated that the effect of vocabulary scores on the cognitive composite scores was larger in patients with MTBI than in community controls at 2 weeks and at 3 months after injury (P=.001). Thus, group differences in the cognitive composite score varied as a function of vocabulary scores, with the biggest differences seen among participants with lower vocabulary scores. There were no significant differences in the cognitive composite score between patients with (n=29) and without (n=131) postconcussion syndrome at 2 weeks or 3 months after injury. CONCLUSION Cognitive reserve, but not postconcussion syndrome, was associated with cognitive outcome after MTBI. This supports the cognitive reserve hypothesis in the MTBI context and suggests that persons with low cognitive reserve are more vulnerable to reduced cognitive functioning if they sustain an MTBI.
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26
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Dams-O'Connor K, Sy KTL, Landau A, Bodien Y, Dikmen S, Felix ER, Giacino JT, Gibbons L, Hammond FM, Hart T, Johnson-Greene D, Lengenfelder J, Lequerica A, Newman J, Novack T, O'Neil-Pirozzi TM, Whiteneck G. The Feasibility of Telephone-Administered Cognitive Testing in Individuals 1 and 2 Years after Inpatient Rehabilitation for Traumatic Brain Injury. J Neurotrauma 2018; 35:1138-1145. [PMID: 29648959 DOI: 10.1089/neu.2017.5347] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Traumatic brain injury (TBI) often results in cognitive impairment, and trajectories of cognitive functioning can vary tremendously over time across survivors. Traditional approaches to measuring cognitive performance require face-to-face administration of a battery of objective neuropsychological tests, which can be time- and labor-intensive. There are numerous clinical and research contexts in which in-person testing is undesirable or unfeasible, including clinical monitoring of older adults or individuals with disability for whom travel is challenging, and epidemiological studies of geographically dispersed participants. A telephone-based method for measuring cognition could conserve resources and improve efficiency. The objective of this study is to examine the feasibility and usefulness of the Brief Test of Adult Cognition by Telephone (BTACT) among individuals who are 1 and 2 years post-moderate-to-severe TBI. A total of 463 individuals participated in the study at Year 1 post-injury, and 386 participated at Year 2. The sample was mostly male (73%) and white (59%), with an average age of (mean ± standard deviation) 47.9 ± 20.9 years, and 73% experienced a duration of post-traumatic amnesia (PTA) greater than 7 days. A majority of participants were able to complete the BTACT subtests (61-69% and 56-64% for Years 1 and 2 respectively); score imputation for those unable to complete a test due to severity of cognitive impairment yields complete data for 74-79% of the sample. BTACT subtests showed expected changes between Years 1-2, and summary scores demonstrated expected associations with injury severity, employment status, and cognitive status as measured by the Functional Independence Measure. Results indicate it is feasible, efficient, and useful to measure cognition over the telephone among individuals with moderate-severe TBI.
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Affiliation(s)
- Kristen Dams-O'Connor
- 1 Department of Rehabilitation Medicine, Icahn School of Medicine at Mount Sinai , New York, New York.,2 Department of Neurology, Icahn School of Medicine at Mount Sinai , New York, New York
| | - Karla Therese L Sy
- 1 Department of Rehabilitation Medicine, Icahn School of Medicine at Mount Sinai , New York, New York
| | - Alexandra Landau
- 1 Department of Rehabilitation Medicine, Icahn School of Medicine at Mount Sinai , New York, New York
| | - Yelena Bodien
- 3 Department of Physical Medicine and Rehabilitation, Spaulding Rehabilitation Hospital and Harvard Medical School , Boston, Massachusetts.,4 Department of Neurology, Massachusetts General Hospital and Harvard Medical School , Boston, Massachusetts
| | - Sureyya Dikmen
- 5 Department of Rehabilitation Medicine, University of Washington , Seattle, Washington
| | - Elizabeth R Felix
- 6 Department of Physical Medicine and Rehabilitation, University of Miami , Miami, Florida.,7 Research Service, Miami Veterans Administration Medical Center , Miami, Florida
| | - Joseph T Giacino
- 3 Department of Physical Medicine and Rehabilitation, Spaulding Rehabilitation Hospital and Harvard Medical School , Boston, Massachusetts
| | - Laura Gibbons
- 8 Department of General Internal Medicine, University of Washington , Seattle, Washington
| | - Flora M Hammond
- 9 Department of Physical Medicine and Rehabilitation, Indiana University School of Medicine , Indianapolis, Indiana.,10 Rehabilitation Hospital of Indiana , Indianapolis, Indiana
| | - Tessa Hart
- 11 Moss Rehabilitation Research Institute , Elkins Park, Pennsylvania
| | - Doug Johnson-Greene
- 6 Department of Physical Medicine and Rehabilitation, University of Miami , Miami, Florida
| | | | | | | | - Thomas Novack
- 14 Department of Physical Medicine and Rehabilitation, University of Alabama at Birmingham , Birmingham, Alabama
| | - Therese M O'Neil-Pirozzi
- 3 Department of Physical Medicine and Rehabilitation, Spaulding Rehabilitation Hospital and Harvard Medical School , Boston, Massachusetts.,15 Department of Communication Sciences and Disorders, Northeastern University , Boston, Massachusetts
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27
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Snell DL, Iverson GL, Panenka WJ, Silverberg ND. Preliminary Validation of the World Health Organization Disability Assessment Schedule 2.0 for Mild Traumatic Brain Injury. J Neurotrauma 2017; 34:3256-3261. [DOI: 10.1089/neu.2017.5234] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
- Deborah L. Snell
- Concussion Clinic, Canterbury District Health Board, Department of Orthopaedic Surgery and Musculoskeletal Medicine, University of Otago Christchurch, Burwood Hospital, Christchurch, New Zealand
| | - Grant L. Iverson
- Department of Physical Medicine and Rehabilitation, Harvard Medical School, Spaulding Rehabilitation Hospital, and Home Base, A Red Sox Foundation and Massachusetts General Hospital Program, Boston, Massachusetts
| | - William J. Panenka
- British Columbia Neuropsychiatry Program, Department of Psychiatry, University of British Columbia, Vancouver, British Columbia, Canada
| | - Noah D. Silverberg
- Division of Physical Medicine and Rehabilitation, University of British Columbia, Rehabilitation Research Program, GF Strong Rehab Centre, Rehabilitation Research Program, Vancouver, British Columbia, Canada
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28
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Vogel EW, Morales FN, Meaney DF, Bass CR, Morrison B. Phosphodiesterase-4 inhibition restored hippocampal long term potentiation after primary blast. Exp Neurol 2017; 293:91-100. [PMID: 28366471 PMCID: PMC6016024 DOI: 10.1016/j.expneurol.2017.03.025] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2016] [Revised: 03/08/2017] [Accepted: 03/30/2017] [Indexed: 01/03/2023]
Abstract
Due to recent military conflicts and terrorist attacks, blast-induced traumatic brain injury (bTBI) presents a health concern for military and civilian personnel alike. Although secondary blast (penetrating injury) and tertiary blast (inertia-driven brain deformation) are known to be injurious, the effects of primary blast caused by the supersonic shock wave interacting with the skull and brain remain debated. Our group previously reported that in vitro primary blast exposure reduced long-term potentiation (LTP), the electrophysiological correlate of learning and memory, in rat organotypic hippocampal slice cultures (OHSCs) and that primary blast affects key proteins governing LTP. Recent studies have investigated phosphodiesterase-4 (PDE4) inhibition as a therapeutic strategy for reducing LTP deficits following inertia-driven TBI. We investigated the therapeutic potential of PDE4 inhibitors, specifically roflumilast, to ameliorate primary blast-induced deficits in LTP. We found that roflumilast at concentrations of 1nM or greater prevented deficits in neuronal plasticity measured 24h post-injury. We also observed a therapeutic window of at least 6h, but <23h. Additionally, we investigated molecular mechanisms that could elucidate this therapeutic effect. Roflumilast treatment (1nM delivered 6h post-injury) significantly increased total AMPA glutamate receptor 1 (GluR1) subunit expression, phosphorylation of the GluR1 subunit at the serine-831 site, and phosphorylation of stargazin at the serine-239/240 site upon LTP induction, measured 24h following injury. Roflumilast treatment significantly increased PSD-95 regardless of LTP induction. These findings indicate that further investigation into the translation of PDE4 inhibition as a therapy following bTBI is warranted.
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Affiliation(s)
- Edward W Vogel
- Department of Biomedical Engineering, Columbia University, New York, NY 10027, USA
| | - Fatima N Morales
- Department of Biomedical Engineering, Columbia University, New York, NY 10027, USA
| | - David F Meaney
- Department of Bioengineering, University of Pennsylvania, Philadelphia, PA 19104, USA
| | - Cameron R Bass
- Department of Biomedical Engineering, Duke University, Durham, NC 27705, USA
| | - Barclay Morrison
- Department of Biomedical Engineering, Columbia University, New York, NY 10027, USA.
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29
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Abstract
The role of the physiatrist in provision of medicolegal expert testimony in cases involving traumatic brain injury is challenging and complex. This article provides an overview of how such work should be conducted from a practical perspective including discussion of ethical, legal, medical, and business aspects of such activities. Additionally, pointers are provided with regards to how information including preinjury, injury, and postinjury (including neuroimaging and neuropsychological data) should be considered and integrated into medicolegal opinions and testimony.
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Affiliation(s)
- Nathan D Zasler
- Concussion Care Centre of Virginia, Ltd, 3721 Westerre Parkway, Suite B, Richmond, VA 23233, USA; Tree of Life Services, Inc, Richmond, VA, USA; Department of Physical Medicine and Rehabilitation, Virginia Commonwealth University, Richmond, VA, USA; Department of Physical Medicine and Rehabilitation, University of Virginia, Charlottesville, VA, USA; IBIA.
| | - Erin Bigler
- Brigham Young University, 1001 Kimball Tower, Provo, UT 84602, USA
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30
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31
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Gardner RC, Langa KM, Yaffe K. Subjective and objective cognitive function among older adults with a history of traumatic brain injury: A population-based cohort study. PLoS Med 2017; 14:e1002246. [PMID: 28267747 PMCID: PMC5340352 DOI: 10.1371/journal.pmed.1002246] [Citation(s) in RCA: 31] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/14/2016] [Accepted: 01/25/2017] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Traumatic brain injury (TBI) is extremely common across the lifespan and is an established risk factor for dementia. The cognitive profile of the large and growing population of older adults with prior TBI who do not have a diagnosis of dementia, however, has not been well described. Our aim was to describe the cognitive profile associated with prior TBI exposure among community-dwelling older adults without dementia-an understudied but potentially vulnerable population. METHODS AND FINDINGS In this population-based cohort study, we studied 984 community-dwelling older adults (age 51 y and older and their spouses) without dementia who had been randomly selected from respondents to the 2014 wave of the Health and Retirement Study to participate in a comprehensive TBI survey and who either reported no prior TBI (n = 737) or prior symptomatic TBI resulting in treatment in a hospital (n = 247). Mean time since first TBI was 38 ± 19 y. Outcomes assessed included measures of global cognitive function, verbal episodic memory, semantic fluency, and calculation as well as a measure of subjective memory ("How would you rate your memory at the present time?"). We compared outcomes between the two TBI groups using regression models adjusting for demographics, medical comorbidities, and depression. Sensitivity analyses were performed stratified by TBI severity (no TBI, TBI without loss of consciousness [LOC], and TBI with LOC). Respondents with TBI were younger (mean age 64 ± 10 y versus 68 ± 11 y), were less likely to be female, and had higher prevalence of medical comorbidities and depression than respondents without TBI. Respondents with TBI did not perform significantly differently from respondents without TBI on any measure of objective cognitive function in either raw or adjusted models (fully adjusted: global cognitive function score 15.4 versus 15.2, p = 0.68; verbal episodic memory score 4.4 versus 4.3, p = 0.79; semantic fluency score 15.7 versus 14.0, p = 0.21; calculation impairment 22% versus 26%, risk ratio [RR] [95% CI] = 0.86 [0.67-1.11], p = 0.24). Sensitivity analyses stratified by TBI severity produced similar results. TBI was associated with significantly increased risk for subjective memory impairment in models adjusted for demographics and medical comorbidities (29% versus 24%; RR [95% CI]: 1.26 [1.02-1.57], p = 0.036). After further adjustment for active depression, however, risk for subjective memory impairment was no longer significant (RR [95% CI]: 1.18 [0.95-1.47], p = 0.13). Sensitivity analyses revealed that risk of subjective memory impairment was increased only among respondents with TBI with LOC and not among those with TBI without LOC. Furthermore, the risk of subjective memory impairment was significantly greater among those with TBI with LOC versus those without TBI even after adjustment for depression (RR [95% CI]: partially adjusted, 1.38 [1.09-1.74], p = 0.008; fully adjusted, 1.28 [1.01-1.61], p = 0.039). CONCLUSIONS In this population-based study of community-dwelling older adults without dementia, those with prior TBI with LOC were more likely to report subjective memory impairment compared to those without TBI even after adjustment for demographics, medical comorbidities, and active depression. Lack of greater objective cognitive impairment among those with versus without TBI may be due to poor sensitivity of the cognitive battery or survival bias, or may suggest that post-TBI cognitive impairment primarily affects executive function and processing speed, which were not rigorously assessed in this study. Our findings show that among community-dwelling non-demented older adults, history of TBI is common but may not preferentially impact cognitive domains of episodic memory, attention, working memory, verbal semantic fluency, or calculation.
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Affiliation(s)
- Raquel C. Gardner
- Memory and Aging Center, Department of Neurology, University of California San Francisco, San Francisco, California, United States of America
- San Francisco Veterans Affairs Medical Center, San Francisco, California, United States of America
- * E-mail:
| | - Kenneth M. Langa
- Division of General Medicine, University of Michigan Health System, Ann Arbor, Michigan, United States of America
- Veterans Affairs Center for Practice Management and Outcomes Research, Ann Arbor, Michigan, United States of America
- Institute for Social Research, University of Michigan, Ann Arbor, Michigan, United States of America
- Institute of Gerontology, University of Michigan, Ann Arbor, Michigan, United States of America
- Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, Michigan, United States of America
| | - Kristine Yaffe
- Memory and Aging Center, Department of Neurology, University of California San Francisco, San Francisco, California, United States of America
- San Francisco Veterans Affairs Medical Center, San Francisco, California, United States of America
- Department of Psychiatry, University of California San Francisco, San Francisco, California, United States of America
- Department of Epidemiology & Biostatistics, University of California San Francisco, San Francisco, California, United States of America
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Pu H, Jiang X, Wei Z, Hong D, Hassan S, Zhang W, Liu J, Meng H, Shi Y, Chen L, Chen J. Repetitive and Prolonged Omega-3 Fatty Acid Treatment After Traumatic Brain Injury Enhances Long-Term Tissue Restoration and Cognitive Recovery. Cell Transplant 2016; 26:555-569. [PMID: 27938482 DOI: 10.3727/096368916x693842] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
Traumatic brain injury (TBI) is one of the most disabling clinical conditions that could lead to neurocognitive disorders in survivors. Our group and others previously reported that prophylactic enrichment of dietary omega-3 polyunsaturated fatty acids (n-3 PUFAs) markedly ameliorate cognitive deficits after TBI. However, it remains unclear whether a clinically relevant therapeutic regimen with n-3 PUFAs administered after TBI would still offer significant improvement of long-term cognitive recovery. In the present study, we employed the decline of spatial cognitive function as a main outcome after TBI to investigate the therapeutic efficacy of post-TBI n-3 PUFA treatment and the underlying mechanisms. Mice were subjected to sham operation or controlled cortical impact, followed by random assignment to receive the following four treatments: (1) vehicle control; (2) daily intraperitoneal injections of n-3 PUFAs for 2 weeks, beginning 2 h after TBI; (3) fish oil dietary supplementation throughout the study, beginning 1 day after TBI; or (4) combination of treatments (2) and (3). Spatial cognitive deficits and chronic brain tissue loss, as well as endogenous brain repair processes such as neurogenesis, angiogenesis, and oligodendrogenesis, were evaluated up to 35 days after TBI. The results revealed prominent spatial cognitive deficits and massive tissue loss caused by TBI. Among all mice receiving post-TBI n-3 PUFA treatments, the combined treatment of fish oil dietary supplement and n-3 PUFA injections demonstrated a reproducible beneficial effect in attenuating cognitive deficits although without reducing gross tissue loss. Mechanistically, the combined treatment promoted post-TBI restorative processes in the brain, including generation of immature neurons, microvessels, and oligodendrocytes, each of which was significantly correlated with the improved cognitive recovery. These results indicated that repetitive and prolonged n-3 PUFA treatments after TBI are capable of enhancing brain remodeling and could be developed as a potential therapy to treat TBI victims in the clinic.
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