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

Gender and race in neurotrauma: part 2-underrepresentation in clinical trial enrollment and impact on clinical outcomes

The underrepresentation of women and racial minorities in clinical trials populations remains a persistent challenge across many medical specialties, including Neurosurgery. A diverse research cohort brings varied perspectives and experiences, which can lead to more innovative solutions to medical problems, generalizable findings, and the foundations to provide culturally competent care to the populations most affected by the condition at hand. The importance of representative Neurotrauma trial populations cannot be overstated, as results are essential to inform decision making and gender and race have both been shown to significantly influence patient outcomes, as seen in the traumatic brain injury and spinal cord injury populations. Although the path towards gender and racial parity in clinical trial participants has been slow, numerous actions have been taken, including the FDA Safety and Innovation Act (2012) and Omnibus Reform Act (2022) on a systemic level. In this paper, we aimed to explore the barriers to and implications of inadequate representation in neurotrauma trials to outline a roadmap towards more diverse trial inclusion and retention. Key strategies moving forward include recruiting a diverse research team, developing flexible study protocols that support the varying needs of individuals of different backgrounds, establishing methods of data analysis that control for social and demographic factors instead of excluding individuals from participating, introducing patient navigators, reflecting on systemically engrained biases, implementing mandatory reporting of gender and race data, establishing and analyzing policies that keep researchers accountable towards goals of inclusive recruitment, and identifying and addressing unique barriers that individuals at the intersection of gender and racial minority status face.

Disparities between native americans and white individuals in global outcome trajectories over the 5 years after traumatic brain injury: A model systems study

PURPOSE

Traumatic brain injury (TBI) can lead to a host of challenges and negatively impacts Native Americans more than any other ethnic group in the U.S. Despite this, little research exists on Native Americans with TBI. The current study examined disparities in global outcome trajectories (overall level of function post-injury) between Native Americans and White individuals in the 5 years following TBI and whether sociodemographic or injury-related characteristics could account for this disparity.

METHOD

The current study used a sample of 75 Native Americans demographically matched by sex, age, and injury severity to 75 White individuals from the U.S. Traumatic Brian Injury Model Systems (TBIMS) database (n =  150). A series of hierarchical linear models (HLMs) was used to examine longitudinal global outcome trajectories between the two groups.

RESULTS

Native Americans showed lower global outcome scores than their White counterparts with this difference worsening (i.e., growing larger) over time. The difference in scores and the differential movement over time were associated with differences between the ethnic groups in employment at the time of injury, substance use patterns, and type of insurance.

CONCLUSION

This study highlights the need for identification of and early intervention for risk factors that predict disparities in rehabilitation outcomes and points to the need for greater access to culturally informed care for Native Americans with TBI.

Sex and Genotype Affect Mouse Hippocampal Gene Expression in Response to Blast-Induced Traumatic Brain Injury

Blast-induced traumatic brain injury (bTBI) has been identified as an increasingly prevalent cause of morbidity and mortality in both military and civilian populations over the past few decades. Functional outcomes following bTBI vary widely among individuals, and chronic neurodegenerative effects including cognitive impairments can develop without effective diagnosis and treatment. Genetic predispositions and sex differences may affect gene expression changes in response to bTBI and influence an individual's probability of sustaining long-term damage or exhibiting resilience and tissue repair. Male and female mice from eight genetically diverse and distinct strains (129S1/SvImJ, A/J, C57BL/6J, CAST/EiJ, NOD/ShiLtJ, NZO/HlLtJ, PWK/PhJ, WSB/EiJ) which encompassed 90% of the genetic variability in commercially available laboratory mice were exposed to a single bTBI (180 kPa) using a well-established shock tube system. Subacute changes in hippocampal gene expression due to blast exposure were assessed using RNA-seq at 1-month post-injury. We identified patterns of dysregulation in gene ontology terms and canonical pathways related to mitochondrial function, ribosomal structure, synaptic plasticity, protein degradation, and intracellular signaling that varied by sex and/or strain, including significant changes in genes encoding respiratory complex I of the electron transport chain in male WSB/EiJ mice and the glutamatergic synapse across more than half of our groups. This study represents a multi-level examination of how genetic variability may influence response to bTBI and provides a foundation for the identification of potential therapeutic targets that could be modulated to improve the health of Veterans and others with histories of blast exposures.

Socioeconomic Disparities in the Clinical Outcomes of Pediatric Traumatic Brain Injury: A Nationwide Analysis of the Past Decade

BACKGROUND

Socioeconomic status has historically influenced traumatic brain injury (TBI) outcomes, yet pediatric TBI disparities remain understudied. We aimed to analyze the National Inpatient Sample database for socioeconomic disparities in the outcomes of pediatric TBI patients.

METHODS

The National Inpatient Sample from 2011 to 2020 was retrospectively analyzed for pediatric TBI patients. Socioeconomic variables included age, sex, race, household income, geographic location, and primary expected payer. Outcomes included length of stay (LOS), in-hospital mortality, mortality risk, and illness severity.

RESULTS

A total 45,109 pediatric TBI patients (63.9% male) were identified. Mean age was 7.76 years, mean LOS was 4.57 days, and overall mortality rate was 3.2%. African-American or Native American patients had significantly longer LOS (1.6 and 3.4 days, respectively; P < 0.01) than White patients. African-American patients had an odds ratio of mortality of 1.57 compared to White patients. Female patients had significantly higher mortality risk and LOS (0.5 days) than male patients (P < 0.001). Patients in the bottom 50% of income and those in rural counties had higher odds of mortality (2.20 and 1.27, respectively) compared to higher-income and urban patients. Regional mortality rate differences were significant (P < 0.001), with the East South Central region having the highest rate. Medicaid and self-pay patients had higher LOS (P < 0.001) and odds ratios of mortality (1.19 and 2.36, respectively) compared to private insurance patients.

CONCLUSIONS

This study highlights significant differences based on race, sex, income, insurance type, and geographic location in pediatric TBI outcomes. Future research should focus on identifying factors contributing to inequalities and developing strategies to mitigate them.

Sociodemographic and Health Characteristics of Hispanic Veteran Patients With Traumatic Brain Injury and Its Association to Mortality: A Pilot Study

INTRODUCTION

Traumatic brain injury (TBI) is among the most common conditions in the military. VA Caribbean Healthcare System (VACHS) patients with Traumatic Brain Injury (TBI) have a higher mortality rate than Veterans in other VA health care systems in the United States. The main goal of this study was to develop sociodemographic profiles and outline health characteristics of Hispanic patients with TBI treated at the VA Caribbean Healthcare System in a search for potential explanations to account for the higher mortality rate. This study advocates for equity in health services provided for minorities inside the militia.

MATERIALS AND METHODS

Data collected from electronic medical records and VA databases were used to create sociodemographic and health characteristics profiles, in addition to survival models. The population of the study were post 911 Veteran soldiers who had been diagnosed with TBI. Adjusted models were created to provide hazard ratios (HR) for mortality risk.

RESULTS

Out of the 16,549 files available from all 10 selected VA sites, 526 individuals were identified as treated at the VACHS. Of 526 subjects screened, 39 complied with the inclusion/exclusion criteria. Results include: 94.4% male, 48.7% between the ages of 21 and 41 years, 89.7% have depression, 66.7% have post-traumatic stress disorder (PTSD), 82.1% receive occupational therapy, 94.9% have severe headaches, 100% suffer from pain, 94.9% have memory problems, and 10.3% have had suicidal thoughts. Over 60% had a first-hand explosion experience, be it just the explosion or with another type of injury. Data showed that 33% of our patients had a Magnetic Resonance Imaging (MRI), 31% had a CT, 15.4% had a SPECT, and 2.6% had PET scan. Significant associations were found between MRIs and speech therapies, and MRIs and total comorbidities. The Cox proportional-hazards model for survival adjusted for age, gender, race/ethnicity, and comorbidities shows that VACHS Veterans diagnosed with a TBI had a higher mortality risk rate (HR 1.23 [95% CI 1.10, 1.37]) when compared to the other 9 health centers with the highest percentage of Hispanic Veterans.

CONCLUSIONS

Since explosions were the most common mechanism of injury, further research is needed into the experiences of Veterans in connection with this specific variable. A high percentage of the patients suffered from depression and PTSD. Additionally, over half of the patients had an unmeasured TBI severity. The effects these aspects have on symptomatology and how they hinder the recovery process in Hispanic patients should be examined in further detail. It is also important to highlight that family and friends' support could be key for injury treatment. This study highlights the use of the 4 types of scans (MRI, CT, PET/CT, and SPECT/CT) as ideal diagnosis tools. The alarming number of patients with suicidal thoughts should be a focus in upcoming studies. Future studies should aim to determine whether increased death rates in TBI Veterans can be linked to other United States islander territories. Concepts, such as language barriers, equal resource allocation, and the experiences of Veterans with TBIs should be further explored in this Veteran population.

Nanoparticle targeting strategies for traumatic brain injury

Nanoparticle (NP)-based drug delivery systems hold immense potential for targeted therapy and diagnosis of neurological disorders, overcoming the limitations of conventional treatment modalities. This review explores the design considerations and functionalization strategies of NPs for precise targeting of the brain and central nervous system. This review discusses the challenges associated with drug delivery to the brain, including the blood-brain barrier and the complex heterogeneity of traumatic brain injury. We also examine the physicochemical properties of NPs, emphasizing the role of size, shape, and surface characteristics in their interactions with biological barriers and cellular uptake mechanisms. The review concludes by exploring the options of targeting ligands designed to augment NP affinity and retention to specific brain regions or cell types. Various targeting ligands are discussed for their ability to mimic receptor-ligand interaction, and brain-specific extracellular matrix components. Strategies to mimic viral mechanisms to increase uptake are discussed. Finally, the emergence of antibody, antibody fragments, and antibody mimicking peptides are discussed as promising targeting strategies. By integrating insights from these scientific fields, this review provides an understanding of NP-based targeting strategies for personalized medicine approaches to neurological disorders. The design considerations discussed here pave the way for the development of NP platforms with enhanced therapeutic efficacy and minimized off-target effects, ultimately advancing the field of neural engineering.

Epidemiology of Head Injury and Associations with Clinical and Neuropsychological Test Scores in Older American Indians: Data from the Strong Heart Study

BACKGROUND

American Indians have the highest mortality and hospitalizations from head injury of all US groups; however, little is known about prevalence, risk, or outcomes in this population.

METHODS

The Strong Heart Study recruited American Indians representing 11 tribes and communities across three regions for two sequential examinations in 2010-2019. Participants were asked to self-report prior head injury, loss of consciousness (LOC), cause, sociodemographics, and behaviors (age, sex, education, bilingual, smoking, alcohol use, stroke). Cognitive testing covered executive function, phonemic fluency, processing speed, and memory. Analyses tabulated summaries and multivariate logistic regressions estimated risk associations.

RESULTS

This older cohort of American Indians (visit 1 N = 818, follow-up visit 2 N = 403) was mean age 73 at intake, with mean 6.7 years between exams. At visit 1, 40% reported prior head injury, majority with LOC; 4-6% reported injury with LOC > 20 min. Incidence analysis estimated 3.5 cases per 100 person-years. Primary causes were falls, motor vehicles, sports, fight or assault, military (bullet, blast, fragment), and horse-riding incidents. Male sex and prior stroke were independently associated with higher risk, but age, education, bilingual, smoking, and alcohol use were not associated with risk. Those with previous head injury had significantly worse depressive symptoms, quality of life, fatigue, social functioning, pain, general health, and processing speed.

CONCLUSION

These findings suggest very high prevalence, incidence, and risk of head injury in older American Indians, with substantial impacts on quality of life and well-being. Future research should prospectively evaluate risk and prevention opportunities in this population.

Long-Term Outcomes After Severe Acute Brain Injury Requiring Mechanical Ventilation: Recovery Trajectories Among Patients and Mental Health Symptoms of Their Surrogate Decision Makers

BACKGROUND

Long-term outcomes of patients with severe acute brain injury (SABI) and their surrogate decision makers (SDMs) are insufficiently explored.

METHODS

We conducted a prospective, single-center, observational study of patients with SABI who required mechanical ventilation between September and November 2021. Two telephonic interviews were conducted at 6-12 months and 18-24 months post SABI. Patients' functional outcomes at both time points were measured on the Glasgow Outcome Scale-Extended and categorized as dead (1), dependent (2-4), or independent (5-8). SDMs were interviewed at 18-24 months using validated screening tools for depression, anxiety, and posttraumatic stress disorder and qualitative questions about the hardest challenges during their recovery journey.

RESULTS

We included 103 patients (median age 58 years, 28% female, 77% White, 51% with stroke, 49% with traumatic brain injury); in-hospital mortality was 46%. At 6-12 months and 18-24 months, 34% and 36% were independent, respectively; the Glasgow Outcome Scale-Extended score improved ≥ 1 point for 32% between time points. Quality of life was perceived as acceptable for 47% of all survivors and 58% of independent patients by their SDMs. At 18-24 months, we reached 56 SDMs (median age 58 years, 71% female, 72% White). Symptoms of depression, anxiety, and posttraumatic stress disorder were reported in 18%, 30%, and 7%, respectively (23%, 34%, and 9% in the 35 SDMs of survivors and 10%, 24%, and 5% in the 21 SDMs to deceased patients). Main themes about challenges for patients and SDMs included extrinsic factors related to the health care system, and intrinsic factors related to the brain injury: difficulties in adapting to a new state, mental health symptoms, and social isolation.

CONCLUSIONS

Mental health symptoms among SDMs of patients with SABI were frequent at 18-24 months, and the patients' quality of life was deemed unacceptable for 42% of SDMs to independent survivors. Our findings underscore the need for psychosocial support to SDMs, the importance of addressing modifiable barriers to patient and SDM well-being, and the need for more patient/family-centric outcome measures.

Rehabilitation and violence-related traumatic brain injury: A scoping review

OBJECTIVES

There is a dearth of reviews exploring rehabilitation for violence-related traumatic brain injury (TBI) despite its increasing rates and distinct risk factors and outcomes. The aim of this scoping review is to determine the extent to which rehabilitation is available to and accessed by people who sustain TBI from interpersonal violence.

METHOD

Electronic databases (i.e., MEDLINE, Cochrane CENTRAL Register of Clinical Trials, CINAHL, APA PsycINFO, Criminal Justice Abstracts, Applied Social Sciences Index and Abstracts, and Proquest Nursing and Allied Health) and grey literature (i.e., relevant organizations' websites) were systematically searched for peer-reviewed articles and reports that met eligibility criteria. To be included, articles had to report primary findings on rehabilitation interventions that included individuals who sustained a TBI through interpersonal violence. Articles based on the military population were excluded. Data were synthesized through a descriptive numerical summary and qualitative content analysis.

RESULTS

Fifty-two primary research articles and five grey literature reports were included. Most (77.2%) of these articles described rehabilitation interventions that addressed TBI sequalae without consideration for violence as a mechanism of injury, beyond reporting sample characteristics. Only thirteen articles (22.4%) considered violence-related TBI by investigating the rehabilitation profile (13.8%) or designing programs specifically for survivors of violence-related TBI (8.6%). There was limited attention to social determinants of health across all studies.

CONCLUSION

This is the first scoping review to our knowledge that explored the extent and nature of rehabilitation among persons who experience TBI through violence in civilian populations. Priorities for education, research, and practice are identified.

Racial and Ethnic Differences in Traumatic Brain Injury Outcomes From 2009 to 2023: Protocol for a Systematic Review

BACKGROUND

In 2009, Gary and colleagues reviewed prior research examining racial and ethnic differences in outcomes after traumatic brain injury (TBI). Over the past 15 years, advances in research and changes in the demographic composition of the United States warrant a comprehensive understanding of racial and ethnic disparities after TBI.

OBJECTIVE

A systematic review will be conducted to examine racial and ethnic differences in TBI outcomes from 2009 to 2023.

METHODS

Preliminary searches and study screening processes will identify relevant English-language articles published from January 2009 to December 2023 using the CINAHL, Gale OneFile, PsycINFO (Ovid), and PubMed electronic databases. Relevant articles will include quantitative or mixed method approaches, involve individuals with TBI or their caregivers, and compare 2 or more groups by race or ethnicity on post-TBI outcomes. Quality will be assessed using the Newcastle-Ottawa Scale. This systematic review protocol was developed following PRISMA-P (Preferred Reporting Items for Systematic Review and Meta-Analysis Protocols) guidelines. Results will be summarized, and a subgroup analysis may be conducted based on demographics (eg, age, gender, or sex).

RESULTS

We have already identified abstracts using the search strategy for all 4 of the included electronic databases. We recently updated the search and will begin abstract screening of the additional abstracts identified from the last search completed in January 2024. This systematic review is anticipated to be completed by fall 2024, and its findings will be disseminated to the scientific community, persons with TBI, caregivers, and the lay audience.

CONCLUSIONS

This systematic review will advance our understanding regarding outcome disparities among minoritized individuals with TBI, examine progress over the past 15 years in minimizing barriers encountered by these racial and ethnic groups, and provide professionals with a roadmap illustrating existing gaps in rehabilitation care, making way for further development and implementation of evidence-based interventions to improve health equity in TBI outcomes.

TRIAL REGISTRATION

PROSPERO CRD42023394529; https://tinyurl.com/53mtcz9b.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

PRR1-10.2196/58763.

Clinical implications of head trauma in frontotemporal dementia and primary progressive aphasia

BACKGROUND

Traumatic brain injury (TBI) and repetitive head impacts (RHI) have been linked to increased risk for multiple types of neurodegenerative disease, higher dementia risk, and earlier age of dementia symptom onset, suggesting transdiagnostic implications for later-life brain health. Frontotemporal dementia (FTD) and primary progressive aphasia (PPA) represent a spectrum of clinical phenotypes that are neuropathologically diverse. FTD/PPA diagnoses bring unique challenges due to complex cognitive and behavioral symptoms that disproportionately present as an early-onset dementia (before age 65). We performed a detailed characterization of lifetime head trauma exposure in individuals with FTD and PPA compared to healthy controls to examine frequency of lifetime TBI and RHI and associated clinical implications.

METHODS

We studied 132 FTD/PPA (age 68.9 ± 8.1, 65% male) and 132 sex-matched healthy controls (HC; age 73.4 ± 7.6). We compared rates of prior TBI and RHI (contact/collision sports) between FTD/PPA and HC (chi-square, logistic regression, analysis of variance). Within FTD/PPA, we evaluated associations with age of symptom onset (analysis of variance). Within behavioral variant FTD, we evaluated associations with cognitive function and neuropsychiatric symptoms (linear regression controlling for age, sex, and years of education).

RESULTS

Years of participation were greater in FTD/PPA than HC for any contact/collision sport (8.5 ± 6.7yrs vs. 5.3 ± 4.5yrs, p = .008) and for American football (6.2yrs ± 4.3yrs vs. 3.1 ± 2.4yrs; p = .003). Within FTD/PPA, there were dose-dependent associations with earlier age of symptom onset for TBI (0 TBI: 62.1 ± 8.1, 1 TBI: 59.9 ± 6.9, 2 + TBI: 57.3 ± 8.4; p = .03) and years of American football (0yrs: 62.2 ± 8.7, 1-4yrs: 59.7 ± 7.0, 5 + yrs: 55.9 ± 6.3; p = .009). Within bvFTD, those who played American football had worse memory (z-score: -2.4 ± 1.2 vs. -1.4 ± 1.6, p = .02, d = 1.1).

CONCLUSIONS

Lifetime head trauma may represent a preventable environmental risk factor for FTD/PPA. Dose-dependent exposure to TBI or RHI influences FTD/PPA symptom onset and memory function in bvFTD. Clinico-pathological studies are needed to better understand the neuropathological correlates linking RHI or TBI to FTD/PPA onset and symptoms.

Traumatic Brain Injury, Seizures, and Cognitive Impairment Among Older Adults

Importance

Traumatic brain injury (TBI), seizures, and dementia increase with age. There is a gap in understanding the associations of TBI, seizures, and medications such as antiseizure and antipsychotics with the progression of cognitive impairment across racial and ethnic groups.

Objective

To investigate the association of TBI and seizures with the risk of cognitive impairment among cognitively normal older adults and the role of medications in moderating the association.

Design, Setting, and Participants

This multicenter cohort study was a secondary analysis of the Uniform Data Set collected between June 1, 2005, and June 30, 2020, from the National Alzheimer's Coordination Center. Statistical analysis was performed from February 1 to April 3, 2024. Data were collected from participants from 36 Alzheimer's Disease Research Centers in the US who were 65 years or older at baseline, cognitively normal at baseline (Clinical Dementia Rating of 0 and no impairment based on a presumptive etiologic diagnosis of AD), and had complete information on race and ethnicity, age, sex, educational level, and apolipoprotein E genotype.

Exposure

Health history of TBI, seizures, or both conditions.

Main Outcomes and Measures

Progression to cognitive impairment measured by a Clinical Dementia Rating greater than 0.

Results

Among the cohort of 7180 older adults (median age, 74 years [range, 65-102 years]; 4729 women [65.9%]), 1036 were African American or Black (14.4%), 21 were American Indian or Alaska Native (0.3%), 143 were Asian (2.0%), 332 were Hispanic (4.6%), and 5648 were non-Hispanic White (78.7%); the median educational level was 16.0 years (range, 1.0-29.0 years). After adjustment for selection basis using propensity score weighting, seizure was associated with a 40% higher risk of cognitive impairment (hazard ratio [HR], 1.40; 95% CI, 1.19-1.65), TBI with a 25% higher risk of cognitive impairment (HR, 1.25; 95% CI, 1.17-1.34), and both seizure and TBI were associated with a 57% higher risk (HR, 1.57; 95% CI, 1.23-2.01). The interaction models indicated that Hispanic participants with TBI and seizures had a higher risk of cognitive impairment compared with other racial and ethnic groups. The use of antiseizure medications (HR, 1.23; 95% CI, 0.99-1.53), antidepressants (HR, 1.32; 95% CI, 1.17-1.50), and antipsychotics (HR, 2.15; 95% CI, 1.18-3.89) was associated with a higher risk of cognitive impairment, while anxiolytic, sedative, or hypnotic use (HR, 0.88; 95% CI, 0.83-0.94) was associated with a lower risk.

Conclusions and Relevance

This study highlights the importance of addressing TBI and seizures as risk factors for cognitive impairment among older adults. Addressing the broader social determinants of health and bridging the health divide across various racial and ethnic groups are essential for the comprehensive management and prevention of dementia.

Traumatic brain injury, race, ethnicity and cognition in newly diagnosed persons with multiple sclerosis

We sought to determine whether a history of traumatic brain injury (TBI) could explain the lower symbol digit modalities test (SDMT) scores observed among newly diagnosed multiple sclerosis (MS) and control participants identifying as Black or Hispanic versus white in the MS Sunshine Study (n = 1172). 330 (29.2 %) participants reported a history of ≥1 TBI. Accounting for TBI did not explain the significant independent associations between having MS, being Black or Hispanic and lower SDMT. The pervasive effects of systemic racism in the United States remain the best explanation for the lower SDMT scores observed in Black and Hispanic participants.

Linking Type and Extent of Head Trauma to Cavum Septum Pellucidum in Older Adults With and Without Alzheimer Disease and Related Dementias

BACKGROUND AND OBJECTIVES

Cavum septum pellucidum (CSP) is a common but nonspecific MRI finding in individuals with prior head trauma. The type and extent of head trauma related to CSP, CSP features specific to head trauma, and the impact of brain atrophy on CSP are unknown. We evaluated CSP cross-sectionally and longitudinally in healthy and clinically impaired older adults who underwent detailed lifetime head trauma characterization.

METHODS

This is an observational cohort study of University of California, San Francisco Memory and Aging Center participants (healthy controls [HCs], those with Alzheimer disease or related dementias [ADRDs], subset with traumatic encephalopathy syndrome [TES]). We characterized traumatic brain injury (TBI) and repetitive head impacts (RHI) through contact/collision sports. Study groups were no RHI/TBI, prior TBI only, prior RHI only, and prior RHI + TBI. We additionally looked within TBI (1, 2, or 3+) and RHI (1-4, 5-10, and 11+ years). All underwent baseline MRI, and 67% completed a second MRI (median follow-up = 5.4 years). CSP measures included grade (0-4) and length (millimeters). Groups were compared on likelihood of CSP (logistic regression, odds ratios [ORs]) and whether CSP length discriminated groups (area under the curve [AUC]).

RESULTS

Our sample included 266 participants (N = 160 HCs, N = 106 with ADRD or TES; age 66.8 ± 8.2 years, 45.3% female). Overall, 123 (49.8%) participants had no RHI/TBI, 52 (21.1%) had TBI only, 41 (16.6%) had RHI only, 31 (12.6%) had RHI + TBI, and 20 were classified as those with TES (7.5%). Compared with no RHI/TBI, RHI + TBI (OR 3.11 [1.23-7.88]) and TES (OR 11.6 [2.46-54.8]) had greater odds of CSP. Approximately 5-10 years (OR 2.96 [1.13-7.77]) and 11+ years of RHI (OR 3.14 [1.06-9.31]) had higher odds of CSP. CSP length modestly discriminated participants with 5-10 years (AUC 0.63 [0.51-0.75]) and 11+ years of prior RHI (AUC 0.69 [0.55-0.84]) from no RHI/TBI (cut point = 6 mm). Strongest effects were noted in analyses of American football participation. Longitudinally, CSP grade was unchanged in 165 (91.7%), and length was unchanged in 171 (95.5%) participants.

DISCUSSION

Among older adults with and without neurodegenerative disease, risk of CSP is driven more by duration (years) of RHI, especially American football, than number of TBI. CSP length (≥6 mm) is relatively specific to individuals who have had substantial prior RHI. Neurodegenerative disease and progressive atrophy do not clearly influence development or worsening of CSP.

What Are the Predictors for and Psychosocial Correlates of Chronic Headache After Moderate to Severe Traumatic Brain Injury?

OBJECTIVE

Although headache (HA) is a common sequela of traumatic brain injury (TBI), early predictors of chronic HA after moderate to severe TBI are not well established, and the relationship chronic HA has with psychosocial functioning is understudied. Thus, we sought to (1) determine demographic and injury predictors of chronic HA 1 or more years after moderate to severe TBI and (2) examine associations between chronic HA and psychosocial outcomes.

SETTING

Community.

PARTICIPANTS

Participants in the TBI Model System (TBIMS) with moderate to severe TBI who consented for additional chronic pain questionnaires at the time of TBIMS follow-up.

DESIGN

Multisite, observational cohort study using LASSO (least absolute shrinkage and selection operator) regression for prediction modeling and independent t tests for psychosocial associations.

MAIN OUTCOME MEASURES

Chronic HA after TBI at year 1 or 2 postinjury and more remotely (5 or more years).

RESULTS

The LASSO model for chronic HA at 1 to 2 years achieved acceptable predictability (cross-validated area under the curve [AUC] = 0.70). At 5 or more years, predictability was nearly acceptable (cross-validated AUC = 0.68), but much more complex, with more than twice as many variables contributing. Injury characteristics had stronger predictive value at postinjury years 1 to 2 versus 5 or more years, especially sustained intracranial pressure elevation (odds ratio [OR] = 3.8) and skull fragments on head computed tomography (CT) (OR = 2.5). Additional TBI(s) was a risk factor at both time frames, as were multiple socioeconomic characteristics, including lower education level, younger age, female gender, and Black race. Lower education level was a particularly strong predictor at 5 or more years (OR up to 3.5). Emotional and participation outcomes were broadly poorer among persons with chronic HA after moderate to severe TBI.

CONCLUSIONS

Among people with moderate to severe TBI, chronic HA is associated with significant psychosocial burden. The identified risk factors will enable targeted clinical screening and monitoring strategies to enhance clinical care pathways that could lead to better outcomes. They may also be useful as stratification or covariates in future clinical trial research on treatments.

Phytochemical Constituents from the Seeds of Capsella bursa-pastoris and Their Antioxidant Activities

Phytochemical investigation of 70% EtOH extract of the seeds of Capsella bursa-pastoris led to the isolation of a new cyclobutane organic acid (1), and fourteen known compounds, including two organosulfur compounds (2, 3), two quinonoids (4, 5), five flavonoids (6-10), three sterols (11-13) and two other types (14, 15). The structures of the compounds were elucidated by extensive spectroscopic analyses as well as comparison of their spectroscopic data with those reported in the literature. The antioxidant capacities of all compounds and extractive fractions were evaluated by the 2,2-diphenyl-1-picrylhydrazyl (DPPH) radical-scavenging test and ferric reducing antioxidant power (FRAP) assay. Then the antioxidative substances were evaluated for their neuroprotective effects against H2O2-induced HT22 cell injury. The results indicated the strong scavenging ability to free radical of the extractive fractions and compounds 1-3, 8-10 and 13, and the ferric reducing antioxidant power of the extractive fractions and compounds 1-3, 8 and 10, which were close to or higher than that of the positive control trolox. The EtOAc fraction, n-BuOH fraction, and compounds 1, 3 and 8 can protect HT-22 cells from oxidative damage.

Pediatric Traumatic Brain Injury: Impact on the Developing Brain

Traumatic brain injury (TBI) is a serious public health concern impacting millions of children and adolescents each year. Experiencing a brain injury during key critical periods of brain development can affect the normal formation of brain networks that are responsible for a range of complex neurocognitive outcomes. In addition, there are multiple pre- and postinjury factors that influence the trajectory of recovery and outcomes. In this review, we will focus on the current state of the literature within pediatric TBI; systematically review the available research on developmental aspects of TBI in children, focusing on the pathophysiology of the injury and its impact on the developing brain; and highlight knowledge gaps for further exploration.

An update on pediatric traumatic brain injury

INTRODUCTION

Traumatic brain injury (TBI) remains the commonest neurological and neurosurgical cause of death and survivor disability among children and young adults. This review summarizes some of the important recent publications that have added to our understanding of the condition and advanced clinical practice.

METHODS

Targeted review of the literature on various aspects of paediatric TBI over the last 5 years.

RESULTS

Recent literature has provided new insights into the burden of paediatric TBI and patient outcome across geographical divides and the severity spectrum. Although CT scans remain a standard, rapid sequence MRI without sedation has been increasingly used in the frontline. Advanced MRI sequences are also being used to better understand pathology and to improve prognostication. Various initiatives in paediatric and adult TBI have contributed regionally and internationally to harmonising research efforts in mild and severe TBI. Emerging data on advanced brain monitoring from paediatric studies and extrapolated from adult studies continues to slowly advance our understanding of its role. There has been growing interest in non-invasive monitoring, although the clinical applications remain somewhat unclear. Contributions of the first large scale comparative effectiveness trial have advanced knowledge, especially for the use of hyperosmolar therapies and cerebrospinal fluid drainage in severe paediatric TBI. Finally, the growth of large and even global networks is a welcome development that addresses the limitations of small sample size and generalizability typical of single-centre studies.

CONCLUSION

Publications in recent years have contributed iteratively to progress in understanding paediatric TBI and how best to manage patients.

Psychiatric sequelae of traumatic brain injury - future directions in research

Despite growing appreciation that traumatic brain injury (TBI) is an important public health burden, our understanding of the psychiatric and behavioural consequences of TBI remains limited. These changes are particularly detrimental to a person's sense of self, their relationships and their participation in the wider community, and they continue to have devastating individual and cumulative effects long after TBI. This Review relates specifically to TBIs that confer objective clinical or biomarker evidence of structural brain injury; symptomatic head injuries without such evidence are outside the scope of this article. Common psychiatric, affective and behavioural sequelae of TBI and their proposed underlying mechanisms are outlined, along with a brief overview of current treatments. Suggestions for how scientists and clinicians can work together in the future to address the chasms in clinical care and knowledge are discussed in depth.

Pediatric Traumatic Brain Injury in Malawi: A Propensity-Weighted Analysis of Outcomes and Trends Over Time

BACKGROUND

Pediatric injuries contribute to substantial mortality and morbidity worldwide, particularly in sub-Saharan Africa. We aim to identify predictors of mortality and time trends for pediatric traumatic brain injuries (TBIs) in Malawi.

METHODS

We performed a propensity-matched analysis of data from the trauma registry at Kamuzu Central Hospital in Malawi from 2008 to 2021. All children ≤16 years of age were included. Demographic and clinical data were collected. Outcomes were compared between patients with and without head injuries.

RESULTS

A cohort of 54,878 patients was included, with 1755 having TBI. The mean ages of patients with and without TBI were 7.8 ± 7.8 years and 7.1 ± 4.5 years, respectively. The most common mechanism for patients with and without TBI was road traffic injury and falls, respectively (48.2% vs. 47.8%, P < 0.01). The crude mortality rate for the TBI cohort was 20.9% compared to 2.0% in the non-TBI cohort (P < 0.01). After propensity matching, patients with TBI had 4.7 higher odds of mortality (95% confidence interval 1.9-11.8). Over time, patients with TBI had an increasing predicted probability of mortality for all age categories, with the most significant increase among children younger than 1 year.

CONCLUSIONS

TBI confers a greater than 4-fold higher likelihood of mortality in this pediatric trauma population in a low-resource setting. These trends have worsened over time.