Long-term causes of death after traumatic brain injury

Cardiorespiratory fitness assessment and training in the early sub-acute phase of recovery following traumatic brain injury: a systematic review

OBJECTIVES

To examine the safety of cardiorespiratory fitness (CRF) assessment and training in the early sub-acute phase of recovery (≤3 months) following moderate-to-extremely severe traumatic brain injury (TBI).

METHODS

A systematic review was completed in accordance with the PRISMA guidelines. Studies investigating adults and adolescents ≥15 years with moderate-to-extremely severe TBI were considered for inclusion. The methodological quality of the included studies was evaluated according to the McMaster Guidelines for Critical Review Form - Quantitative Studies.

RESULTS

Eleven studies with a total of 380 participants were included in the review. Adverse events (AEs) and symptom monitoring were poorly reported. Only four studies reported on the occurrence of AEs, with a total of eight AEs reported. Three of the reported AEs were concussion-like symptoms with no further exercise-induced symptom exacerbation reported. No serious AEs were reported.

CONCLUSION

There is no evidence to suggest that CRF assessment and training is unsafe in the early sub-acute phase of recovery following moderate-to-extremely severe TBI. However, despite the low AE and symptom exacerbation rates identified, a timeframe for safe commencement was unable to be established due to poor reporting and/or monitoring of exercise-induced symptoms and AEs in the current literature.

The impact of physical activity on the quality of life of a sample of Italian people with physical disability

Physical activity promotes psychophysical health; however, to date, only few studies have investigated the association between regular physical activity and the quality-of-life perception and satisfaction in disabled persons. Our aim was to compare the quality and satisfaction for life, self-efficacy, and personal wellbeing of two samples of Italian people with physical disability (amputation, spinal cord dysfunction, neurological disability): one group with people who practiced regular physical activity (active group, n = 33) and the other group consisting of sedentary individuals (inactive group, n = 26). We compared the mean scores of the groups in the World Health Organization Quality of Life Questionnaire (WHOQoL-BRIEF), the Personal Wellbeing Index, and the Satisfaction With Life and General Self-Efficacy scales. We also compared the impact of rehabilitation, sport, family support, income, job/school, and raising a family on social life and life quality by means of separate MANOVAs. Results of the WHOQoL showed better quality of life in the active than in the inactive group (overall QOL, 4.09 ± 0.7 vs. 3.50 ± 0.9; psychological domain, 72.09 ± 12.7 vs. 62 ± 21.6; social relationships domain, 76.54 ± 16.4 vs. 59.52 ± 24.2). No difference was found for satisfaction with health and life, personal wellbeing, and self-efficacy. The impact of sport on social life and quality of life was greater in active than in inactive individuals. Findings suggest positive effects of physical activity on the perception of quality of life in disabled people. However, they do not allow disentangling whether physical activity is practiced by patients with good quality of life or whether physical activity is responsible for better quality of life.

Carotid Arterial Compliance and Aerobic Exercise Training in Chronic Traumatic Brain Injury: A Pilot Study

OBJECTIVE

Decreased carotid arterial compliance (CAC) is associated with cerebral microvascular damage, cerebral blood flow (CBF) dysregulation, and increased risk for stroke and dementia, which are reported to be prevalent after traumatic brain injury (TBI). However, the effect of TBI on CAC has not been reported. The purposes of this pilot study were to (1) compare CAC between participants with chronic traumatic brain injury (cTBI) and age-matched healthy control (HC) subjects and (2) to examine whether CAC changed after 3 months of exercise training in those with cTBI.

SETTING

Community based.

PARTICIPANTS

Nineteen participants with cTBI (6-72 months postinjury) and 19 HC matched for age and sex were tested at baseline. The same cTBI cohort was enrolled in a proof-of-concept randomized controlled exercise training program to investigate the effects of 3 months of aerobic exercise training (AET) or nonaerobic stretching and toning (SAT) on cerebrovascular parameters.

DESIGN

Cross-sectional study and randomized controlled trial.

MAIN MEASURES

CAC was measured by tonometry and ultrasonography at the common carotid artery; CBF was measured by ultrasonography at the bilateral internal carotid and vertebral arteries, and pulsatile CBF was measured by transcranial Doppler ultrasonography at the middle cerebral arteries. Cerebrovascular resistance (CVR) was calculated as mean arterial pressure divided by total CBF.

RESULTS

Relative to HC, the participants with cTBI had lower CAC (0.10 ± 0.03 vs 0.12 ± 0.03 mm 2 /mm Hg, P = .046) and higher CVR (0.17 ± 0.03 vs 0.15 ± 0.03 mm Hg/mL/min, P = .028). CAC tended to increase after AET compared with SAT ( P = .080). Increases in CAC were associated with decreased pulsatile CBF ( r = -0.689, P = .003).

CONCLUSION

These findings suggest that the individuals with cTBI have decreased CAC, which may potentially be improved by AET.

Prevalence of suicidal ideation and suicide attempt among patients with traumatic brain injury: A meta-analysis

BACKGROUND

Suicidality is common among patients with traumatic brain injury (TBI). This meta-analysis aimed to assess the prevalence of suicidal ideation (SI) and suicide attempt (SA) in TBI patients.

METHODS

Databases including PubMed, Cochrane Library, Embase, CINAHL, Web of Science, PsycINFO, China National Knowledge Infrastructure (CNKI), VIP, WanFang Data, and Chinese Biomedical Literature Database (CBM) were searched for relevant literature from inception to 9th January 2021. Random effects models were used to estimate the prevalence of SI and SA. The methodological quality of the included studies was assessed using the modified Newcastle-Ottawa Scale. Subgroup analysis was performed based on the geographical location of the institutions.

RESULTS

A total of 16 studies involving 1,146,271 patients with TBI were included in our meta-analysis. The prevalence of SI and SA were 19.1% (95% CI 13.6-24.6%) and 2.1% (95% CI 1.8-2.4%), respectively, while the prevalence of SA in Asian and non-Asian countries were 2.0% (95% CI 0.3-3.7%) and 2.0% (95% CI 1.6-2.3%). Meta-regression analyses revealed that the publication year and age were positively associated, while the geographical location of the institution and sample size were negatively associated with the pooled prevalence of SI. On the other hand, the geographical location of the institution, sample size and age were negatively associated with the pooled prevalence of SA.

LIMITATIONS

The overall heterogeneity between studies was high.

CONCLUSION

SI and SA are common among TBI patients. Therefore, targeted preventive measures are paramount to manage TBI-related suicide.

The timeframe for safe resumption of high-level mobility following traumatic brain injury is currently unknown: a systematic review

PURPOSE

To examine the safety of high-level mobility (HLM) prescription in the early sub-acute phase of recovery following moderate-to-extremely severe traumatic brain injury (TBI) with specific focus on provocation of concussion-like symptoms.

DESIGN

Systematic review. PROSPERO ID: CRD42017069369.

MAIN MEASURES

Extracted data included study design, brain injury severity, time to commence HLM, type of HLM, physiological and symptom monitoring, and rate of adverse events.

RESULTS

Nineteen studies were included in the review. Fifteen studies included participants who commenced HLM within 6 weeks of injury, with the earliest time to commencement being 3 days. Overall, adverse events and symptom monitoring were poorly reported. A total of six adverse events were reported across three studies. One of the six adverse events was a concussion-like symptom. No falls were reported. No studies monitored concussion-like symptom provocation in direct relation to HLM.

CONCLUSION

A safe timeframe for return to HLM after moderate-to-extremely severe TBI could not be determined due to insufficient reporting of symptom monitoring and adverse events. Further research into the safety of HLM in the early sub-acute rehabilitative stage after moderate-to-extremely severe TBI is required in order to better understand potential sequelae in this population.IMPLICATIONS FOR REHABILITATIONHigh-level mobility assessment and training is commonly reported in the early sub-acute phase of recovery following moderate-to-extremely severe traumatic brain injury.There is no consensus on a safe timeframe to commence high-level mobility assessment or training after moderate-to-extremely severe traumatic brain injury.High-level mobility assessment and training appears to be safe in the early sub-acute phase following moderate-to-extremely severe traumatic brain injury, however, adverse events and symptoms are poorly reported.Clinicians should continue to proceed with caution when assessing and prescribing high-level mobility for patients with moderate-to-extremely severe traumatic brain injury in the early sub-acute phase of recovery and monitor for risks such as falls and exacerbation of concussion-like symptoms.

Cause of Death after Traumatic Brain Injury: A Population-Based Health Record Review Analysis Referenced for Nonhead Trauma

INTRODUCTION

Traumatic brain injury (TBI) is a leading cause of disability and is associated with decreased survival. Although it is generally accepted that TBI increases risk of death in acute and postacute periods after injury, causes of premature death after TBI in the long term are less clear.

METHODS

A cohort sample of Olmsted County, Minnesota, residents with confirmed TBI from January 1987 through December 1999 was identified. Each case was assigned an age- and sex-matched non-TBI referent case, called regular referent. Confirmed TBI cases with simultaneous nonhead injuries were identified, labeled special cases. These were assigned 2 age- and sex-matched special referents with nonhead injuries of similar severity. Underlying causes of death in each case were categorized using death certificates, International Classification of Diseases, Ninth Revision, International Statistical Classification of Diseases, Tenth Revision, and manual health record review. Comparisons were made over the study period and among 6-month survivors.

RESULTS

Case-regular referent pairs (n = 1,257) were identified over the study period, and 221 were special cases. In total, 237 deaths occurred among these pairs. A statistically significant difference was observed between total number of deaths among all cases (n = 139, 11%) and regular referents (n = 98, 8%) (p = 0.006) over the entire period. This outcome was not true for special cases (32/221, 14%) and special referents (61/441, 14%) (p = 0.81). A greater proportion of deaths by external cause than all other causes was observed in all cases (52/139, 37%) versus regular referents (3/98, 3%) and in special cases (13/32, 41%) versus special referents (5/61, 8%) (p < 0.001 for both). Among all case-referent pairs surviving 6 months, no difference was found between total number of deaths (p = 0.82). The underlying cause of death between these 2 groups was significantly different for external causes only (p < 0.01). For special cases surviving 6 months versus special referents, no difference was observed in total number of deaths (p = 0.24) or underlying causes of death (p = 1.00) between groups.

DISCUSSION/CONCLUSION

This population-based case-matched referent study showed that increased risk of death after TBI existed only during the first 6 months after injury, and the difference was due to external causes.

The effects of exercise to promote quality of life in individuals with traumatic brain injuries: a systematic review

OBJECTIVE

To systematically review the effects of exercise interventions that may enhance quality of life (QOL) in individuals with traumatic brain injury (TBI).

METHODS

A systematic search was conducted using five databases up to April 2018. Studies were included if QOL was quantified following an exercise programme for people with a TBI. Methodological quality was assessed using a validated scoring checklist. Two independent reviewers assessed study inclusion and methodological quality.

RESULTS

Thirteen studies met the inclusion criteria (seven RCTs, six non-RCTs). The median total scores for the quality assessment tool were 26.1 (RCTs), and 21.3 (non-RCTs), out of 33. Eight out of the 13 studies reported improved QOL following an exercise programme. The duration of the interventions varied from 8-12 weeks. The most common programmes involved moderate to vigorous exercise; with a frequency and duration of 3-5 times/week for 30-60 minutes.

CONCLUSION

Due to the diversity of the exercise training interventions, heterogeneity of patient characteristics, multitude of QOL instruments and outcome domains assessed, it was not possible to draw any definitive conclusion about the effectiveness of exercise interventions. However, this review identified positive trends to enhance various aspects of QOL measured using a range of assessment tools.

Contributions of posttraumatic stress disorder (PTSD) and mild TBI (mTBI) history to suicidality in the INTRuST consortium

OBJECTIVE

Mild TBI (mTBI) and posttraumatic stress disorder (PTSD) are independent risk factors for suicidal behaviour (SB). Further, co-occurring mTBI and PTSD increase one's risk for negative health and psychiatric outcomes. However, little research has examined the role of comorbid mTBI and PTSD on suicide risk.

METHODS

The present study utilized data from the Injury and TRaUmatic STress (INTRuST) Consortium to examine the prevalence of suicidal ideation (SI) and behaviours among four groups: 1) comorbid mTBI+PTSD, 2) PTSD only, 3) mTBI only, and 4) healthy controls.

RESULTS

Prevalence of lifetime SI, current SI, and lifetime SB for individuals with mTBI+PTSD was 40%, 25%, and 19%, respectively. Prevalence of lifetime SI, current SI, and lifetime SB for individuals with PTSD only was 29%, 11%, and 11%, respectively. Prevalence of lifetime SI, current SI, and lifetime SB for individuals with mTBI only was 14%, 1%, and 2%, respectively. Group comparisons showed that individuals with mTBI alone experienced elevated rates of lifetime SI compared to healthy controls. History of mTBI did not add significantly to risk for suicidal ideation and behaviour beyond what is accounted for by PTSD.

CONCLUSION

Findings suggest that PTSD seems to be driving risk for suicidal behaviour.

Physical Activity Intolerance and Cardiorespiratory Dysfunction in Patients with Moderate-to-Severe Traumatic Brain Injury

Moderate-to-severe traumatic brain injury (TBI) is a chronic health condition with multi-systemic effects. Survivors face significant long-term functional limitations, including physical activity intolerance and disordered sleep. Persistent cardiorespiratory dysfunction is a potentially modifiable yet often overlooked major contributor to the alarmingly high long-term morbidity and mortality rates in these patients. This narrative review was developed through systematic and non-systematic searches for research relating cardiorespiratory function to moderate-to-severe TBI. The literature reveals patients who have survived moderate-to-severe TBI have ~ 25-35% reduction in maximal aerobic capacity 6-18 months post-injury, resting pulmonary capacity parameters that are reduced 25-40% for weeks to years post-injury, increased sedentary behavior, and elevated risk of cardiorespiratory-related morbidity and mortality. Synthesis of data from other patient populations reveals that cardiorespiratory dysfunction is likely a consequence of ventilator-induced diaphragmatic dysfunction (VIDD), which is not currently addressed in TBI management. Thus, cardiopulmonary exercise testing should be routinely performed in this patient population and those with cardiorespiratory deficits should be further evaluated for diaphragmatic dysfunction. Lack of targeted treatment for underlying cardiorespiratory dysfunction, including VIDD, likely contributes to physical activity intolerance and poor functional outcomes in these patients. Interventional studies have demonstrated that short-term exercise training programs are effective in patients with moderate-to-severe TBI, though improvement is variable. Inspiratory muscle training is beneficial in other patient populations with diaphragmatic dysfunction, and may be valuable for patients with TBI who have been mechanically ventilated. Thus, clinicians with expertise in cardiorespiratory fitness assessment and exercise training interventions should be included in patient management for individuals with moderate-to-severe TBI.

The association between the etiology of a spinal cord injury and time to mortality in the United States: A 44-year investigation

Objective: To determine the association between spinal cord injury (SCI) etiology categories and mortality, and examine the association between etiology sub-categories and mortality. Design: Prospective cohort study. Setting: Model Systems and Shriners Hospital SCI units. Participants: Data were analyzed from 42,627 cases in the SCI Model System Collaborative Survival Study Database from 1973 to 2017. Those with SCI etiologies categorized as vehicular, violent, sports, falls, pedestrian, and medical were included. Interventions: Not applicable. Outcome Measure: Time to mortality after SCI. Results: Relative to the sports related etiology category, those with medical, pedestrian, violence, falls, and vehicular related SCIs had a 2.00 (95% confidence intervals (CIs): 1.79-2.24), 1.57 (CIs: 1.34-1.83), 1.54 (CIs: 1.41-1.68), 1.35 (CIs: 1.25-1.45), and 1.26 (CIs: 1.17-1.35) higher hazard for mortality, respectfully. Persons with SCIs from automobile crashes had a 1.38 (CIs: 1.23-1.56) higher hazard for mortality, whereas those with SCIs from motorcycle crashes had a 1.21 (CIs: 1.04-1.39) higher hazard for mortality, relative to other etiologies within the vehicular category. Those with SCIs from diving had a 1.37 (CIs: 1.18-1.59) higher hazard for mortality relative to other etiologies within the sports category. Conclusions: Injury etiology categories and certain sub-categories were associated with a higher risk for early mortality. Understanding how additional factors such as socioeconomic status, co-occurring injuries, medical co-morbidities, and environmental aspects interact with SCI etiologies may provide insights for how etiology of injury impacts survival. These findings may serve as a development for extending long-term life expectancy by informing SCI prevention programs and care post-injury.

Traumatic Brain Injury Modifies the Relationship Between Physical Activity and Global and Cognitive Health: Results From the Barcelona Brain Health Initiative

Physical activity has many health benefits for individuals with and without history of brain injury. Here, we evaluated in a large cohort study the impact of physical activity on global and cognitive health as measured by the PROMIS global health and NeuroQoL cognitive function questionnaires. A nested case control study assessed the influence of a history of traumatic brain injury (TBI) on the effects of physical activity since underlying pathophysiology and barriers to physical activity in individuals with TBI may mean the effects of physical activity on perceived health outcomes differ compared to the general population. Those with a history of TBI (n = 81) had significantly lower Global health (β = -1.66, p = 0.010) and NeuroQoL cognitive function (β = -2.65, p = 0.006) compared to healthy adults (n = 405). A similar proportion of individuals in both groups reported being active compared to being insufficiently active (X ( 1 ) 2 = 0.519 p = 0.471). Furthermore, the effect of physical activity on global health (β = 0.061, p = 0.076) and particularly for NeuroQoL (β = 0.159, p = 0.002) was greater in those with a history of TBI. Individuals with a history of TBI can adhere to a physically active lifestyle, and if so, that is associated with higher global and cognitive health perceptions. Adhering to a physically active lifestyle is non-trivial, particularly for individuals with TBI, and therefore adapted strategies to increase participation in physical activity is critical for the promotion of public health.

External causes of death after severe traumatic brain injury in a multicentre inception cohort: clinical description and risk factors

Objective: To characterize the clinical profile of patients dying from external causes (EC) following severe traumatic brain injury (TBI). Design and Methods: Data from 2545 patients forming the NSW-BIRP inception cohort discharged from post-acute inpatient rehabilitation between 1 July 1990 and 1 October 2007 were retrospectively reviewed. Standardized mortality ratios (SMRs) were calculated for EC sub-categories. Demographic, clinical and rehabilitation service factors were compared between deaths from EC, deaths from other causes (OC), and non-deceased. Clinical profiles of EC sub-categories were analysed descriptively. Results: Overall, patients with TBI were 5.2x more likely to die from EC relative to the general population. Risk of death was elevated in all EC sub-categories examined, with the largest risks relating to other accidental threats to breathing (SMR = 33.0; 95%CI = 13.79-60.45) and falls (SMR = 14.3; 95%CI = 5.01-28.39). The EC group were younger, more likely to have pre-injury psychiatric histories, less severe injuries, greater functional independence, and die earlier than the OC group. There was considerable heterogeneity in the clinical profiles of patients dying from different EC sub-categories. Conclusions: EC constitutes one of the largest causes of mortality following TBI in patients surviving beyond the post-acute phase. Potential implications for risk modification and prevention of premature and avoidable deaths are discussed.

Cost-Effectiveness of Biomarker Screening for Traumatic Brain Injury

Intracranial hemorrhage after traumatic brain injury (TBI) can be life threatening and requires prompt diagnosis. Computed tomography (CT) scans are a rapid and accurate way to evaluate for hemorrhage. In patients with mild and moderate TBI, however, in whom the incidence of intracranial pathology is low, scanning every patient with CT can be costly. The Food and Drug Administration recently approved a novel biomarker screen, the Banyan Trauma Indicator (BTI), to help streamline the decision for CT scanning in mild to moderate TBI. The BTI screen diagnoses intracranial lesions with a sensitivity and specificity of 97.5% and 99.6%, respectively. We performed cost analyses of the BTI screen to determine the threshold of cost-effectiveness, compared with application of clinical decision rules or routine CT scans, for cases of mild or moderate TBI. With a 0.104 probability of an intracranial lesion in mild TBI, the biomarker screen is cost-effective if the cost is $308.96 or below per test. In moderate TBI, because of the greater prevalence of intracranial lesions at 0.663, there is a lower need for screening, and BTI becomes cost-effective up to $73.41 per test.

Long-term survival and five year hospital resource usage following traumatic brain injury in Scotland from 1997 to 2015: A population-based retrospective cohort study

BACKGROUND

It is unclear if traumatic brain injury (TBI) results in excess mortality compared with head injury without injury to neural structures (HI). Because TBI populations exhibit significant demographic differences from uninjured populations, to determine the effect of TBI on survival, it is essential that a similarly injured control population be used. We aimed to determine if survival and hospital resource usage differ following TBI compared with HI.

METHODS

This retrospective population-based cohort study included all 25 319 patients admitted to a Scottish NHS hospital from 1997 to 2015 with TBI. Participants were identified using previously validated ICD-10 based definitions. For comparison, a control group of all 194 049 HI cases was also identified. Our main outcome measures were hazards of all-cause mortality for patients with TBI, compared with those with HI, over the 18-year follow-up period; and odds of mortality at one month post-injury. Number of days spent as inpatients and number of outpatient attendances per surviving month post-injury were used as measures of resource utilisation.

RESULTS

The adjusted odds ratio for mortality in the first month post-injury for TBI, compared with HI, was 7.12 (95% confidence interval [CI] 6.73-7.52; p < 0.001). For the remaining 18-year study period, the hazards of morality after TBI were 0.93 (CI 0.90-0.96; p < 0.001). During the five-year post-injury period, brain injury was associated with 2.15 (CI 2.10-2.20; p < 0.001) more days spent as inpatient and 1.09 times more outpatient attendances (CI 1.07-1.11; p < 0.001) compared with HI.

CONCLUSIONS

Although initial mortality following TBI is high, survivors of the first month post-injury can achieve comparable long-term survival to HI. However, this is associated with, and may require, increased utilisation of hospital services in the TBI group.

Association Between Traumatic Brain Injury and Risk of Suicide

IMPORTANCE

Traumatic brain injuries (TBIs) can have serious long-term consequences, including psychiatric disorders. However, few studies have assessed the association between TBI and risk of suicide.

OBJECTIVE

To examine the association between TBI and subsequent suicide.

DESIGN, SETTING, AND PARTICIPANTS

Retrospective cohort study using nationwide registers covering 7 418 391 individuals (≥10 years) living in Denmark (1980-2014) with 164 265 624 person-years' follow-up; 567 823 (7.6%) had a medical contact for TBI. Data were analyzed using Poisson regression adjusted for relevant covariates, including fractures not involving the skull, psychiatric diagnoses, and deliberate self-harm.

EXPOSURE

Medical contacts for TBI recorded in the National Patient Register (1977-2014) as mild TBI (concussion), skull fracture without documented TBI, and severe TBI (head injuries with evidence of structural brain injury).

MAIN OUTCOMES AND MEASURES

Suicide recorded in the Danish Cause of Death register until December 31, 2014.

RESULTS

Of 34 529 individuals who died by suicide (mean age, 52 years [SD, 18 years]; 32.7% women; absolute rate 21 per 100 000 person-years [95% CI, 20.8-21.2]), 3536 (10.2%) had medical contact: 2701 with mild TBI, 174 with skull fracture without documented TBI, and 661 with severe TBI. The absolute suicide rate was 41 per 100 000 person-years (95% CI, 39.2-41.9) among those with TBI vs 20 per 100 000 person-years (95% CI, 19.7-20.1) among those with no diagnosis of TBI. The adjusted incidence rate ratio (IRR) was 1.90 (95% CI, 1.83-1.97). Compared with those without TBI, severe TBI (absolute rate, 50.8 per 100 000 person-years; 95% CI, 46.9-54.6) was associated with an IRR of 2.38 (95% CI, 2.20-2.58), whereas mild TBI (absolute rate, 38.6 per 100 000 person-years; 95% CI, 37.1-40.0), and skull fracture without documented TBI (absolute rate, 42.4 per 100 000 person-years; 95% CI, 36.1-48.7) had an IRR of 1.81 (95% CI, 1.74-1.88) and an IRR of 2.01 (95% CI, 1.73-2.34), respectively. Suicide risk was associated with number of medical contacts for TBI compared with those with no TBI contacts: 1 TBI contact, absolute rate, 34.3 per 100 000 person-years (95% CI, 33.0-35.7; IRR, 1.75; 95% CI, 1.68-1.83); 2 TBI contacts, absolute rate, 59.8 per 100 000 person-years (95% CI, 55.1-64.6; IRR, 2.31; 95% CI, 2.13-2.51); and 3 or more TBI contacts, absolute rate, 90.6 per 100 000 person-years (95% CI, 82.3-98.9; IRR, 2.59; 95% CI, 2.35-2.85; all P < .001 for the IRR's). Compared with the general population, temporal proximity since the last medical contact for TBI was associated with risk of suicide (P<.001), with an IRR of 3.67 (95% CI, 3.33-4.04) within the first 6 months and an incidence IRR of 1.76 (95% CI, 1.67-1.86) after 7 years.

CONCLUSIONS AND RELEVANCE

In this nationwide registry-based retrospective cohort study individuals with medical contact for TBI, compared with the general population without TBI, had increased suicide risk.

Eyeball pressure stimulation induces subtle sympathetic activation in patients with a history of moderate or severe traumatic brain injury

OBJECTIVE

After traumatic brain injury (TBI), there may be persistent central-autonomic-network (CAN) dysfunction causing cardiovascular-autonomic dysregulation. Eyeball-pressure-stimulation (EPS) normally induces cardiovagal activation. In patients with a history of moderate or severe TBI (post-moderate-severe-TBI), we determined whether EPS unveils cardiovascular-autonomic dysregulation.

METHODS

In 51 post-moderate-severe-TBI patients (32.7 ± 10.5 years old, 43.1 ± 33.4 months post-injury), and 30 controls (29.1 ± 9.8 years), we recorded respiration, RR-intervals (RRI), systolic and diastolic blood-pressure (BPsys, BPdia), before and during EPS (120 sec; 30 mmHg), using an ocular-pressure-device (Okulopressor®). We calculated spectral-powers of mainly sympathetic low (LF: 0.04-0.15 Hz) and parasympathetic high (HF: 0.15-0.5 Hz) frequency RRI-fluctuations, sympathetically mediated LF-powers of BPsys, and calculated normalized (nu) LF- and HF-powers of RRI. We compared parameters between groups before and during EPS by repeated-measurement-analysis-of-variance with post-hoc analysis (significance: p < 0.05).

RESULTS

At rest, sympathetically mediated LF-BPsys-powers were significantly lower in the patients than the controls. During EPS, only controls significantly increased RRIs and parasympathetically mediated HFnu-RRI-powers, but decreased LF-RRI-powers, LFnu-RRI-powers, and LF-BPsys-powers; in contrast, the patients slightly though significantly increased BPsys upon EPS, without changing any other parameter.

CONCLUSIONS

In post-moderate-severe-TBI patients, autonomic BP-modulation was already compromised at rest. During EPS, our patients failed to activate cardiovagal modulation but slightly increased BPsys, indicating persistent CAN dysregulation.

SIGNIFICANCE

Our findings unveil persistence of subtle cardiovascular-autonomic dysregulation even years after TBI.

Survival and mortality following TBI

OBJECTIVES

Evaluation of life expectancy (LE) post traumatic brain injury (TBI) is important for planning services for patients and for dealing with medico-legal aspects. We hypothesized that LE for patients who survived 2 years post injury is equal to that of the general population (GP).

METHODS

A cohort of 279 patients was assembled during a 5-year period and was followed for 22-27 years. During follow-up, 32 patients (11.5%) died, creating a huge censored data (88.5%). Analyses included standard mortality ratio (SMR), Kaplan-Meier method (KM), Cox proportional hazards regression analysis (PH) and calculations of life expectancy.

RESULTS

About 77% of the patients were under 35 years of age at injury. This age cut-off point yielded differences for survival longevity by χ² tests (p < 0.0001), by KM analysis (p < 0.0001) and by Cox PH regression analysis (p < 0.0001, HR = 13.95). SMR for the entire cohort was 1.86. Shortening of LE in comparison with the GP is 3.58 years. Estimated shortening of LE by severity for mild, moderate and severe injury were -0.51, 4.11 and 13.77 years, respectively.

CONCLUSIONS

Patients with mild TBI have a LE similar to the GP, and a reduction in LE was closely related to moderate and severe brain injury.

The Impact of Traumatic Brain Injury on Later Life: Effects on Normal Aging and Neurodegenerative Diseases

The acute and chronic effects of traumatic brain injury (TBI) have been widely described; however, there is limited knowledge on how a TBI sustained during early adulthood or mid-adulthood will influence aging. Epidemiological studies have explored whether TBI poses a risk for dementia and other neurodegenerative diseases associated with aging. We will discuss the influence of TBI and resulting medical comorbidities such as endocrine, sleep, and inflammatory disturbances on age-related gray and white matter changes and cognitive decline. Post mortem studies examining amyloid, tau, and other proteins will be discussed within the context of neurodegenerative diseases and chronic traumatic encephalopathy. The data support the suggestion that pathological changes triggered by an earlier TBI will have an influence on normal aging processes and will interact with neurodegenerative disease processes rather than the development of a specific disease, such as Alzheimer's or Parkinson's. Chronic neurophysiologic change after TBI may have detrimental effects on neurodegenerative disease.

[Long-term survival after severe trauma]

Long-term survival after severe trauma is rarely addressed in German trauma journals although knowledge of life expectancy and identification of factors contributing to increased mortality are important for lifetime care management, development of service models, and targeting health promotion and prevention interventions. As reliable data in Germany are lacking, we compiled data mainly from the USA and Australia to describe life expectancy, risk factors, and predictors of outcome in patients experiencing traumatic spinal cord injury, traumatic brain injury, and polytrauma. Two years after trauma, life expectancy in all three categories was significantly lower than that of the general population. It depends strongly on severity of disability, age, and gender and is quantifiable. Whereas improvements in medical care have led to a marked decline in short-term mortality, surprisingly long-term survival in severe trauma has not changed over the past 30 years. Therefore, there is need to intensify long-term trauma patient care and to find new strategies to limit primary damage.

Preliminary Evidence of Reduced Urge to Cough and Cough Response in Four Individuals following Remote Traumatic Brain Injury with Tracheostomy

Cough and swallow protect the lungs and are frequently impaired following traumatic brain injury (TBI). This project examined cough response to inhaled capsaicin solution challenge in a cohort of four young adults with a history of TBI within the preceding five years. All participants had a history of tracheostomy with subsequent decannulation and dysphagia after their injuries (resolved for all but one participant). Urge to cough (UTC) and cough response were measured and compared to an existing database of normative cough response data obtained from 32 healthy controls (HCs). Participants displayed decreased UTC and cough responses compared to HCs. It is unknown if these preliminary results manifest as a consequence of disrupted sensory (afferent) projections, an inability to perceive or discriminate cough stimuli, disrupted motor (efferent) response, peripheral weakness, or any combination of these factors. Future work should attempt to clarify if the observed phenomena are borne out in a larger sample of individuals with TBI, determine the relative contributions of central versus peripheral nervous system structures to cough sensory perceptual changes following TBI (should they exist), and formulate recommendations for systematic screening and assessment of cough sensory perception in order to facilitate rehabilitative efforts. This project is identified with the National Clinical Trials NCT02240329.

Long-Term Survival Following Traumatic Brain Injury: A Population-Based Parametric Survival Analysis

BACKGROUND

Long-term mortality may be increased following traumatic brain injury (TBI); however, the degree to which survival could be reduced is unknown. We aimed at modelling life expectancy following post-acute TBI to provide predictions of longevity and quantify differences in survivorship with the general population.

METHODS

A population-based retrospective cohort study using data from the Rochester Epidemiology Project (REP) was performed. A random sample of patients from Olmsted County, Minnesota with a confirmed TBI between 1987 and 2000 was identified and vital status determined in 2013. Parametric survival modelling was then used to develop a model to predict life expectancy following TBI conditional on age at injury. Survivorship following TBI was also compared with the general population and age- and gender-matched non-head injured REP controls.

RESULTS

Seven hundred and sixty nine patients were included in complete case analyses. The median follow-up time was 16.1 years (interquartile range 9.0-20.4) with 120 deaths occurring in the cohort during the study period. Survival after acute TBI was well represented by a Gompertz distribution. Victims of TBI surviving for at least 6 months post-injury demonstrated a much higher ongoing mortality rate compared to the US general population and non-TBI controls (hazard ratio 1.47, 95% CI 1.15-1.87). US general population cohort life table data was used to update the Gompertz model's shape and scale parameters to account for cohort effects and allow prediction of life expectancy in contemporary TBI.

CONCLUSIONS

Survivors of TBI have decreased life expectancy compared to the general population. This may be secondary to the head injury itself or result from patient characteristics associated with both the propensity for TBI and increased early mortality. Post-TBI life expectancy estimates may be useful to guide prognosis, in public health planning, for actuarial applications and in the extrapolation of outcomes for TBI economic models.

Nature and extent of external-cause deaths of nursing home residents in Victoria, Australia

OBJECTIVES

To describe the nature and extent of external-cause deaths of residents of nursing homes in Victoria, Australia.

DESIGN

A retrospective cohort study of all decedents using routinely collected data contained within the National Coronial Information System.

SETTING

Accredited nursing homes in Victoria.

PARTICIPANTS

Nursing home residents who had died from external causes and whose deaths were reported to the Coroners Court between July 1, 2000, and December 31, 2012.

MEASUREMENTS

Basic descriptive analysis was conducted to measure frequencies and proportion of exposures within each outcome group, and rates were calculated using population data.

RESULTS

One thousand two hundred ninety-six external cause deaths of nursing home residents were identified. Deaths were due to falls (n=1,155, 89.1%), choking (n=89, 6.9%), suicide (n=17, 1.3%), complications of clinical care (n=8, 0.6%) and resident-on-resident assault (n=7, 0.5%). Deaths occurred more frequently in women (n=814, 62.8%), in keeping with the sex distribution in nursing homes, and residents aged 85 and older (n=923, 71.2%). The number of inquests held to investigate a death as a matter of public interest was small (n=24, 1.9%).

CONCLUSION

A significant proportion of nursing home resident deaths are from external causes and are potentially preventable. A shift in community attitudes is required toward an understanding that premature death of a resident from injury is not a natural part of life.

Cognitive changes and dementia risk after traumatic brain injury: implications for aging military personnel

Traumatic brain injury (TBI) is recognized as an important risk factor for the long-term cognitive health of military personnel, particularly in light of growing evidence that TBI increases risk for Alzheimer's disease and other dementias. In this article, we review the neurocognitive and neuropathologic changes after TBI with particular focus on the potential risk for cognitive decline across the life span in military service members. Implications for monitoring and surveillance of cognition in the aging military population are discussed. Additional studies are needed to clarify the factors that increase risk for later life cognitive decline, define the mechanistic link between these factors and dementia, and provide empirically supported interventions to mitigate the impact of TBI on cognition across the life span.

Accelerated death rate in population-based cohort of persons with traumatic brain injury

OBJECTIVES

To determine the influence of preexisting heart, liver, kidney, cancer, stroke, and mental health problems and examine the influence of low socioeconomic status on mortality after discharge from acute care facilities for individuals with traumatic brain injury.

PARTICIPANTS

Population-based retrospective cohort study of 33695 persons discharged from acute care hospital with traumatic brain injury in South Carolina, 1999-2010.

MAIN MEASURES

Days elapsing from the dates of injury to death established the survival time (T). Data were censored at the 145th month. Multivariable Cox regression was used to examine the independent effect of the variables on death. Age-adjusted cumulative probability of death for each chronic disease of interest was plotted.

RESULTS

By the 70th month of follow-up, rate of death was accelerated from 10-fold for heart diseases to 2.5-fold for mental health problems. Adjusted hazard ratios for diseases of the heart (2.13), liver-renal (3.25), cancer (2.64), neurological diseases and stroke (2.07), diabetes (1.89), hypertension (1.43), and mental health problems (1.59) were highly significant (each with P < .001). Compared with persons with private insurance, the hazard ratio was significantly elevated with Medicaid (1.67), Medicare (1.54), and uninsured (1.27) (each with P < .001).

CONCLUSION

Specific chronic diseases strongly influenced postdischarge mortality after traumatic brain injury. Low socioeconomic status as measured by the type of insurance elevated the risk of death.

Mortality and morbidity 15 years after hospital admission with mild head injury: a prospective case-controlled population study

OBJECTIVE

To investigate mortality rate in a population of adults admitted to hospital with mild head injury (MHI) 15 years later.

DESIGN

A prospective case control, record linkage study.

PARTICIPANTS

2428 adults with MHI and an equal number of community controls (CC) were case-matched for age, gender and social deprivation. A further control group admitted with a non-head injury was in addition matched for duration of hospital admission. Controls with a history of head injury prior to study entry were excluded.

MAIN OUTCOME MEASURES

Death or survival 15 years poststudy entry.

RESULTS

Mortality per 1000 per year after MHI (24.49; 95% CI 23.21 to 25.79) was higher than in CC (13.34; 95% CI 12.29 to 14.44; p<0.0001) or 'other injury' controls (OIC) (19.63; 95% CI 18.43 to 20.87; p<0.0001). Age at injury was important: younger adults (15-54 years) with MHI had a 4.2-fold greater risk of death than CC; in adults aged over 54, the risk was 1.4 times higher. Gender and social deprivation showed a similar association with death in the MHI and control groups. Repeated head injury was a risk factor for death in the MHI group. The frequency of hospital admission with systemic disease preinjury and postinjury was higher in both injury groups than in CC and higher in MHI than OIC. Prospective data in the MHI group suggest an association between preinjury lifestyle and mortality. Causes of death after MHI were similar to those of the control groups.

CONCLUSIONS

Adults hospitalised with MHI had greater risk of death in the following 15 years than matched controls. The extent to which lifestyle and potential chronic changes in neuropathology explain these findings is unclear. Lifestyle factors do contribute to risk of death after MHI and this finding has implications for lifestyle management interventions.

Population-based incidence and 5-year survival for hospital-admitted traumatic brain and spinal cord injury, Western Australia, 2003-2008

This study aimed at analysing first-time hospitalisations for traumatic brain injury (TBI) and spinal cord injury (SCI) in Western Australia (WA), in terms of socio-demographic profile, cause of injury, relative risks and survival, using tabular and regression analyses of linked hospital discharge and mortality census files and comparing results with published standardised mortality rates (SMRs) for TBI. Participants were all 9,114 first hospital admissions for TBI or SCI from 7/2003 to 6/2008, linked to mortality census data through 12/2008, and the main outcome measures were number of cases by cause, SMRs in hospital and post-discharge by year through year 5. Road crashes accounted for 34 % of hospitalised TBI and 52 % of hospitalised SCI. 8,460 live TBI discharges experienced 580 deaths during 24,494 person-years of follow-up. The life-table expectation of deaths in the cohort was 164. Post-discharge SMRs were 7.66 in year 1, 3.86 in year 2 and averaged 2.31 in years 3 through 5. 317 live SCI discharges experienced 18 deaths during 929 years of follow-up. Post-discharge SMRs were 7.36 in year 1 and a fluctuating average of 2.13 in years 2 through 5. Use of data from model systems does not appear to yield biased SMRs. Similarly no systematic variation was observed between all-age studies and the more numerous studies that focused on those aged 14 to 16 and older. Based on two studies, SMRs for TBI, however, may be higher in year 2 post-discharge in Australia than elsewhere. That possibility and its cause warrant exploration. Expanding public TBI/SCI compensation in WA from road crash to all causes might triple TBI compensation and double SCI compensation.

Age-related trends in late mortality following traumatic brain injury: A multicentre inception cohort study

AIM

To investigate age-related mortality risk following traumatic brain injury (TBI).

METHODS

Review of 2545 consecutive discharges from three metropolitan rehabilitation centres in New South Wales, between 1 January 1990 and 1 October 2007. Survival status was censored on 1 October 2009. Between-group differences were assessed for older/younger patients. Multivariate Cox hazard regression was used to evaluate age-related mortality risk. Crude mortality rates, standardised mortality ratios and cause of death data were derived for each age decade.

RESULTS

After controlling for known mortality risk factors, older patients were three times more likely to die than younger patients. Crude mortality rates increased exponentially with advancing age. However, when compared to normative population data, younger adults with TBI (<50 years) had the highest risk of death relative to their non-injured peers.

CONCLUSIONS

Crude mortality rates, which do not account for the naturally increasing rate of death associated with ageing, artificially inflate estimates of age-related mortality risk following TBI.

Ventilatory anaerobic thresholds of individuals recovering from traumatic brain injury compared with noninjured controls

OBJECTIVE

The purpose of this study was to compare the peak aerobic capacities and ventilatory anaerobic thresholds (VAT) of individuals with a traumatic brain injury (TBI) to age- and gender-matched controls.

METHODS

Nineteen participants that previously suffered a mild to moderate TBI and 19 apparently healthy controls volunteered as subjects. Traumatic brain injury and healthy controls were matched for age and gender and were similar in weight and body mass index. Volunteers performed a maximal graded treadmill test to volitional failure where oxygen consumption ((Equation is included in full-text article.)O2), carbon dioxide production ((Equation is included in full-text article.)CO2, ventilation ((Equation is included in full-text article.)E, and heart rate were measured continuously. From metabolic and ventilatory data, VAT was measured using a previously described method. VAT and peak exercise responses of participants with a TBI were compared with healthy controls.

RESULTS

The (Equation is included in full-text article.)O2, and (Equation is included in full-text article.)CO2 at VAT and peak exercise were lower for TBI compared with healthy controls. (Equation is included in full-text article.)E was also lower for TBI at VAT and peak exercise. Heart rate was lower for TBI at VAT; however, TBI had similar heart rate to healthy controls at peak exercise.

CONCLUSIONS

The VAT and peak exercise capacities of participants with a TBI were below the metabolic demands of many routine daily activities. The data suggest that therapeutic interventions for individuals with a TBI should include targeted exercise prescriptions to improve cardiorespiratory fitness.

Suicide, fatal injuries, and other causes of premature mortality in patients with traumatic brain injury: a 41-year Swedish population study

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IMPORTANCE

Longer-term mortality in individuals who have survived a traumatic brain injury (TBI) is not known.

OBJECTIVES

To examine the relationship between TBI and premature mortality, particularly by external causes, and determine the role of psychiatric comorbidity.

DESIGN, SETTING, AND PATIENTS

We studied all persons born in 1954 or later in Sweden who received inpatient and outpatient International Classification of Diseases-based diagnoses of TBI from 1969 to 2009 (n = 218,300). We compared mortality rates 6 months or more after TBI to general population controls matched on age and sex (n = 2,163,190) and to unaffected siblings of patients with TBI (n = 150,513). Furthermore, we specifically examined external causes of death (suicide, injury, or assault). We conducted sensitivity analyses to investigate whether mortality rates differed by sex, age at death, severity (including concussion), and different follow-up times after diagnosis.

MAIN OUTCOMES AND MEASURES

Adjusted odds ratios (AORs) of premature death by external causes in patients with TBI compared with general population controls.

RESULTS

Among those who survived 6 months after TBI, we found a 3-fold increased odds of mortality (AOR, 3.2; 95% CI, 3.0-3.4) compared with general population controls and an adjusted increased odds of mortality of 2.6 (95% CI, 2.3-2.8) compared with unaffected siblings. Risks of mortality from external causes were elevated, including for suicide (AOR, 3.3; 95% CI, 2.9-3.7), injuries (AOR, 4.3; 95% CI, 3.8-4.8), and assault (AOR, 3.9; 95% CI, 2.7-5.7). Among those with TBI, absolute rates of death were high in those with any psychiatric or substance abuse comorbidity (3.8% died prematurely) and those with solely substance abuse (6.2%) compared with those without comorbidity (0.5%).

CONCLUSIONS AND RELEVANCE

Traumatic brain injury is associated with substantially elevated risks of premature mortality, particularly for suicide, injuries, and assaults, even after adjustment for sociodemographic and familial factors. Current clinical guidelines may need revision to reduce mortality risks beyond the first few months after injury and address high rates of psychiatric comorbidity and substance abuse.

Traumatic brain injury - modeling neuropsychiatric symptoms in rodents

Each year in the US, ∼1.5 million people sustain a traumatic brain injury (TBI). Victims of TBI can suffer from chronic post-TBI symptoms, such as sensory and motor deficits, cognitive impairments including problems with memory, learning, and attention, and neuropsychiatric symptoms such as depression, anxiety, irritability, aggression, and suicidal rumination. Although partially associated with the site and severity of injury, the biological mechanisms associated with many of these symptoms - and why some patients experience differing assortments of persistent maladies - are largely unknown. The use of animal models is a promising strategy for elucidation of the mechanisms of impairment and treatment, and learning, memory, sensory, and motor tests have widespread utility in rodent models of TBI and psychopharmacology. Comparatively, behavioral tests for the evaluation of neuropsychiatric symptomatology are rarely employed in animal models of TBI and, as determined in this review, the results have been inconsistent. Animal behavioral studies contribute to the understanding of the biological mechanisms by which TBI is associated with neurobehavioral symptoms and offer a powerful means for pre-clinical treatment validation. Therefore, further exploration of the utility of animal behavioral tests for the study of injury mechanisms and therapeutic strategies for the alleviation of emotional symptoms are relevant and essential.

Health outcome disparities among subgroups of people with disabilities: a scoping review

BACKGROUND

A growing body of research has found that people with disabilities experience lower health status and an excess burden of disease relative to the general US population. However, the population of people with disabilities is quite diverse. Thus, it is important to understand health differences between subgroups of people with disabilities in order to most effectively target interventions to address disparities. An initial step in this process is reviewing and synthesizing available research addressing these subgroup differences.

OBJECTIVES

To conduct a scoping review of literature to describe recent research activity that has examined health outcome disparities within populations of people with disabilities.

METHODS

We searched for relevant articles in MEDLINE, PsycINFO, and CINAHL databases. Three staff independently reviewed abstracts according to inclusion criteria. Two authors then independently extracted data from each included article.

RESULTS

For many of the health outcomes of interest, there was no published literature in relation to key disparity factors (e.g. race, income) within the population of people with disabilities. The health outcomes most frequently examined were diabetes and heart disease. The most frequently examined disparity factors were the type of disabling condition and gender.

CONCLUSIONS

There are significant gaps in available research. Building a body of research that identifies disparities and potentially vulnerable subgroups may improve understanding of the causes of disparities and contribute to efforts to improve quality of life and health outcomes for individuals with disabilities.

Long-term disability and survival in traumatic brain injury: results from the National Institute on Disability and Rehabilitation Research Model Systems

OBJECTIVES

To document long-term survival in 1-year survivors of traumatic brain injury (TBI); to compare the use of the Disability Rating Scale (DRS) and FIM as factors in the estimation of survival probabilities; and to investigate the effect of time since injury and secular trends in mortality.

DESIGN

Cohort study of 1-year survivors of TBI followed up to 20 years postinjury. Statistical methods include standardized mortality ratio, Kaplan-Meier survival curve, proportional hazards regression, and person-year logistic regression.

SETTING

Postdischarge from rehabilitation units.

PARTICIPANTS

Population-based sample of persons (N=7228) who were admitted to a TBI Model Systems facility and survived at least 1 year postinjury. These persons contributed 32,505 person-years, with 537 deaths, over the 1989 to 2011 study period.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURE

Survival.

RESULTS

Survival was poorer than that of the general population (standardized mortality ratio=2.1; 95% confidence interval, 1.9-2.3). Age, sex, and functional disability were significant risk factors for mortality (P<.001). FIM- and DRS-based proportional hazards survival models had comparable predictive performance (C index: .80 vs .80; Akaike information criterion: 11,005 vs 11,015). Time since injury and current calendar year were not significant predictors of long-term survival (both P>.05).

CONCLUSIONS

Long-term survival prognosis in TBI depends on age, sex, and disability. FIM and DRS are useful prognostic measures with comparable statistical performance. Age- and disability-specific mortality rates in TBI have not declined over the last 20 years. A survival prognosis calculator is available online (http://www.LifeExpectancy.org/tbims.shtml).

Suicidal Ideation and Behaviours after Traumatic Brain Injury: A Systematic Review

Traumatic brain injury (TBI) is prevalent among many populations and existing data suggest that those with TBI are at increased risk for death by suicide. This systematic review serves as an update to a previous review, with the aim of evaluating the current state of evidence regarding prevalence and risk of suicide deaths, post-TBI suicidal ideation and suicide attempts, and treatments to reduce suicide-related outcomes among TBI survivors. Review procedures followed the PRISMA statement guidelines. In all, 1014 abstracts and 83 full-text articles were reviewed to identify 16 studies meeting inclusion criteria. Risk of bias for individual studies ranged from low to high, and very few studies were designed to examine a priori hypotheses related to suicide outcomes of interest. Overall, findings from this systematic review supported an increased risk of suicide among TBI survivors compared to those with no history of TBI. Evidence pertaining to suicidal thoughts and attempts was less clear, mainly due to heterogeneity of methodological quality across studies. One small randomised controlled trial was identified that targeted suicide prevention in TBI survivors. Further research is needed to identify the prevalence of post-TBI ideation and attempts, and to establish evidence-based suicide prevention practices among TBI survivors.

Late mortality after severe traumatic brain injury in New South Wales: a multicentre study

OBJECTIVES

To determine the long-term mortality pattern of adults with severe traumatic brain injury (TBI), and to identify the risk factors associated with death in this group.

DESIGN, PATIENTS AND SETTING

Inception cohort study of 2545 adults consecutively discharged from one of three metropolitan tertiary, post-acute inpatient rehabilitation services of the New South Wales Brain Injury Rehabilitation Program from 1 January 1990 to 1 October 2007 after inpatient rehabilitation for primary TBI.

MAIN OUTCOME MEASURE

Survival status at 1 October 2009.

RESULTS

258 deaths were recorded in this sample, yielding a standardised mortality ratio of 3.19 (95% CI, 2.80-3.60). Risk of death remained elevated above societal norms for at least 8 years after discharge from rehabilitation. Mortality risk was increased by: functional dependence at discharge; age at injury; pre-injury drug and alcohol misuse; pre-injury epilepsy; and discharge to an aged care facility. The risk of death from external causes, and respiratory system and nervous system disorders was six to seven times higher, and the risk of death from disorders of the digestive system, and mental and behavioural disorders was five times higher in adults with severe TBI than in the general population.

CONCLUSIONS

People who survive to discharge from inpatient rehabilitation following a severe TBI were found to have a sustained increase in risk of death for eight years post discharge. Various demographic and injury-related variables selectively increase mortality risk and may be modifiable in order to reduce the observed increase in mortality.

Is aggressive treatment of traumatic brain injury cost-effective?

OBJECT

The object of this study was to determine whether aggressive treatment of severe traumatic brain injury (TBI), including invasive intracranial monitoring and decompressive craniectomy, is cost-effective.

METHODS

A decision-analytical model was created to compare costs, outcomes, and cost-effectiveness of 3 strategies for treating a patient with severe TBI. The aggressive-care approach is compared with "routine care," in which Brain Trauma Foundation guidelines are not followed. A "comfort care" category, in which a single day in the ICU is followed by routine floor care, is included for comparison only. Probabilities of each treatment resulting in various Glasgow Outcome Scale (GOS) scores were obtained from the literature. The GOS scores were converted to quality-adjusted life years (QALYs), based on expected longevity and calculated quality of life associated with each GOS category. Estimated direct (acute and long-term medical care) and indirect (loss of productivity) costs were calculated from the perspective of society. Sensitivity analyses employed a 2D Monte Carlo simulation of 1000 trials, each with 1000 patients. The model was also used to estimate these values for patients 40, 60, and 80 years of age.

RESULTS

For the average 20-year-old, aggressive care yields 11.7 (± 1.6 [SD]) QALYs, compared with routine care (10.0 ± 1.5 QALYs). This difference is highly significant (p < 0.0001). Although the differences in effectiveness between the 2 strategies diminish with advancing age, aggressive care remains significantly better at all ages. When all costs are considered, aggressive care is also significantly less costly than routine care ($1,264,000 ± $118,000 vs $1,361,000 ± $107,000) for the average 20-year-old. Aggressive care remains significantly less costly until age 80, at which age it costs more than routine care. However, even in the 80-year-old, aggressive care is likely the more cost-effective approach. Comfort care is associated with poorer outcomes at all ages and with higher costs for all groups except 80-year-olds.

CONCLUSIONS

When all the costs of severe TBI are considered, aggressive treatment is a cost-effective option, even for older patients. Comfort care for severe TBI is associated with poor outcomes and high costs, and should be reserved for situations in which aggressive approaches have failed or testing suggests such treatment is futile.

Aspiration Pneumonia Following Severe Traumatic Brain Injury: Prevalence and Risk Factors for Long-Term Mortality

Dysphagia and aspiration pneumonia are prevalent but infrequently studied complications following severe traumatic brain injury (TBI). Aspiration pneumonia is responsible for a significant number of long-term deaths in this population, however, the reported number of deaths attributed to aspiration pneumonia may be inaccurate. This multicentre inception cohort (n= 2545) study analysed consecutive discharges from 3 metropolitan inpatient brain injury rehabilitation units from January 1990 to October 2007 following inpatient rehabilitation following primary TBI. Subject data was linked to national death registries to determine cause of death where relevant. This study aimed to (a) evaluate the prevalence of aspiration pneumonia, percutaneous endoscopic gastrostomy (PEG) insertion and dysphagia following TBI, (b) identify the number of deaths ascribed to aspiration pneumonia, and (c) characterise associated risk factors for long-term aspiration pneumonia related deaths compared to all other causes of death. In-hospital PEG insertion occurred in 18.4% of the sample, two thirds of whom remained dysphagic at discharge. In-hospital aspiration pneumonia was recorded in 3.6% of the sample. Postdischarge, people with TBI were 79 times more likely to die from aspiration pneumonia than the general population. Risks were higher for subjects discharged to a nursing home, with severe ongoing functional disability, dysphagia at discharge, in those who had experienced in-hospital aspiration pneumonia or required PEG insertion. Early identification and risk management of dysphagia and aspiration pneumonia in TBI nursing home populations may maximise these individuals' quality and length of life.

Half a Century of Care

The issue of long-term care and support of people with acquired brain injury has been a significant clinical and policy issue for some time; however. as evidence accrues about increases in incidence and survival from brain injury, the focus on this issue sharpens (Kolpan, 1990; McCluskey, 2005). The net effect of these increases (in the number of new brain injuries per year plus survival beyond the acute phase) is a sharp increase in prevalence, or the number of people living with the effects of brain injury in a given population. Add to that new information that has recently been published regarding long-term survival, and it becomes immediately apparent that factors are converging to produce an immanent increase in the economic and human costs of acquired brain injuries, at least in the developed world.

Risk factors for reduced survival after traumatic brain injury: a 30-year follow-up study

PRIMARY OBJECTIVE

To evaluate risk factors for reduced survival in subjects with traumatic brain injury (TBI).

PARTICIPANTS AND METHODS

A retrospective follow-up of three decades included 192 subjects with TBI. Cognitive testing was carried out on average 2 years after the injury (at mean age of 39.0 years), during the years 1966-1972. Cox's regression and logistic regression analyses were used and the survival of the subjects was compared with the general population using the standardized mortality ratio (SMR).

RESULTS

Reduced survival was significantly associated with age at injury (p < 0.001) and vocational outcome (p = 0.003). Vocational outcome in turn was associated with age (p = 0.010), TBI severity (p < 0.001), cognitive impairment (p = 0.010), later TBIs (p = 0.007) and alcohol abuse (p = 0.015). Mortality in the younger patient group (age at death <40 years) was higher than in the general population (SMR 4.50, 95% CI = 2.02-10.01).

CONCLUSIONS

A reduced working ability, influenced by age-, injury- and lifestyle-related factors, is associated with long-term survival after TBI. The mortality among younger patients is high, a finding which should be considered when planning the care after TBI.

Neuropsychiatric complications of traumatic brain injury

Traumatic brain injury (TBI) may be defined as any extracranial mechanical force to the brain that results in any period of loss of consciousness, any loss of memory for events immediately before or after the event, or any alteration in mental status at the time of the event. The major causes are automobile accidents, falls, sporting injuries, and assaults. Many soldiers returning from combat in Afghanistan and Iraq have also experienced TBI. This article provides an overview of the neuropsychiatric complications of TBI, including impairment of consciousness, posttraumatic amnesia, cognitive disorders and dementia, posttraumatic epilepsy, aphasia, depression, mania, psychosis, anxiety disorders, personality changes, aggression, behavioral dyscontrol, fatigue/apathy, and increased risk of suicide. Discussion will focus primarily on issues affecting mental health clinicians. Because mental health providers are more involved in care of chronic issues related to TBI, these issues will be discussed in more detail, although acute neuropsychiatric complications of TBI will be briefly explained.

A survey of very-long-term outcomes after traumatic brain injury among members of a population-based incident cohort

To assess quality of life and barriers to participation in vocational and community life for persons with traumatic brain injury (TBI) over the very-long term, a population-based cohort was identified in Olmsted County, Minnesota; 1623 individuals were identified as having experienced a confirmed TBI while a resident of Olmsted County, Minnesota, during the period from 1935-2000. A survey was sent to eligible individuals that included elements of standardized instruments addressing health status and disability, and questions that assessed issues important to successful social reintegration after TBI. Of 1623 eligible participants sent surveys, 605 responded (37% response rate). Thirty-nine percent of respondents were female and 79% had mild injuries. Mean age at injury was 30.8 years, and mean years since injury was 28.8. Overall, respondents reported living in the community; the majority were married and had achieved education beyond high school. Problems with memory, thinking, and physical and emotional health were most often reported. Respondents reported low levels of depression and anxiety, and high levels of satisfaction with life. Seventy-three percent of respondents reported no problems that they attributed to their TBI. Increasing injury severity was associated with a significant risk of reporting injury-related problems at survey completion. Respondents with a longer time since injury were less likely to report any TBI-related problems. These results indicate that self-reported outcomes and adaptation to impairment-related limitations improve as the time since injury increases. These findings highlight the importance of providing coordinated medical rehabilitation and community-based support services to promote positive outcomes over the life span after TBI.