Correspondence of the Boston Assessment of Traumatic Brain Injury-Lifetime and the VA Comprehensive TBI Evaluation

Evaluation of clinical outcomes and employment status in veterans with dual diagnosis of traumatic brain injury and spinal cord injury

PURPOSE

To examine clinical outcomes and employment status in Veterans with and without a dual diagnosis of traumatic brain injury (TBI) and spinal cord injury (SCI).

METHODS

This cross-sectional study examined a national sample of Veterans enrolled in the VA Million Veteran Program who completed the Comprehensive TBI Evaluation (CTBIE) as part of the Veterans Health Administration's TBI Screening and Evaluation Program. Veterans (N = 12,985) were classified into the following TBI/SCI groups using CTBIE data: those with a dual diagnosis of TBI and SCI (TBI+/SCI+); those with a history of TBI but no SCI (TBI+/SCI-); and those with no history of TBI or SCI (TBI-/SCI-; i.e., the control group). CTBIE-derived outcomes included neurobehavioral symptoms, comorbid psychiatric symptoms, pain and pain interference, and employment status.

RESULTS

Chi-square analyses showed significant associations between TBI/SCI group and all clinical outcomes evaluated (all p's < .001; V = 0.07-0.11). In general, the TBI+/SCI+ and TBI +/SCI- groups endorsed comparable levels of neurobehavioral symptoms, psychiatric symptoms, and pain, but significantly greater rates of symptoms and pain relative to the TBI-/SCI- group. Effect sizes for all pairwise comparisons were small (φ = 0.01-0.11). Finally, there was no significant association between TBI/SCI group and employment status (p = .170; V = 0.02), with all three groups showing relatively comparable rates of unemployment.

CONCLUSIONS

Regardless of SCI status, Veterans with TBI history endorsed poorer clinical outcomes than Veterans without TBI and SCI. However, rates of unemployment were similarly high across all three groups. Findings suggest that any Veteran completing the CTBIE may be at risk for poor clinical and employment outcomes.

Alzheimer's disease and related dementias among aging veterans: Examining gene-by-environment interactions with post-traumatic stress disorder and traumatic brain injury

INTRODUCTION

Post-traumatic stress disorder (PTSD) and traumatic brain injury (TBI) confer risk for Alzheimer's disease and related dementias (ADRD).

METHODS

This study from the Million Veteran Program (MVP) evaluated the impact of apolipoprotein E (APOE) ε4, PTSD, and TBI on ADRD prevalence in veteran cohorts of European ancestry (EA; n = 11,112 ADRD cases, 170,361 controls) and African ancestry (AA; n = 1443 ADRD cases, 16,191 controls). Additive-scale interactions were estimated using the relative excess risk due to interaction (RERI) statistic.

RESULTS

PTSD, TBI, and APOE ε4 showed strong main-effect associations with ADRD. RERI analysis revealed significant additive APOE ε4 interactions with PTSD and TBI in the EA cohort and TBI in the AA cohort. These additive interactions indicate that ADRD prevalence associated with PTSD and TBI increased with the number of inherited APOE ε4 alleles.

DISCUSSION

PTSD and TBI history will be an important part of interpreting the results of ADRD genetic testing and doing accurate ADRD risk assessment.

Self-reported physical functioning, cardiometabolic health conditions, and health care utilization patterns in Million Veteran Program enrollees with Traumatic Brain Injury Screening and Evaluation Program data

BACKGROUND

Examining the health outcomes of veterans who have completed the United States Veterans Health Administration's (VHA's) Traumatic Brain Injury (TBI) Screening and Evaluation Program may aid in the refinement and improvement of clinical care initiatives within the VHA. This study compared self-reported physical functioning, cardiometabolic health conditions, and health care utilization patterns in Million Veteran Program enrollees with TBI Screening and Evaluation Program data (collected between 2007 and 2019), with the goal of enhancing understanding of potentially modifiable health conditions in this population.

METHODS

In this observational cohort study, veterans (n = 16,452) were grouped based on the diagnostic outcome of the TBI Screening and Evaluation Program: 1) negative TBI screen (Screen^-); 2) positive TBI screen but no confirmed TBI diagnosis [Screen⁺/ Comprehensive TBI Evaluation (CTBIE)^-]; or 3) positive TBI screen and confirmed TBI diagnosis (Screen⁺/CTBIE⁺). Chi-square tests and analysis of covariance were used to explore group differences in physical functioning, cardiometabolic health conditions, and health care utilization patterns, and logistic regressions were used to examine predictors of Screen^+/- and CTBIE^+/- group status.

RESULTS

The results showed that veterans in the Screen⁺/CTBIE^- and Screen⁺/CTBIE⁺ groups generally reported poorer levels of physical functioning (P's < 0.001, n_p² = 0.02 to 0.03), higher rates of cardiometabolic health conditions (P's < 0.001, φ = 0.14 to 0.52), and increased health care utilization (P's < 0.001, φ = 0.14 to > 0.5) compared with the Screen^- group; however, health outcomes were generally comparable between the Screen⁺/CTBIE^- and Screen⁺/CTBIE⁺ groups. Follow-up analyses confirmed that while physical functioning, hypertension, stroke, healthcare utilization, and prescription medication use reliably distinguished between the Screen^- and Screen⁺ groups (P's < 0.02, OR's 0.78 to 3.38), only physical functioning distinguished between the Screen⁺/CTBIE^- and Screen⁺/CTBIE⁺ groups (P < 0.001, OR 0.99).

CONCLUSIONS

The findings suggest that veterans who screen positive for TBI, regardless of whether they are ultimately diagnosed with TBI, are at greater risk for negative health outcomes, signifying that these veterans represent a vulnerable group that may benefit from increased clinical care and prevention efforts.

Characterizing Sex Differences in Clinical and Functional Outcomes Among Military Veterans with a Comprehensive Traumatic Brain Injury Evaluation (CTBIE): A Million Veteran Program (MVP) Study

Using a diverse sample of military Veterans enrolled in the VA's Million Veteran Program (N=14,378; n=1,361 females [9.5%]; all previously deployed), we examined sex differences on the Comprehensive Traumatic Brain Injury Evaluation (CTBIE), a structured traumatic brain injury (TBI) interview routinely administered within the VA. Confirmed TBI diagnoses were more frequent among males than females (65% vs. 58%). Additionally, when compared to females, a greater proportion of males with CTBIE-confirmed TBI histories experienced blast-related injuries and were employed. In contrast, a greater proportion of females reported experiencing falls, sustaining a TBI since deployment, and having more severe neurobehavioral symptoms (particularly affective-related symptoms). Results indicate that males and females experience differential clinical and functional outcomes in the aftermath of military TBI. Findings underscore the need to increase female representation in TBI research to increase understanding of sex-specific experiences with TBI and to improve the clinical care targeted to this vulnerable population.

Subjective cognitive and psychiatric well-being in U.S. Military Veterans screened for deployment-related traumatic brain injury: A Million Veteran Program Study

The purpose of this study was to examine subjective cognitive and psychiatric functioning in post-deployed military Veterans who underwent the Veterans Health Administration's Traumatic Brain Injury (TBI) Screening and Evaluation Program and enrolled in the VA's Million Veteran Program (MVP). Veterans (N = 7483) were classified into three groups based on outcomes from the TBI Screening and Evaluation Program: (1) negative TBI screen ('Screen-'), (2) positive TBI screen but no TBI diagnosis ('Screen+/TBI-'), or (3) positive TBI screen and TBI diagnosis ('Screen+/TBI+'). Chi-square analyses revealed significant group differences across all self-reported cognitive and psychiatric health conditions (e.g., memory loss, depression), and ANCOVAs similarly showed a significant association between group and subjective symptom reporting. Specifically, the relationship between TBI group and clinical outcome (i.e., health conditions and symptoms) was such that the Screen+/TBI+ group fared the worst, followed by the Screen+/TBI- group, and finally the Screen- group. However, evaluation of effect sizes suggested that Veterans in the two Screen+ groups (Screen+/TBI+ and Screen+/TBI-) are faring similarly to one another on subjective cognitive and psychiatric functioning, but that both Screen+ groups are faring significantly worse than the Screen- group. Our results have meaningful clinical implications and suggest that Veterans who screen positive for TBI, regardless of ultimate TBI diagnosis, be eligible for similar clinical services so that both groups can benefit from valuable treatments and therapeutics. Finally, this research sets the stage for follow-up work to be conducted within MVP that will address the neurobiological underpinnings of cognitive and psychiatric distress in this population.

Characterization of Million Veteran Program (MVP) enrollees with Comprehensive Traumatic Brain Injury Evaluation (CTBIE) data: An analysis of neurobehavioral symptoms

The purpose of this study was to examine neurobehavioral symptom reporting in a large sample of military veterans (N = 12,144) who completed the Comprehensive Traumatic Brain Injury Evaluation (CTBIE) and enrolled in the VA's Million Veteran Program (MVP). The CTBIE is a clinician-administered interview that assesses for historical, deployment-related traumatic brain injury (TBI) and evaluates symptoms using the Neurobehavioral Symptom Inventory (NSI). Clinicians completing the CTBIE made clinical determinations about participants' (1) TBI diagnostic status (i.e., CTBIE+ or CTBIE-) and (2) current symptom etiology (i.e., Symptom Resolution, TBI, Behavioral Health, Comorbid TBI + Behavioral Health [Comorbid], or Other). We evaluated the association of TBI diagnostic status and symptom etiology group with neurobehavioral symptoms. Results showed a significant association between TBI diagnostic status and all NSI variables, with CTBIE+ veterans endorsing greater symptoms than CTBIE- veterans. There was also a significant association between symptom etiology group and all NSI variables; specifically, the Comorbid and Behavioral Health groups generally endorsed significantly greater symptoms compared to the other groups. Follow-up analyses showed that relative to the Symptom Resolution group, the Comorbid and Behavioral Health groups had increased odds of severe/very severe cognitive and affective symptoms, whereas the TBI and Other groups did not. Finally, presence of psychiatric symptoms, pain, post-traumatic amnesia, loss of consciousness, and blast exposure significantly predicted Comorbid symptom etiology group membership. Findings from this large epidemiologic MVP study have relevant clinical implications and further highlight the importance of prioritizing integrated behavioral health interventions for this vulnerable population.

Occupational Risk of Low-Level Blast Exposure and TBI-Related Medical Diagnoses: A Population-Based Epidemiological Investigation (2005-2015)

Because traumatic brain injury (TBI)—most often caused by exposure to high-level blast (HLB)—is a leading cause of medical evacuations of deployed U.S. service members in recent conflicts, researchers seek to identify risk factors for TBI. Previous research using self-reported data has identified low-level blast (LLB) as one such risk factor and suggests an association with susceptibility to and symptoms associated with TBI. This article presents a population-based study of all branches of military service that examines the association between occupational risk for LLB and both clinically diagnosed TBIs—from concussions to severe and penetrating TBIs—and conditions commonly comorbid with concussion. Using archival medical and career records from >2 million service members between 2005–2015, this work demonstrates that occupational risk of LLB is associated with any TBI, mild TBI, moderate TBI, cognitive problems, communication problems, hearing problems, headaches, any behavioral health condition, anxiety, drug abuse/dependence, alcohol abuse/dependence, delirium/dementia, posttraumatic stress disorder, post-concussive syndrome, tinnitus, fatigue, and migraines. Understanding the full scope of the effects of LLB on service members will help ensure the health and readiness of service members and may influence both military policy and clinical practice guidelines for blast-induced injuries.

Resting-state magnetoencephalography source magnitude imaging with deep-learning neural network for classification of symptomatic combat-related mild traumatic brain injury

Combat‐related mild traumatic brain injury (cmTBI) is a leading cause of sustained physical, cognitive, emotional, and behavioral disabilities in Veterans and active‐duty military personnel. Accurate diagnosis of cmTBI is challenging since the symptom spectrum is broad and conventional neuroimaging techniques are insensitive to the underlying neuropathology. The present study developed a novel deep‐learning neural network method, 3D‐MEGNET, and applied it to resting‐state magnetoencephalography (rs‐MEG) source‐magnitude imaging data from 59 symptomatic cmTBI individuals and 42 combat‐deployed healthy controls (HCs). Analytic models of individual frequency bands and all bands together were tested. The All‐frequency model, which combined delta‐theta (1–7 Hz), alpha (8–12 Hz), beta (15–30 Hz), and gamma (30–80 Hz) frequency bands, outperformed models based on individual bands. The optimized 3D‐MEGNET method distinguished cmTBI individuals from HCs with excellent sensitivity (99.9 ± 0.38%) and specificity (98.9 ± 1.54%). Receiver‐operator‐characteristic curve analysis showed that diagnostic accuracy was 0.99. The gamma and delta‐theta band models outperformed alpha and beta band models. Among cmTBI individuals, but not controls, hyper delta‐theta and gamma‐band activity correlated with lower performance on neuropsychological tests, whereas hypo alpha and beta‐band activity also correlated with lower neuropsychological test performance. This study provides an integrated framework for condensing large source‐imaging variable sets into optimal combinations of regions and frequencies with high diagnostic accuracy and cognitive relevance in cmTBI. The all‐frequency model offered more discriminative power than each frequency‐band model alone. This approach offers an effective path for optimal characterization of behaviorally relevant neuroimaging features in neurological and psychiatric disorders.