Understanding Traumatic Brain Injury in Females: A State-of-the-Art Summary and Future Directions

Activation of Cytosolic Cathepsin B Activity in the Brain by Traumatic Brain Injury and Inhibition by the Neutral pH Selective Inhibitor Probe Z-Arg-Lys-AOMK

Cathepsin B has been shown to contribute to deficits in traumatic brain injury (TBI), an important risk factor for Alzheimer's disease (AD). Cathepsin B is elevated in TBI and AD patients, as well as in animal models of these conditions. Knockout of the cathepsin B gene results in amelioration of TBI-induced motor dysfunction and improvement of AD memory deficit in mice. The mechanism of cathepsin B pathogenesis in these brain disorders has been hypothesized to involve its translocation to the cytosol from its normal lysosomal location. This study, therefore, evaluated brain cytosolic cathepsin B activity in the controlled cortical impact (CCI) mouse model of TBI. CCI-TBI resulted in motor deficits demonstrated by the rotarod assay, brain tissue lesions, and disorganization of the hippocampus. Significantly, CCI-TBI increased cytosolic cathepsin B activity in the brain cortex in the ipsilateral brain hemisphere that received the CCI-TBI injury, with a concomitant decrease in the lysosomal fraction. Cathepsin B activity was monitored using the substrate Z-Nle-Lys-Arg-AMC which specifically detects cathepsin B activity but not other cysteine proteases. The normal lysosomal distribution of cathepsin B was observed by its discrete localization in brain cortical cells. CCI-TBI resulted in a more diffuse cellular distribution of cathepsin B consistent with translocation to the cytosol. Further studies utilized the novel neutral pH-selective inhibitor, Z-Arg-Lys-AOMK, that specifically inhibits cathepsin B at neutral pH 7.2 of the cytosol but not at acidic pH 4.6 of lysosomes. Daily administration of Z-Arg-Lys-AOMK (ip), beginning 1 day before CCI-TBI, resulted in the reduction of the increased cytosolic cathepsin B activity induced by CCI-TBI. The inhibitor also reduced cathepsin B activities in homogenates of the brain cortex and hippocampus which were increased by CCI-TBI. Furthermore, the Z-Arg-Lys-AOMK inhibitor resulted in the reduction of motor function deficit resulting from CCI-TBI. These findings demonstrate the activation of cytosolic cathepsin B activity in CCI-TBI mouse brain injury.

Evaluating brain injury outcomes in female subjects: A computational approach to accident reconstruction of fatal and non-fatal cases

Traumatic brain injury remains a significant concern in public health, affecting millions of individuals globally and leading to long-term cognitive and physical impairments. Historically, research in this field has primarily focused on male subjects, often neglecting to consider the substantial biomechanical and anatomical differences between genders and individuals of varying ages. The present study investigates sex-specific biomechanical responses to head impacts in real-world accidents, employing an advanced female finite element head model, with a particular focus on critical brain structures such as the corpus callosum and pituitary gland. Two real-world accident scenarios were simulated: a non-fatal e-scooter collision and a fatal work-related incident involving a falling prop. A finite element analysis was conducted to determine the strain and stress distributions within the brain in response to impact conditions, assessing the potential for injury considering established failure criteria. The analysis revealed notable discrepancies in strain and stress distributions between anthropometric models. The smallest percentiles exhibited a higher risk of strain-related injury, while larger individuals demonstrated higher strain levels in key brain regions under similar impact conditions. Additionally, it was evaluated the efficacy of a safety helmet in a work-related scenario. These findings highlight the importance of subject-specific analyses in understanding TBIs and emphasise the need for continued refinement of FEHMs to improve the accuracy of injury prediction.

Development and Pilot Implementation of a Theory-Based Cognitive Rehabilitation Protocol for Adults With Chronic Cognitive Complaints After Mild Traumatic Brain Injury

PURPOSE

The aim of this study was to describe the development of and pilot feasibility outcomes for a strategy-based, brief, intensive cognitive rehabilitation intervention delivered to U.S. service members and veterans with mild traumatic brain injury in a recently completed 3-year pragmatic clinical trial: Symptom-Targeted Approach to Rehabilitation for Concussion (STAR-C).

METHOD

To develop STAR-C, we used the Rehabilitation Treatment Specification System to identify core elements and principles from a previous randomized clinical trial of cognitive rehabilitation, and incorporated principles of neuroplasticity (e.g., high-dose spaced practice of personally meaningful tasks), best clinical practices (e.g., client-centered goal setting), health psychology (e.g., a focus on self-efficacy and motivation), and community-based participation research (e.g., the protocol was co-designed by clinicians and researchers). Treatment was based on a resource-allocation theory of everyday cognitive challenges, which predicted that automatic strategy use would reduce cognitive demands of everyday activities and therefore reduce cognitive symptoms. Treatment was delivered by speech-language pathologists (SLPs) and occupational therapists (OTs), using a protocol that included a problem-focused intake questionnaire, manualized treatment, and clinician resources. Therapy was delivered individually in six to 10 virtual or in-person sessions over 3-4 weeks. Therapy focused on desired changes in function, scaled using Goal Attainment Scaling.

RESULTS

Trained SLPs and OTs delivered STAR-C to 53 U.S. service members and veterans, with treatment fidelity > 95%. Participants and clinicians rated STAR-C as acceptable, feasible, and appropriate, and most participants attained and maintained targets.

CONCLUSION

STAR-C appears to be a feasible method for improving everyday cognitive performance and efficacy should be tested in a controlled study.

SUPPLEMENTAL MATERIAL

https://doi.org/10.23641/asha.28222613.

Research Letter: Relationship of Blood Biomarkers of Inflammation With Acute Concussion Symptoms and Recovery in the CARE Consortium

OBJECTIVE

Determine the association of inflammatory biomarkers with clinical measures and recovery in participants with concussion.

SETTING

Multicenter study in National Collegiate Athletic Association member institutions including military service academies.

PARTICIPANTS

Four hundred twenty-two participants with acute concussion.

DESIGN

Clinical visits and blood draws were completed preinjury and at multiple visits postconcussion (0-12 hours, 12-36 hours, and 36-60 hours postinjury). Clinical measures included Sport Concussion Assessment Tool (SCAT) symptom severity, Balance Error Scoring System, Standardized Assessment of Concussion (SAC), Brief Symptom Inventory-18 (BSI-18) scores, time to initiation of graduated return-to-play (RTP) protocol, and time to RTP. Interleukin (IL)-6, IL-10, IL-8, IL-1 receptor antagonist (RA), tumor necrosis factor (TNF), c-reactive protein, and vascular endothelial growth factor (VEGF) were measured in serum. Prespecified analyses focused on IL-6 and IL-1RA at 0 to 12 hours; exploratory analyses were conducted with false discovery rate correction.

RESULTS

For prespecified analyses, IL-1RA at 0 to 12 hours in female participants was positively associated with more errors on the SAC (B(standard error, SE) = 0.58(0.27), P < .05) and worse SCAT symptom severity (B(SE) = 0.96(0.44), P < .05). For exploratory analyses, higher levels of IL-1RA at 12 to 36 hours were associated with higher global (B(SE) = 0.55(0.14), q < 0.01), depression (B(SE) = 0.45(0.10), q < 0.005), and somatization scores on the BSI (B(SE) = 0.46(0.12), q < 0.01) in participants with concussion; Higher TNF at 12 to 36 hours was associated with fewer errors on the SAC (B(SE) = - 0.46(0.14), q < 0.05). Subanalyses showed similar results for male participants and participants who were athletes. No associations were discovered in nonathlete cadets. Higher IL-8 at 0 to 12 hours was associated with slower RTP in female participants (OR = 14.47; 95% confidence interval, 2.96-70.66, q < 0.05); no other associations with recovery were observed.

CONCLUSIONS

Peripheral inflammatory markers are associated with clinical symptoms following concussion and potentially represent one mechanism for psychological symptoms observed postinjury. Current results do not provide strong support for a potential prognostic role for these markers.

College students' perceptions of concussion: Illness beliefs and masculinity norms predict stigma and willingness to seek treatment

College students' beliefs and attitudes concerning concussion, and masculinity norms, were examined in relation to stigma and willingness to seek treatment for possible concussion. Beliefs were measured using a revised Illness Perception Questionnaire (IPQ). Participants: Participants were 631 undergraduates at a Northeastern university, most of whom were nonathletes with no concussion. Methods: Data were collected online. Regression analysis were performed to identify predictors of stigma and treatment willingness. Results: Beliefs that concussion symptoms reflect malingering, are controllable, and have psychological causes were related to more stigmatizing attitudes, as was endorsement of masculinity norms regarding winning and risk-taking. Believing that concussion symptoms are long-lasting and endorsing competitiveness, pain discounting, and self-reliance predicted willingness to seek treatment. Preliminary structural models showed adequate fit. Conclusions: In addition to beliefs assessed by the IPQ, traditional conceptions of masculinity warrant greater attention in the study of concussion-related stigma and willingness to seek treatment.

Traumatic Brain Injury and Posttraumatic Stress Disorder Are Associated with Physical Health Burden Among Post-9/11 Women Veterans

Background: Little research focuses on physical health outcomes of traumatic brain injury (TBI) and posttraumatic stress disorder (PTSD) among post-9/11 women veterans (WVs). This study examined lifetime TBI, current PTSD, and their associations with biomarkers of cardiometabolic health, sleep, pain, and functional disability among post-9/11 WVs. Methods: WVs (n = 90) from the Translational Research Center for TBI and Stress Disorders longitudinal cohort study were included in this study. Gold standard clinician administered interviews assessed lifetime TBI (Boston Assessment of TBI-Lifetime) and current PTSD symptoms (Clinician-Administered PTSD Scale-IV). Objective measures of health included waist-hip ratio (WHR) and fasted blood biomarker (high density lipoprotein [HDL], low density lipoprotein [LDL], blood glucose, triglycerides) levels. Self-reported surveys assessed sleep, pain, and functional disability. Results: Just under two-thirds (58.9%) of WVs experienced a lifetime TBI, and just over half (53.3%) of this sample had a current PTSD diagnosis at the time of testing. Lifetime TBI was significantly associated with higher WHR, triglycerides levels, and worse pain and sleep (ps = <0.01 to 0.02; ds = 0.01 to 1.12). Current PTSD was significantly associated with higher WHR, lower HDL, and worse pain and sleep (ps = <0.01 to 0.02; ds = 0.009 to 1.19). PTSD was significantly associated with lower total functioning and each of its subdomains (βs = -0.58 to 0.63; ps = <0.001 to 0.02). Lifetime TBI was significantly associated with total functioning, mobility, and life/work (βs = -0.20 to 0.30; ps = <0.01 to 0.02). Conclusions: These findings highlight the importance of screening for lifetime TBI and cardiovascular disease for WVs and support transdiagnostic treatment approaches targeting physical health outcomes.

Examining acquired brain injury-associated symptoms and fluid-based biomarkers in females surviving intimate partner violence: An observational pilot study protocol

BACKGROUND

Acquired brain injury (ABI), including traumatic brain injury and hypoxic/anoxic injury, presents significant public health concerns; however, existing literature has focused primarily on male populations, such as military personnel and contact sports participants. Sex-related differences in ABI outcomes necessitate focused research due to potential heightened risk and distinct physiological responses among females.

OBJECTIVES

This pilot study aims to explore fluid-based biomarkers for neurological injury and inflammation in females experiencing intimate partner violence (IPV)-related assaults to the head, neck, or face. It seeks to assess the feasibility and acceptability of non-invasive sweat patch collection for biomarker analysis and its association with post-injury symptoms.

DESIGN

This study will be a prospective longitudinal observational pilot study involving approximately 50 participants recruited from two mid-Atlantic-based hospital emergency departments.

METHODS AND ANALYSIS

Participants will undergo clinical interviews, provide blood and sweat samples, and complete questionnaires assessing ABI history, IPV-related symptoms, cognitive function, psychological well-being, and sweat patch acceptability, across three study visits. Screening procedures will identify eligible participants, followed by consent procedures, biosample collection, brain injury and IPV history survey administration, symptom and cognitive function instrument administration, and acute medical record data collection. Analyses will include random effects regression, product moment correlations, and descriptive statistics.

ETHICS

Participants will be informed about the study's purpose, procedures, and potential risks before providing consent. Compensation will be provided for participation, with withdrawal options available. Ethical considerations include ensuring participant confidentiality and addressing psychological disorders beyond exclusion criteria.

DISCUSSION

Understanding fluid-based biomarkers in IPV-related ABI can inform interdisciplinary interventions and precision care models. Findings may facilitate early detection, treatment, and safety planning for affected females, emphasizing the importance of tailored, accessible care for this vulnerable population. Future research should focus on translating these findings into evidence-based practice to improve outcomes for women with ABI, particularly those resulting from IPV.

Lifetime History of Head or Traumatic Brain Injury Before Age 9 and School Outcomes: Results From the Adolescent Brain Cognitive Development Study

BACKGROUND

Limited information about school outcomes among children (especially early childhood) with lifetime history of head injury, including traumatic brain injury (TBI), may inhibit efforts to support their academics and physical and mental health.

METHODS

Baseline data (2016-2018) from the Adolescent Brain Cognitive Development (ABCD) study were analyzed to describe associations between parent-proxy reported lifetime history of head injury or TBI before age 9 and school outcomes and behavioral challenges among 9- and 10-year-old children.

RESULTS

Having a lifetime history of head injury before age 9 was associated with increased odds of parent-perceived poor school performance (adjusted odds ratio [AOR] = 1.44, 95% confidence interval [CI] = 1.14-1.81), a drop in grades (AOR = 1.28, 95%CI = 1.06-1.54), recent receipt of detentions or suspensions (AOR = 1.29, 95%CI = 1.02-1.65), and receipt of special educational services (AOR = 1.23, 95%CI = 1.08-1.41). Of those with a lifetime history of head injury, males displayed poorer school outcomes and greater behavioral challenges than females. Similar associations were observed between lifetime history of TBI before age 9 and worse school outcomes, with males continuing to demonstrate stronger associations.

CONCLUSIONS

These findings underscore the importance of screening for history of head injury and TBI and providing training for school professionals to help ensure students with a history of head or traumatic brain injury have appropriate supports in place.

Factors Influencing Speech-Language Pathology Referral and Utilization in Mild Traumatic Brain Injury: An Exploratory Analysis

PURPOSE

Speech-language pathologists provide important services to people recovering from mild traumatic brain injury (mTBI), also called concussion, although they may be underutilized in outpatient care. Because health care providers face challenges in selecting assessments to efficiently describe patient needs, the purpose of this study was to describe factors related to patients receiving speech-language pathology services after mTBI, as well as how assessments predict amount of services received.

METHOD

In this retrospective chart review study, demographic factors, injury characteristics, and assessment scores were extracted from medical records of patients aged 14-65 years receiving services for recent (within 6 months) mTBI at an outpatient specialty clinic. The Post-Concussion Symptom Scale (PCSS), Montreal Cognitive Assessment, Standardized Assessment of Concussion, and a newly developed self-report measure of cognitive-communication function-the Cognitive-Communication Referral Indicator for Concussion (CCoRI-C)-were used as dependent variables to predict speech-language pathology service referral. For those referred, Repeatable Battery for the Assessment of Neuropsychological Status (RBANS) and Behavior Rating Inventory of Executive Function (BRIEF) scores were added as dependent variables predicting speech-language pathology dosage.

RESULTS

A total of 132 patient charts met inclusion and exclusion criteria. In addition to CCoRI-C and PCSS symptoms, receiving imaging, being injured in a motor vehicle crash, experiencing loss of consciousness, and being of female sex were related to speech-language pathology referrals. Of the 77 patients referred for speech-language pathology care, higher CCoRI-C, PCSS, BRIEF, RBANS total, and RBANS visuospatial scores were associated with recommended speech-language pathology dosage. Only the CCoRI-C, BRIEF-Adult Version (BRIEF-A) Behavioral Regulation, and BRIEF-A Metacognition were associated with actual number of speech-language pathology sessions attended.

CONCLUSIONS

Cognitive-communication symptoms and executive function may be important to planning speech-language pathology rehabilitative episodes of care for people with mTBI. Future work should continue to evaluate how assessments augment demographic and injury characteristics in decision making for both referral to and use of speech-language pathology services after mTBI.

An objective neurophysiological study of subconcussion in female and male high school student athletes

Emerging evidence from neurophysiological brain vital sign studies show repeatable sensitivity to cumulative subconcussive impairments over a season of contact sports. The current study addressed the need for research comparing a low-contact control group to high-contact group. Importantly, the study also expanded the scope of neurophysiological changes related to repetitive head impacts to include female athletes in addition to male athletes. In total, 89 high school student athletes underwent 231 brain vital sign scans over a full calendar year. The results replicated prior subconcussive cognitive impairments (N400 delays) and sensory impairments (N100 amplitude reductions) in male athletes and demonstrated similar subconcussive impairments for the first time in female athletes. While there was no significant subconcussive difference between female and male athletes, female athletes show overall larger responses in general. The findings demonstrated that subconcussive impairments are detectable in a controlled experimental comparison for both female and male high school athletes. The study highlights the opportunity to monitor subconcussive changes in cognitive processing for both female and male athletes to help advance prevention, mitigation and management efforts aimed at reducing athletes' risk of potential long-term negative health outcomes related to cumulative exposure to repetitive head impacts.

Pediatric Brain Injuries are Associated With Intimate Partner Violence-Related Brain Injuries Among Women in Adulthood

OBJECTIVE

Prior studies have reported associations between childhood physical abuse and intimate partner violence (IPV). However, there has been limited literature examining the relationship between pediatric brain injuries and IPV-related brain injuries later in life. We examined the association between childhood brain injuries and brain injuries sustained from IPV in adulthood.

SETTING

Participants were recruited through Mass General Brigham's "Rally," social media, and information sheets distributed in locations likely to serve women in current or past abusive relationships (eg, domestic violence shelters, and IPV support programs).

PARTICIPANTS

Women who have experienced IPV with and without brain injury (n = 129), ages 19 to 69.

DESIGN

Retrospective, cross-sectional study design.

MAIN MEASURES

We administered the Ohio State University Traumatic Brain Injury Identification Method and the Brain Injury Severity Assessment to assess brain injury history, and the Childhood Trauma Questionnaire (CTQ). A logistic regression was used to examine the association between pediatric brain injuries and IPV-related brain injuries, adjusting for childhood trauma, years of education, and age.

RESULTS

A majority of participants (64.3%) reported experiencing at least 1 IPV-related brain injury, and 30.2% experienced at least 1 childhood brain injury. Child abuse-related brain injuries occurred in 10.9% of the sample, whereas childhood brain injuries from other causes occurred in 19.4% of participants. Participants who sustained at least 1 childhood BI were significantly more likely to sustain a future IPV-related brain injury as an adult (OR = 4.652, P = .004). For each additional childhood BI sustained, participants were more likely to sustain an IPV-related BI (OR = 3.198, P = .005).

CONCLUSION

This study illustrates a high prevalence of childhood brain injuries among women who have experienced IPV and identifies an association between pediatric brain injuries and brain injuries due to partner violence in adulthood. Our findings speak to the urgency of increasing our understanding of childhood brain injuries and whether they or other related factors might confer an increased risk for brain injuries or possibly IPV later in life.

Sex Differences in Moderate-to-Severe Traumatic Brain Injury Randomized Controlled Trials

BACKGROUND

Understanding sex differences among persons with moderate-to-severe traumatic brain injury (TBI) is critical to addressing the unique needs of both males and females from acute care through to rehabilitation. Epidemiological studies suggest that 7 of every 10 persons with moderate-to-severe TBI are male, with females representing about 30%-33%.

OBJECTIVE

To examine the proportion of female and male individuals included in randomized controlled trials (RCTs) of interventions for moderate-to-severe TBI.

METHODS

A systematic review was conducted in line with Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines up to and including December 2022 using MEDLINE, PubMed, Scopus, CINAHL, EMBASE and PsycINFO databases. Studies were included if they met the following criteria: (1) human participants with a mean age ≥18 years, (2) ≥50% of the sample had moderate-to-severe TBI and (3) the study design was a RCT. Data extracted included author, year, country, sample size, number of female/male participants and time post-injury.

RESULTS

595 RCTs met the criteria for inclusion, published between 1978 and 2022, totaling 86,662 participants. The average proportion of female participants was 23.14%, and the percentage increased a small but significant amount over time. There was a significantly lower percentage of female participants in RCTs initiated in the acute phase (≤ 1 month) when compared with RCTs conducted in the chronic phase (≥ 6 months) post-injury (p < 0.001).

CONCLUSIONS

Female participants are underrepresented in RCTs of moderate-to-severe TBI. Addressing this underrepresentation is critical to establish effective treatments for all persons with TBI.

IPV survivors' and service providers' perspectives on brain injury screening/evaluation process and impact

This study explores the perspectives of intimate partner violence (IPV) survivors and staff of brain injury (BI) screening, and the neuropsychological evaluation (NPE) process. We gathered qualitative data from 17 participants - 10 IPV survivors, at risk for a BI, who had received BI screening and a NPE and a total of 7 staff in IPV-serving organizations. Interviews were recorded, transcribed verbatim and analysed for key themes using thematic analysis. Survivors were over 18 years of age; the majority were between 19 and 45 years old, unemployed, unmarried, and had children. Survivors were angry, scared, and embarrassed to learn that they might have an IPV-related BI. They were thankful to have an explanation for some of their cognitive symptoms, which disrupted their daily activities, social relationships, and overall quality of life. Staff were pleased to be able to provide valuable information to their clients that could have a positive impact on their wellbeing. Overall, screening for a BI and participation in the NPE were well tolerated by IPV survivors with a possible BI. Inclusion of the perspectives of IPV survivors and support staff is an essential first step to better understanding their needs so interventions can be developed to aid their recovery.

Assessment of Sports Concussion in Female Athletes: A Role for Neuroinformatics?

Over the past decade, the intricacies of sports-related concussions among female athletes have become readily apparent. Traditional clinical methods for diagnosing concussions suffer limitations when applied to female athletes, often failing to capture subtle changes in brain structure and function. Advanced neuroinformatics techniques and machine learning models have become invaluable assets in this endeavor. While these technologies have been extensively employed in understanding concussion in male athletes, there remains a significant gap in our comprehension of their effectiveness for female athletes. With its remarkable data analysis capacity, machine learning offers a promising avenue to bridge this deficit. By harnessing the power of machine learning, researchers can link observed phenotypic neuroimaging data to sex-specific biological mechanisms, unraveling the mysteries of concussions in female athletes. Furthermore, embedding methods within machine learning enable examining brain architecture and its alterations beyond the conventional anatomical reference frame. In turn, allows researchers to gain deeper insights into the dynamics of concussions, treatment responses, and recovery processes. This paper endeavors to address the crucial issue of sex differences in multimodal neuroimaging experimental design and machine learning approaches within female athlete populations, ultimately ensuring that they receive the tailored care they require when facing the challenges of concussions. Through better data integration, feature identification, knowledge representation, validation, etc., neuroinformaticists, are ideally suited to bring clarity, context, and explainabilty to the study of sports-related head injuries in males and in females, and helping to define recovery.

Examining the Utility of Veterans Health Administration (VHA) Traumatic Brain Injury Screening among Women Veterans: Recommendations for Expansion to Include Interpersonal Violence

Women veterans (WVs) are more likely than men veterans to experience traumatic brain injury (TBI) from causes unrelated to deployment. Yet, current Veterans Health Administration (VHA) TBI screening focuses on deployment. This study examines the utility of the VHA TBI screening tool for WVs. Using the Boston Assessment for TBI-Lifetime (BAT-L) as the gold standard, sensitivity and specificity of the VHA screen were identified for deployment and non-deployment injuries. Injuries missed by the screen were thematically described. Sensitivity and specificity were compared by context (research, clinical). Ninety WVs were included; fifty-three (60.9%) met TBI criteria per the BAT-L. For TBIs occurring during deployment, sensitivity was higher in research (89.1%) compared to clinics (61.7%); specificity was lower in research (60.7%) compared to clinics (93.0%). The BAT-L identified 27 non-deployment TBIs not captured by the VHA screen, most frequently from physical assault or sports. The VHA screen does not include non-deployment events; thus, non-deployment sensitivity and specificity could not be calculated. For lifetime TBIs (deployment + non-deployment etiologies), sensitivity was higher in research (73.5%) compared to clinics (48.9%). Specificity was lower in research (60.0%) compared to clinics (100.0%). Findings can inform improvements to TBI screening among WVs, including expansion for interpersonal violence.

Sex differences in postconcussive symptom reporting in those with history of concussion: Findings from the federal interagency traumatic brain injury research (FITBIR) database

Objective: This study investigated influence of biological sex on postconcussive symptoms (PCS) following concussion using the Federal Interagency Traumatic Brain Injury Research (FITBIR) database. Method: All studies with publicly released data as of 4/7/21 that included both males and females, enough information to determine severity of injury consistent with concussion, a measure of PCS, and objective measures of neurocognitive functioning were used. This resulted in 6 studies with a total of 9890 participants (3206 females, 6684 males); 815 participants completed the Neurobehavioral Symptom Inventory (NSI), 471 completed the Rivermead Post-Concussion Symptoms Questionnaire (RPSQ), and 8604 completed the Sport Concussion Assessment Tool-3rd Edition (SCAT 3). Questionnaires were harmonized and the following symptom composite scores were computed: total score, somatic, cognitive, and affective. Data were analyzed using linear mixed-effects models. Results: Females endorsed higher total symptoms relative to males and that military personnel endorsed higher symptoms relative to civilians. Additionally, there was a small but significant interaction effect, such that female military personnel endorsed even higher symptoms than would be predicted by the main effects. Similar patterns were observed for somatic, cognitive, and affective symptom domains. Conclusions: Further understanding sex differences in PCS reporting is key to informing the most appropriate treatment options. Future work will need to examine whether sex differences in symptom reporting is due to sex differences in endorsement styles or genuine differences in symptom presentation, as well as the relationship between study population (e.g., military, civilian, sport) and sex on objective cognitive functioning and other functional outcomes.

Long-Term Quality of Life After Pediatric Traumatic Brain Injury Treated in the Intensive Care Unit

BACKGROUND

To examine the long-term health-related quality of life (HRQL) after pediatric traumatic brain injury (TBI) treated in the intensive care unit (ICU).

METHODS

This retrospective cohort study was conducted using data from four university hospital ICUs in Finland. Children aged < 18 years with TBI treated in the ICU during 2003 to 2013 were included. Patients alive at the end of 2020 were sent two different HRQL questionnaires 15/16-dimensional (15D/16D) and RAND-36  and questions regarding chronic diseases, socioeconomical status, and the need for health care support. HRQL was defined as poor when the 15D/16D score total score was below the age- and sex-matched mean population score in Finland minus the minimal clinically important difference.

RESULTS

A total of 150 of 337 (44%) patients responded (n = 144 15D/16D responses). Median follow-up time was 11 years. Seventy patients (49%) had a poor HRQL according to 15D/16D score. Patients with TBI had significantly poorer 15D scores in every dimension when compared with the matched population mean values. A higher Helsinki CT score, mechanical ventilation, and female sex were associated with poor long-term HRQL according to the 15D/16D. Patients with poor 15D/16D scores also needed significantly more health care services and medications and had more comorbidities than patients with normal scores. A poor 15D/16D score was associated with lower socioeconomic status.

CONCLUSIONS

Half of long-term pediatric ICU-treated TBI survivors had poor HRQL 11 years after injury. More severe head computed tomographic findings at admission and female sex associated with poor HRQL.

The Uncoupling Effect of 17β-Estradiol Underlies the Resilience of Female-Derived Mitochondria to Damage after Experimental TBI

Current literature finds females have improved outcomes over their male counterparts after severe traumatic brain injury (TBI), while the opposite seems to be true for mild TBI. This begs the question as to what may be driving these sex differences after TBI. Estrogen is thought to be neuroprotective in certain diseases, and its actions have been shown to influence mitochondrial function. Mitochondrial impairment is a major hallmark of TBI, and interestingly, this dysfunction has been shown to be more severe in males than females after brain injury. This suggests estrogen could be playing a role in promoting "mitoprotection" following TBI. Despite the existence of estrogen receptors in mitochondria, few studies have examined the direct role of estrogen on mitochondrial function, and no studies have explored this after TBI. We hypothesized ex vivo treatment of isolated mitochondria with 17β-estradiol (E2) would improve mitochondrial function after experimental TBI in mice. Total mitochondria from the ipsilateral (injured) and contralateral (control) cortices of male and female mice were isolated 24 h post-controlled severe cortical impact (CCI) and treated with vehicle, 2 nM E2, or 20 nM E2 immediately before measuring reactive oxygen species (ROS) production, bioenergetics, electron transport chain complex (ETC) activities, and β-oxidation of palmitoyl carnitine. Protein expression of oxidative phosphorylation (OXPHOS) complexes was also measured in these mitochondrial samples to determine whether this influenced functional outcomes with respect to sex or injury. While mitochondrial ROS production was affected by CCI in both sexes, there were other sex-specific patterns of mitochondrial injury 24 h following severe CCI. For instance, mitochondria from males were more susceptible to CCI-induced injury with respect to bioenergetics and ETC complex activities, whereas mitochondria from females showed only Complex II impairment and reduced β-oxidation after injury. Neither concentration of E2 influenced ETC complex activities themselves, but 20 nM E2 appeared to uncouple mitochondria isolated from the contralateral cortex in both sexes, as well as the injured ipsilateral cortex of females. These studies highlight the significance of measuring mitochondrial dysfunction in both sexes after TBI and also shed light on another potential neuroprotective mechanism in which E2 may attenuate mitochondrial dysfunction after TBI in vivo.

Natural course and predictors of consciousness recovery in children with prolonged disorder of consciousness

Prolonged disorder of consciousness (DoC) is a rising challenge. Pediatric data on diagnosis and prognosis of prolonged DoC were too limited and heterogeneous, making it difficult to define the natural course and evaluate the prognosis. The present study explored the emergence from the Minimally Conscious State (eMCS) incidence at different months postinjury drawing the natural course, and detected the predictors of the incidence in children with prolonged DoC. A hospital-based prospective cohort study was conducted. Kaplan-Meier curves, as well as univariate and multivariate COX regression analysis, were performed. The study enrolled 383 pediatric DoC individuals, including 220 males (57.4%), with an average age of 3.9 (1.9-7.3) years. The median duration between onset and rehabilitation is 30.0 (21.0-46.0) days. At enrollment, the ratio of vegetative state/unresponsive wakefulness syndrome (VS/WUS) to MCS is 78.9%-21.1%. Traumatic brain injury and infection are the major etiologies (36.8% and 37.1%, respectively), followed by hypoxia cerebral injury (12.3%). For children with prolonged DoC, the cumulative incidence of eMCS at months 3, 6, 12, and 24 was 0.510, 0.652, 0.731, 0.784 VS 0.290, 0.418, 0.539, 0.603 in the traumatic VS non-traumatic subgroup, respectively. For children in a persistent vegetative state (PVS), the cumulative incidence of emergence at months in 3, 6, 12, 24, 36 and 48 was testified as 0.439, 0.591, 0.683, 0.724, 0.743 and 0.743 in the traumatic subgroup, and 0.204, 0.349, 0.469, 0.534, 0.589 and 0.620 in the non-traumatic subgroup. Participants who exhibit any of the following four demographical and/or clinical characteristics-namely, older than 4 years at onset, accepted rehabilitation within 28 days of onset, remained MCS at enrollment, or with etiology of traumatic brain injuries-had a significantly positive outcome of consciousness recovery (eMCS). Moreover, both prolongation of the central somatosensory conductive time (CCT) (level 2) and absence of N20 (level 3) independently predict a negative outcome. In children with prolonged DoC, we found that 12 months postinjury was critical to eMCS, and a preferred timepoint to define chronic vegetative state (VS). The characteristics including age, etiology, time before rehabilitation, consciousness state, and SEP results were useful predictors of conscious recovery.Trial registration Registered 06/11/2018, the registration number is chiCTR1800019330 (chictr.org.cn). Registered prospectively.

Experiences of Domestic Violence in Adult Patients with Brain Injury: A Select Overview of Screening, Reporting, and Next Steps

This select overview examines the important intersection of adult domestic violence, including intimate partner violence and elder abuse, with brain injury. Despite the high prevalence of domestic violence amongst brain injury patients, there is a notable gap in screening and management training for providers. To provide optimal patient care, brain injury medicine clinicians must screen, recognize, and treat patients who have experienced domestic violence. This select overview highlights barriers to screening, validated screening tools from other medical disciplines, and management considerations for the brain injury clinician. A suggested protocol for domestic violence screening and management, as well as recommended resources for providers and patients, is summarized.

Efficacy of restitutive interventions for oculomotor deficits in adults with mild traumatic brain injury: a systematic review and meta-analysis

BACKGROUND

Mild traumatic brain injury (mTBI) can cause persistent symptoms suggestive of oculomotor deficits. This research synthesized evidence on restitutive interventions for reducing oculomotor deficits in adults with mTBI to understand if these interventions have clinical utility for improving recovery.

METHODS

Medline, EMBASE, CINHAL, PsychInfo, and Scopus, databases were searched for experimental studies published in English. We rated risk of bias (RoB) using recommended tools, and the certainty of the evidence according to GRADE guidelines. We conducted meta-analyses for similar outcomes reported in at least two studies.

RESULTS

Out of 5,328 citations, 12 studies (seven case series and five crossover design), with a combined sample size of 354 participants; (43% males) met the inclusion criteria and were analyzed. The analysis revealed a trend toward improvement of oculomotor deficits and visual tasks in response to restitutive intervention. None of the studies addressed sex or gender effects. All studies had high RoB, suggesting low certainty in the reported results.

DISCUSSION

Restitutive interventions may be beneficial for adults with oculomotor deficits after mTBI, however overall certainty of the evidence remains low. Future efforts must include enhancing attention to study methodology and reporting, sex and gender analyses, and reaching a consensus on outcome measures.

PROSPERO REGISTRATION NUMBER

CRD42022352276.

Impact of menopause-associated frailty on traumatic brain injury

Navigating menopause involves traversing a complex terrain of hormonal changes that extend far beyond reproductive consequences. Menopausal transition is characterized by a decrease in estradiol-17β (E2), and the impact of menopause resonates not only in the reproductive system but also through the central nervous system, musculoskeletal, and gastrointestinal domains. As women undergo menopausal transition, they become more susceptible to frailty, amplifying the risk and severity of injuries, including traumatic brain injury (TBI). Menopause triggers a cascade of changes leading to a decline in muscle mass, accompanied by diminished tone and excitability, thereby restricting the availability of irisin, a crucial hormone derived from muscles. Concurrently, bone mass undergoes reduction, culminating in the onset of osteoporosis and altering the dynamics of osteocalcin, a hormone originating from bones. The diminishing levels of E2 during menopause extend their influence on the gut microbiota, resulting in a reduction in the availability of tyrosine, tryptophan, and serotonin metabolites, affecting neurotransmitter synthesis and function. Understanding the interplay between menopause, frailty, E2 decline, and the intricate metabolisms of bone, gut, and muscle is imperative when unraveling the nuances of TBI after menopause. The current review underscores the significance of accounting for menopause-associated frailty in the incidence and consequences of TBI. The review also explores potential mechanisms to enhance gut, bone, and muscle health in menopausal women, aiming to mitigate frailty and improve TBI outcomes.

Quantitative assessment of traumatic brain injury risk in diverse age groups of females: Insights from computational biomechanics

Traumatic Brain Injury (TBI) stands as a multifaceted health concern, exhibiting varying influences across human population. This study delves into the biomechanical complexities of TBI within gender-specific contexts, focusing on females. Our primary objective is to investigate distinctive injury mechanisms and risks associated with females, emphasizing the imperative for tailored investigations within this cohort. By employing Fluid-Structure Interaction (FSI) Analysis, we conducted simulations to quantify biomechanical responses to traumatic forces across diverse age groups of females. The study utilized a scaling technique to create finite element models (FEMs). The young female FEM, based on anthropometric data, showcased a 15 % smaller head geometry compared to the young male FEM. Moreover, while the elderly female FEM closely mirrored the young female FEM in most structural aspects, it showed distinctive features such as brain atrophy and increased cerebrospinal fluid (CSF) layer thickness. Notably, the child female FEM (ages 7-11 years) replicated around 95 % of the young female FEM's geometry. These structural distinctions meticulously captured age-specific variations across our modeled female age groups. It's noteworthy that identical conditions, encompassing impact intensity, loading type, and boundary conditions, were maintained across all FEMs in this biomechanical finite element analysis, ensuring comparative results. The findings unveiled significant variations in frontal and occipital pressures among diverse age groups, highlighting potential age-related discrepancies in TBI susceptibility among females. These variations were primarily linked to differences in anatomical features, including brain volume, CSF thickness, and brain condition, as the same material properties were used in the FEMs. These results were approximately 4.70, 6.33 and 6.43 % in frontal area of brain in diverse age groups of females (young, elderly, and child) respectively compared to young male FEM. Comparing the FEM results between the young female and the elderly female, we observed a decrease in occipital brain pressure at the same point, reducing from 171,993 to 167,793 Pa, marking an approximate 2.5 % decrease. While typically the elderly exhibit greater brain vulnerability compared to the young, our findings showcase a reduction in brain pressure. Notably, upon assessing the relative movement between the brain and the skull at the point located in occipital area, we observed greater relative movement in the elderly (1.8 mm) compared to the young female (1.04 mm). Therefore, brain atrophy increases the range of motion of the brain within the cranial space. The study underscores the critical necessity for nuanced TBI risk assessment tailored to age and gender, emphasizing the importance of age-specific protective strategies in managing TBIs across diverse demographics. Future research employing individual modeling techniques and exploring a wider age spectrum holds promise in refining our understanding of TBI mechanisms and adopting targeted approaches to mitigate TBI in diverse groups.

IDO-1 inhibition improves outcome after fluid percussion injury in adult male rats

The enzyme indoleamine 2,3 dioxygenase 1 (IDO1) catalyzes the rate-limiting step in the kynurenine pathway (KP) which produces both neuroprotective and neurotoxic metabolites. Neuroinflammatory signals produced as a result of pathological conditions can increase production of IDO1 and boost its enzymatic capacity. IDO1 and the KP have been implicated in behavioral recovery after human traumatic brain injury (TBI), but their roles in experimental models of TBI are for the most part unknown. We hypothesized there is an increase in KP activity in the fluid percussion injury (FPI) model of TBI, and that administration of an IDO1 inhibitor will improve neurological recovery. In this study, adult male Sprague Dawley rats were subjected to FPI or sham injury and received twice-daily oral administration of the IDO1 inhibitor PF-06840003 (100 mg/kg) or vehicle control. FPI resulted in a significant increase in KP activity, as demonstrated by an increased ratio of kynurenine: tryptophan, in the perilesional neocortex and ipsilateral hippocampus 3 days postinjury (DPI), which normalized by 7 DPI. The increase in KP activity was prevented by PF-06840003. IDO1 inhibition also improved memory performance as assessed in the Barnes maze and anxiety behaviors as assessed in open field testing in the first 28 DPI. These results suggest increased KP activity after FPI may mediate neurological dysfunction, and IDO1 inhibition should be further investigated as a potential therapeutic target to improve recovery.

Traumatic Brain Injury in the Long-COVID Era

Major determinants of the biological background or reserve, such as age, biological sex, comorbidities (diabetes, hypertension, obesity, etc.), and medications (e.g., anticoagulants), are known to affect outcome after traumatic brain injury (TBI). With the unparalleled data richness of coronavirus disease 2019 (COVID-19; ∼375,000 and counting!) as well as the chronic form, long-COVID, also called post-acute sequelae SARS-CoV-2 infection (PASC), publications (∼30,000 and counting) covering virtually every aspect of the diseases, pathomechanisms, biomarkers, disease phases, symptomatology, etc., have provided a unique opportunity to better understand and appreciate the holistic nature of diseases, interconnectivity between organ systems, and importance of biological background in modifying disease trajectories and affecting outcomes. Such a holistic approach is badly needed to better understand TBI-induced conditions in their totality. Here, I briefly review what is known about long-COVID/PASC, its underlying-suspected-pathologies, the pathobiological changes induced by TBI, in other words, the TBI endophenotypes, discuss the intersection of long-COVID/PASC and TBI-induced pathobiologies, and how by considering some of the known factors affecting the person's biological background and the inclusion of mechanistic molecular biomarkers can help to improve the clinical management of TBI patients.

Association of Blood Biomarkers of Inflammation With Acute Concussion in Collegiate Athletes and Military Service Academy Cadets

BACKGROUND AND OBJECTIVES

The objective was to characterize the acute effects of concussion (a subset of mild traumatic brain injury) on serum interleukin (IL)-6 and IL-1 receptor antagonist (RA) and 5 additional inflammatory markers in athletes and military service academy members from the Concussion Assessment, Research, and Education Consortium and to determine whether these markers aid in discrimination of concussed participants from controls.

METHODS

Athletes and cadets with concussion and matched controls provided blood at baseline and postinjury visits between January 2015 and March 2020. Linear models investigated changes in inflammatory markers measured using Meso Scale Discovery assays across time points (baseline and 0-12, 12-36, 36-60 hours). Subanalyses were conducted in participants split by sex and injury population. Logistic regression analyses tested whether acute levels of IL-6 and IL-1RA improved discrimination of concussed participants relative to brain injury markers (glial fibrillary acidic protein, tau, neurofilament light, ubiquitin c-terminal hydrolase-L1) or clinical data (Sport Concussion Assessment Tool-Third Edition, Standardized Assessment of Concussion, Balance Error Scoring System).

RESULTS

Participants with concussion (total, N = 422) had elevated IL-6 and IL-1RA at 0-12 hours vs controls (n = 345; IL-6: mean difference [MD] (standard error) = 0.701 (0.091), p < 0.0001; IL-1RA: MD = 0.283 (0.042), p < 0.0001) and relative to baseline (IL-6: MD = 0.656 (0.078), p < 0.0001; IL-1RA: MD = 0.242 (0.038), p < 0.0001), 12-36 hours (IL-6: MD = 0.609 (0.086), p < 0.0001; IL-1RA: MD = 0.322 (0.041), p < 0.0001), and 36-60 hours (IL-6: MD = 0.818 (0.084), p < 0.0001; IL-1RA: MD = 0.317 (0.040), p < 0.0001). IL-6 and IL-1RA were elevated in participants with sport (IL-6: MD = 0.748 (0.115), p < 0.0001; IL-1RA: MD = 0.304 (0.055), p < 0.0001) and combative-related concussions (IL-6: MD = 0.583 (0.178), p = 0.001; IL-1RA: MD = 0.312 (0.081), p = 0.0001). IL-6 was elevated in male (MD = 0.734 (0.105), p < 0.0001) and female participants (MD = 0.600 (0.177), p = 0.0008); IL-1RA was only elevated in male participants (MD = 0.356 (0.047), p < 0.0001). Logistic regression showed the inclusion of IL-6 and IL-1RA at 0-12 hours improved the discrimination of participants with concussion from controls relative to brain injury markers (χ2(2) = 17.855, p = 0.0001; area under the receiver operating characteristic curve [AUC] 0.73 [0.66-0.80] to 0.78 [0.71-0.84]), objective clinical measures (balance and cognition; χ2(2) = 40.661, p < 0.0001; AUC 0.81 [0.76-0.86] to 0.87 [0.83-0.91]), and objective and subjective measures combined (χ2(2) = 13.456, p = 0.001; AUC 0.97 [0.95-0.99] to 0.98 [0.96-0.99]), although improvement in AUC was only significantly relative to objective clinical measures.

DISCUSSION

IL-6 and IL-1RA (male participants only) are elevated in the early-acute window postconcussion and may aid in diagnostic decisions beyond traditional blood markers and common clinical measures. IL-1RA results highlight sex differences in the immune response to concussion which should be considered in future biomarker work.

Neuroprotection or Sex Bias: A Protective Response to Traumatic Brain Injury in the Females

Traumatic brain injury (TBI) is a major healthcare problem and a common cause of mortality and morbidity. Clinical and preclinical research suggests sex-related differences in short- and longterm outcomes following TBI; however, males have been the main focus of TBI research. Females show a protective response against TBI. Female animals in preclinical studies and women in clinical trials have shown comparatively better outcomes against mild, moderate, or severe TBI. This reflects a favorable protective nature of the females compared to the males, primarily attributed to various protective mechanisms that provide better prognosis and recovery in the females after TBI. Understanding the sex difference in the TBI pathophysiology and the underlying mechanisms remains an elusive goal. In this review, we provide insights into various mechanisms related to the anatomical, physiological, hormonal, enzymatic, inflammatory, oxidative, genetic, or mitochondrial basis that support the protective nature of females compared to males. Furthermore, we sought to outline the evidence of multiple biomarkers that are highly potential in the investigation of TBI's prognosis, pathophysiology, and treatment and which can serve as objective measures and novel targets for individualized therapeutic interventions in TBI treatment. Implementations from this review are important for the understanding of the effect of sex on TBI outcomes and possible mechanisms behind the favorable response in females. It also emphasizes the critical need to include females as a biological variable and in sufficient numbers in future TBI studies.

Sex and Age-at-Injury as Determinants of Social Behavior Outcomes After TBI

While our understanding of long-term disability after traumatic brain injury (TBI) has habitually focused on cognitive and sensorimotor functioning, it is increasingly appreciated that changes in social function for survivors of a brain injury are common and have a profound impact on one's quality of life. In this chapter, we highlight the consequences of TBI on social behavior, taking into account evidence from studies of patient populations as well as from preclinical animal models. After first considering the protracted nature of the development of social behavior across the lifespan, including the neurobiological networks that underlie social functioning, we discuss how TBI results in social behavior impairments and how these manifest. We focus particularly on how age-at-injury influences TBI-induced social impairments, with most of the evidence suggesting age-dependent vulnerability after injury at a younger age. In addition, we explore how biological sex is a key determinant of social behavior impairments after TBI, while gender in humans may also influence the nature and extent of social outcomes. Finally, we identify key knowledge gaps and emphasize the need for further research in the field.

In her own words: a phenomenological analysis of stories told by female service members and veterans after traumatic brain injury

PURPOSE

Given the majority of Service Members and Veterans (SMV) who have sustained a traumatic brain injury (TBI) are male, the female experience with TBI has not been captured in the general understanding of TBI. To improve understanding of the experience of female SMV after TBI utilizing a qualitative phenomenological approach on stories as told by female SMV.

MATERIALS AND METHODS

Ten female SMV participated in storytelling workshops and created video stories documenting their personal experience with TBI. Workshops were hosted by the VA Palo Alto Health Care System Polytrauma System of Care (VAPAHCS PSC). A grounded thematic analysis was conducted on the video stories.

RESULTS

Three common content themes emerged from all the stories: (1) negative psychological and emotional impacts of TBI, (2) acceptance and healing process associated with recovery, and (3) military contexts. Negative psychological and emotional impacts included intrapersonal impacts such as negative emotions, suicidal ideation, and dealing with cognitive and physical challenges, and interpersonal impacts in relationships and loss of independence. Notably, all the stories acknowledged an acceptance and healing process, characterized by several subthemes including motivational factors, TBI education, spirituality, and advocacy work. Lastly, each story mentioned military context, highlighting the unique experience within this population.

CONCLUSIONS

This phenomenological examination adds evidence-based understanding to the experience after TBI among female SMV. Each story uncovered nuanced and multifaceted issues that women experience in their TBI recovery. Our findings provide context to guide future intervention on the care, support, and TBI recovery for the female SMV population.

Physical Health and Well-being: Updates and the Way Ahead

INTRODUCTION

The Women in Combat Summit 2021 "Forging the Future: How Women Enhance the Fighting Force" took place during February 9-11, 2021, via a virtual conference platform. The third and final day of the Summit regarded the physical health and well-being of military women and included the topics of urogenital health, nutrition and iron-deficiency anemia, unintended pregnancy and contraception, and traumatic brain injury.

MATERIALS AND METHODS

After presentations on the topics earlier, interested conference attendees were invited to participate in focus groups to discuss and review policy recommendations for physical health and well-being in military women. Discussions centered around the topics discussed during the presentations, and suggestions for future Women in Combat Summits were noted. Specifics of the methods of the Summit are presented elsewhere in this supplement.

RESULTS

We formulated research and policy recommendations for urogenital health, nutrition and iron-deficiency anemia, contraception and unintended pregnancy, and traumatic brain injury.

CONCLUSIONS

In order to continue to develop the future health of military women, health care providers, researchers, and policymakers should consider the recommendations made in this supplement as they continue to build on the state of the science and forge the future.

Electrical stimulation methods and protocols for the treatment of traumatic brain injury: a critical review of preclinical research

BACKGROUND

Traumatic brain injury (TBI) is a leading cause of disabilities resulting from cognitive and neurological deficits, as well as psychological disorders. Only recently, preclinical research on electrical stimulation methods as a potential treatment of TBI sequelae has gained more traction. However, the underlying mechanisms of the anticipated improvements induced by these methods are still not fully understood. It remains unclear in which stage after TBI they are best applied to optimize the therapeutic outcome, preferably with persisting effects. Studies with animal models address these questions and investigate beneficial long- and short-term changes mediated by these novel modalities.

METHODS

In this review, we present the state-of-the-art in preclinical research on electrical stimulation methods used to treat TBI sequelae. We analyze publications on the most commonly used electrical stimulation methods, namely transcranial magnetic stimulation (TMS), transcranial direct current stimulation (tDCS), deep brain stimulation (DBS) and vagus nerve stimulation (VNS), that aim to treat disabilities caused by TBI. We discuss applied stimulation parameters, such as the amplitude, frequency, and length of stimulation, as well as stimulation time frames, specifically the onset of stimulation, how often stimulation sessions were repeated and the total length of the treatment. These parameters are then analyzed in the context of injury severity, the disability under investigation and the stimulated location, and the resulting therapeutic effects are compared. We provide a comprehensive and critical review and discuss directions for future research. RESULTS AND CONCLUSION: We find that the parameters used in studies on each of these stimulation methods vary widely, making it difficult to draw direct comparisons between stimulation protocols and therapeutic outcome. Persisting beneficial effects and adverse consequences of electrical simulation are rarely investigated, leaving many questions about their suitability for clinical applications. Nevertheless, we conclude that the stimulation methods discussed here show promising results that could be further supported by additional research in this field.

The SUCCESS Peer Mentoring Program for College Students with Concussion: Preliminary Results of a Mobile Technology Delivered Intervention

Concussions are caused by a hit or blow to the head that alters normal brain functioning. The Success in College after Concussion with Effective Student Supports (SUCCESS) program was developed to provide students with psychosocial support and resources-both key components of concussion management-to assist in recovery and return-to-learn following concussion. In this preliminary evaluation of intervention efficacy, SUCCESS was delivered through a mobile application connecting mentors (students who have recovered from concussion and successfully returned to school) with mentees who were currently recovering. Mentor-mentee pairs met virtually through the app, using chat and videoconferencing features to share support, resources, and program-specific educational materials. Results from 16 mentoring pairs showed that mentee symptoms (V = 119, p = 0.009) and academic problems decreased (V = 114.5, p = 0.002), while academic self-efficacy increased (V = 13.5, p = 0.009) following mentoring. As expected, mentor measures were stable, indicating that providing mentoring did not exacerbate previously resolved concussion complaints. Virtual peer mentoring provided through a mobile application may be a feasible intervention to support academic success and psychosocial processing during recovery for college students with concussion.

Drosophila melanogaster as a model to study age and sex differences in brain injury and neurodegeneration after mild head trauma

Repetitive physical insults to the head, including those that elicit mild traumatic brain injury (mTBI), are a known risk factor for a variety of neurodegenerative conditions including Alzheimer's disease (AD), Parkinson's disease (PD), and chronic traumatic encephalopathy (CTE). Although most individuals who sustain mTBI typically achieve a seemingly full recovery within a few weeks, a subset experience delayed-onset symptoms later in life. As most mTBI research has focused on the acute phase of injury, there is an incomplete understanding of mechanisms related to the late-life emergence of neurodegeneration after early exposure to mild head trauma. The recent adoption of Drosophila-based brain injury models provides several unique advantages over existing preclinical animal models, including a tractable framework amenable to high-throughput assays and short relative lifespan conducive to lifelong mechanistic investigation. The use of flies also provides an opportunity to investigate important risk factors associated with neurodegenerative conditions, specifically age and sex. In this review, we survey current literature that examines age and sex as contributing factors to head trauma-mediated neurodegeneration in humans and preclinical models, including mammalian and Drosophila models. We discuss similarities and disparities between human and fly in aging, sex differences, and pathophysiology. Finally, we highlight Drosophila as an effective tool for investigating mechanisms underlying head trauma-induced neurodegeneration and for identifying therapeutic targets for treatment and recovery.

Traumatic Brain Injury and Psychopathic Traits in Justice-Involved Adult Women

Studies have documented associations between traumatic brain injury (TBI) and mental disorders. The relationship between psychopathic personality and TBI remains poorly understood, though both are associated with similar characteristics (e.g., low empathy, aggression, disturbances in social/moral behavior). Yet, it is not clear whether assessment of psychopathic features is influenced by presence versus absence of TBI, and which aspects of TBI may be associated with psychopathic traits. This study examined the psychopathy-TBI association in justice-involved women (N = 341) with structural equation modeling. We tested if measurement invariance of psychopathic traits was evident among those with versus without TBI and which TBI variables (number, severity, age at first TBI) predicted psychopathic features in conjunction with symptoms of psychopathology, IQ, and age. Results provided evidence of measurement invariance, and more women with TBI, compared to those without, met criteria for psychopathy. Younger age of TBI and TBI severity predicted interpersonal-affective psychopathic features.

Post-separation abuse: A concept analysis

AIM

To report an analysis of the concept of post-separation abuse and its impact on the health of children and adult survivors.

DESIGN

Concept analysis.

DATA SOURCES

A literature search was conducted via PubMed, Cochrane and Embase and identified articles published from 1987 to 2021.

METHODS

Walker and Avant's (2019) eight stage methodology was used for this concept analysis, including identifying the concept, determining the purpose of analysis, identifying uses of the concept, defining attributes, identifying a model case and contrary case, antecedents and consequences and defining empirical referents.

RESULTS

Post-separation abuse can be defined as the ongoing, willful pattern of intimidation of a former intimate partner including legal abuse, economic abuse, threats and endangerment to children, isolation and discrediting and harassment and stalking. An analysis of literature identified essential attributes including fear and intimidation; domination, power and control; intrusion and entrapment; omnipresence; and manipulation of systems. Antecedents to post-separation abuse include patriarchal norms, physical separation, children, spatiality and availability, pre-separation IPV and coercive control and perpetrator characteristics. Consequences include lethality, adverse health consequences, institutional violence and betrayal, such as loss of child custody and economic deprivation.

CONCLUSION

This concept analysis provides a significant contribution to the literature because it advances the science for understanding the phenomenon of post-separation abuse. It will aid in developing risk assessment tools and interventions to improve standards of care for adult and children survivors following separation from an abusive partner.

IMPACT

This concept analysis of post-separation abuse provides a comprehensive insight into the phenomenon and a theoretical foundation to inform instrument development, future research and intervention. Post-separation abuse is a complex, multi-faceted phenomenon that requires differential social, legal and healthcare systems responses to support the health and well-being of survivors and their children.

Development, validation and a case study: The female finite element head model (FeFEHM)

BACKGROUND AND OBJECTIVE

Traumatic brain injuries are one of the leading causes of death and disability in the world. To better understand the interactions and forces applied in different constituents of the human head, several finite element head models have been developed throughout the years, for offering a good cost-effective and ethical approach compared to experimental tests. Once validated, the female finite element head model (FeFEHM) will allow a better understanding of injury mechanisms resulting in neuronal damage, which can later evolve into neurodegenerative diseases.

METHODS

This work encompasses the approached methodology starting from medical images and finite element modelling until the validation process using novel experimental data of brain displacements conducted on human cadavers. The material modelling of the brain is performed using an age-specific characterization of the brain using microindentation at dynamic rates and under large deformation, with a similar age to the patient used to model the FeFEHM.

RESULTS

The numerical displacement curves are in good accordance with the experimental data, displaying similar peak times and values, in all three anatomical planes. The case study result shows a similarity between the pressure fields of the FeFEHM compared to another model, highlighting the future potential of the model.

CONCLUSIONS

The initial objective was met, and a new female finite element head model has been developed with biofidelic brain motion. This model will be used for the assessment of repetitive impact scenarios and its repercussions on the female brain.

Relationship Between Neighborhood Disadvantage and Mild Traumatic Brain Injury Symptoms

OBJECTIVE

To test the hypotheses that (1) higher neighborhood disadvantage is associated with greater injury-related symptom severity in civilians with mild traumatic brain injury (mTBI) and (2) neighborhood disadvantage remains predictive after controlling for other established predictors.

SETTING

Level 1 trauma center and affiliated academic medical center.

PARTICIPANTS

N = 171 individuals with mTBI.

DESIGN

Prospective cohort study.

MAIN MEASURES

Rivermead Post Concussion Symptoms Questionnaire (RPQ) total score assessed less than 24 hours and at 2 weeks, 3 months, and 6 months postinjury. Linear mixed-effects models were used to assess the relationship between predictor variables and mTBI-related symptom burden (RPQ score). Neighborhood disadvantage was quantified by the Area Deprivation Index (ADI), a composite of 17 markers of socioeconomic position (SEP) scored at the census block group level.

RESULTS

Individuals in the upper ADI quartile of the national distribution displayed higher RPQ symptoms than those in the lower 3 quartiles ( P < .001), with a nonsignificant ADI × visit interaction ( P = .903). In a multivariable model, the effect of ADI remained significant ( P = .034) after adjusting for demographics, individual SEP, and injury factors. Other unique predictors in the multivariable model were gender (gender × visit P = .035), health insurance type ( P = .017), and injury-related litigation ( P = .012).

CONCLUSION

Neighborhood disadvantage as quantified by the ADI is robustly associated with greater mTBI-related symptom burden throughout the first 6 months postinjury. That the effect of ADI remained after controlling for demographics, individual SEP, and injury characteristics implies that neighborhood disadvantage is an important, understudied factor contributing to clinical recovery from mTBI.

Intersectionality of Systemic Disadvantage on Mortality and Care Following TBI

BACKGROUND

People of color (POC), especially those who also hold social identities associated with disadvantage (non-English-speaking, female, older, lower socioeconomic level), continue to be underserved in the health system, which can result in poorer care and worsened health outcomes. Most disparity research in traumatic brain injury (TBI) focuses on the impact of single factors, which misses the compounding effect of belonging to multiple historically marginalized groups.

OBJECTIVE

To examine the intersectional impact of multiple social identities vulnerable to systemic disadvantage following TBI on mortality, opioid usage during acute hospitalization, and discharge location.

METHODS

Retrospective observational design utilizing electronic health records merged with local trauma registry data. Patient groups were defined by race and ethnicity (POC or non-Hispanic White), age, sex, type of insurance, and primary language (English-speaking vs non-English-speaking). Latent class analysis (LCA) was performed to identify clusters of systemic disadvantage. Outcome measures were then assessed across latent classes and tested for differences.

RESULTS

Over an 8-year period, 10 809 admissions with TBI occurred (37% POC). LCA identified a 4-class model. Groups with more systemic disadvantage had higher rates of mortality. Classes with older populations had lower rates of opioid administration and were less likely to discharge to inpatient rehabilitation following acute care. Sensitivity analyses examining additional indicators of TBI severity demonstrated that the younger group with more systemic disadvantage had more severe TBI. Controlling for more indicators of TBI severity changed statistical significance in mortality for younger groups.

CONCLUSION

Results demonstrate significant health inequities in the mortality and access to inpatient rehabilitation following TBI along with higher rates of severe injury in younger patients with more social disadvantages. While many inequities may be related to systemic racism, our findings suggested an additive, deleterious effect for patients who belonged to multiple historically disadvantaged groups. Further research is needed to understand the role of systemic disadvantage for individuals with TBI within the healthcare system.

Biomechanics of Traumatic Head and Neck Injuries on Women: A State-of-the-Art Review and Future Directions

The biomechanics of traumatic injuries of the human body as a consequence of road crashes, falling, contact sports, and military environments have been studied for decades. In particular, traumatic brain injury (TBI), the so-called "silent epidemic", is the traumatic insult responsible for the greatest percentage of death and disability, justifying the relevance of this research topic. Despite its great importance, only recently have research groups started to seriously consider the sex differences regarding the morphology and physiology of women, which differs from men and may result in a specific outcome for a given traumatic event. This work aims to provide a summary of the contributions given in this field so far, from clinical reports to numerical models, covering not only the direct injuries from inertial loading scenarios but also the role sex plays in the conditions that precede an accident, and post-traumatic events, with an emphasis on neuroendocrine dysfunctions and chronic traumatic encephalopathy. A review on finite element head models and finite element neck models for the study of specific traumatic events is also performed, discussing whether sex was a factor in validating them. Based on the information collected, improvement perspectives and future directions are discussed.

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.

Pregnancy After Concussion: A Clarion Call for Attention?

OBJECTIVE

Emerging research shows that women who sustain a mild traumatic brain injury, also termed concussion, have a higher risk of menstrual irregularities and sexual dysfunctions. However, no research exists on how these reproductive disruptions affect women's subsequent pregnancies. The objective of this study was to evaluate pregnancy outcomes after concussion in a cohort of reproductive-aged women (aged 18-45 years), 24 months post-injury. We hypothesized that, compared with their extremity-injured peers in the same cohort, women with concussion will have lower incidence of pregnancies.

SETTING

Emergency department of a level 1 trauma center.

PARTICIPANTS

Women of reproductive age (aged 18-45 years) seeking care for concussion or extremity injury.

DESIGN

Longitudinal cohort study that used data collected at 3 distinct time points: t0, baseline: an original cohort of 245 women recruited in January to July 2017 for exposure assessment; t1, 6(+4) weeks post-injury: evaluation of self-reported postinjury menstrual and sexual changes for subgroup analyses-data collected in March to September 2017 ( n = 135); t2, 24 months post-injury: March 2020 chart review for documentation of pregnancies/pregnancy-related events ( N = 245).

MAIN MEASURE

Poisson regression estimates used to model the incidence rate (IR) of pregnancies, comparing concussion with extremity injury.

RESULTS

We reviewed the charts of 254 women from the t0 cohort. After excluding 9 patients who were either deceased or missing relevant data, we had the 245 (96.5%) charts of 102 concussed and 143 extremity-injured study participants. After adjusting for race and obstetric history, women with concussion had 80% lower incidence of pregnancies than their extremity-injured peers (adjusted [adj] IR = 0.20; 95% CI: 0.07-0.59; P = .003). When we excluded women who were using birth control, the IR of pregnancy for women with concussions was 76% lower than for those who had sustained extremity injuries (adj IR = 0.24; 95% CI: 0.07-0.81; P = .02). Pregnancy incidence remained consistently lower for concussed women in additional sensitivity analyses excluding assault/domestic violence victims and those with a prior/new concussion at t0 and t2. Subgroup analyses of the 135 women who had experienced menstrual and/or sexual dysfunctions at t1 showed 84% reduced incidence of pregnancy for women with concussions compared with those who had sustained an extremity injury (adj IR = 0.16; 95% CI: 0.04-0.73; P = .02).

CONCLUSION AND RELEVANCE

Our study potentially serves as a clarion call to understand the long-term reproductive effects of female concussions.

Characteristics, Outcomes, Sex and Gender Considerations of Community-Based Physical Activity Interventions after Moderate-to-Severe Traumatic Brain Injury: Scoping Review

OBJECTIVE

This scoping review mapped the current evidence about community-based physical activity (PA) interventions for individuals with moderate-to-severe traumatic brain injury (TBI) and identified the reported health-related outcomes, measurement tools used, and considerations given to sex and gender.

METHODS

Searches were conducted in six academic databases for peer-reviewed articles (MEDLINE, EMBASE, Cochrane CENTRAL, CINAHL, SPORTDiscus, and PEDro). PRISMA Scoping Review guidelines were followed. Two reviewers independently screened articles for inclusion and extracted data for the analysis with a modified Consensus on Exercise Reporting Template (CERT). Health-related outcomes were classified with domains of the International Classification of Function, Disability and Health (ICF).

RESULTS

19 studies were identified. Seven PA intervention types were included. CERT scores varied (M = 12.74, SD = 3.51 items), with limited details for replication. ICF outcomes focused on improving body functions (74%), activities and participation (14%), environmental factors (1%), and other: not covered (11%). Only four studies (21%) stratified their results by sex or gender.

CONCLUSIONS

Identified PA interventions from this review revealed common characteristics that led to improved outcomes. Proposed recommendations aim to improve future research and community practice. There is a pressing need for more sex and gender considerations in PA research after moderate-to-severe TBI.

Exploring clinical and patient characteristics for rehabilitation referrals following a concussion: a retrospective analysis

Objective

To explore patterns of postconcussion care at a level 1 trauma center.

Design

Retrospective cohort study.

Setting

U.S. level 1 trauma center and local satellite units.

Participants

Patients of any age with a concussion diagnosis that reported to level 1 trauma center and local satellite units between 2016 and 2018 (N=2417).

Intervention

Not applicable.

Main Outcome Measures

Age, sex, point of entry, rehabilitation referrals, and pre-existing comorbidity diagnosis.

Results

Patient age (mean [SD]) significantly differed among points of entry, from youngest to oldest: 26.0 (14.0) years in sports medicine, 29.3 (23.0) years in the emergency department, 34.6 (23.6) years at primary care providers, and 46.0 (19.7) years at specialty care departments. Sex also significantly differed among points of entry; emergency departments reported more men (55.6%), whereas the other points of entry reported more women (59.3%-65.6%). Patients were more likely to receive a referral from sports medicine (odds ratio [OR]_unadjusted=75.05, P<.001), primary care providers (OR_unadjusted=7.98, P<.001), and specialty care departments (OR_unadjusted=7.62, P<.001) than from the emergency department. Women were more likely to receive a referral (OR_unadjusted=1.92, P<.0001), regardless of point of entry. Lastly, patients with a preexisting comorbidity were more likely (OR_adjusted=2.12, P<.001) to get a rehabilitation referral than patients without a comorbidity.

Conclusions

Point of entry, age, sex, and preexisting comorbidities are associated with postconcussion care rehabilitation referral patterns. Improving concussion education dissemination across all entry points of a level 1 trauma center may standardize the postconcussion rehabilitation referral patterns, potentially improving the time to recovery from a concussion.

The differential impact of the COVID-19 pandemic on healthcare utilization disruption for community-dwelling individuals with and without acquired brain injury

•

All groups experienced notable disruption in health care utilization.

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Disruption in care for traumatic brain injury or mental health was associated with decreased health-related quality of life.

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Telehealth was a viable alternative to in-person visits.

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Telehealth is not a panacea and should be adopted using a nuanced approach.

Objective

To delineate health care disruption for individuals with acquired brain injury (ABI) during the peak of the pandemic and to understand the impact of health care disruption on health-related quality of life (HRQoL).

Design

Cross-sectional survey.

Setting

General community.

Participants

Volunteer sample of adults with traumatic brain injury (TBI; n=33), adults with stroke (n=66), and adults without TBI or stroke (n=108) with access to the internet and personal technology (N=207).

Interventions

Not applicable.

Main Outcome Measures

Not applicable.

Results

Participants with TBI and stroke reported high rates of disruption in care specific to their diagnosis (53%-54.5%), while participants across all groups reported disruption for major medical care (range, 68.2%-80%), general health care (range, 60.3%-72.4%), and mental health care (range, 31.8%-83.3%). During the pandemic, participants with TBI and stroke used telehealth for care specific to their diagnosis (40.9%-42.4%), whereas all participants used telehealth for major medical care (range, 50%-86.7%), general health care (range, 31.2%-53.3%), and mental health care (range, 53.8%-72.7%). Disruption in TBI or stroke care and type of ABI explained 27.1% of the variance in HRQoL scores (F_2,95=16.82, P<.001, R²=0.262), and disruption in mental health care explained 14.8% of the variance (F_1,51=8.86, P=.004, R²=0.148).

Conclusions

Individuals with and without ABI experienced pronounced disruption in health care utilization overall. However, individuals who experienced a disruption in care specific to TBI or mental health care were most vulnerable to decreased HRQoL. Telehealth was a viable alternative to in-person visits for individuals with and without ABI, but limitations included difficulty with technology, difficulty with comprehensive examination, and decreased rapport with providers.

Literature Review of Sex Differences in mTBI

INTRODUCTION

Traumatic brain injury (TBI) remains a significant source of morbidity worldwide and is of particular concern for the military. Scientific literature examining sex differences in TBI is highly contradictory with some reporting better outcomes in men, others reporting better outcomes in women, and others reporting mixed results or no difference. While the exact cause is currently debated, the existence of such differences has important implications for surveillance techniques, treatment options, and management of long-term consequences. As the number of women within the U.S. military ranks increases and with the opening of combat roles to women in 2013, increased awareness of probable sex differences regarding TBI responses will enable better standard of care.

MATERIALS AND METHODS

Using the PubMed database, a keyword search using gender, "sex factors", "sex dependent", "gender disparity", TBI, "traumatic brain injury", mTBI (mild TBI), and "cranial trauma" was used to identify articles of interest. Results were filtered for written in the last 5 years, English, and free full text. References of relevant articles were cross-checked for additional publications. Articles familiar to the authors were also included.

RESULTS

We review literature that includes analysis of age as an interaction in TBI, hypothesized mechanisms to explain variations in outcomes between men and women, and the need for inclusion of sex as a criterion in future studies.

CONCLUSIONS

Emerging studies underscore the complexity of interpreting sex differences in TBI. The long-held belief that women have a neuroprotective advantage compared to men based on higher levels of sex hormones is being re-evaluated. Past conclusions have relied extensively on clinical studies that include a disproportionate number of men or do not stratify results based on sex. While sex hormones may be neuroprotective, underlying mechanisms are far from clarified. Future TBI studies must include women and gonadal hormone levels should be measured to address potential variables. Given the significant number of TBIs within the military, an improved understanding of TBI pathophysiology and outcomes is important considerations for mission success and servicemember longevity.

Trajectory of Long-Term Outcome in Severe Pediatric Diffuse Axonal Injury: An Exploratory Study

Introduction: Pediatric severe traumatic brain injury (TBI) is one of the leading causes of disability and death. One of the classic pathoanatomic brain injury lesions following severe pediatric TBI is diffuse (multifocal) axonal injury (DAI). In this single institution study, our overarching goal was to describe the clinical characteristics and long-term outcome trajectory of severe pediatric TBI patients with DAI.

Methods: Pediatric patients (<18 years of age) with severe TBI who had DAI were retrospectively reviewed. We evaluated the effect of age, sex, Glasgow Coma Scale (GCS) score, early fever ≥ 38.5°C during the first day post-injury, the extent of ICP-directed therapy needed with the Pediatric Intensity Level of Therapy (PILOT) score, and MRI within the first week following trauma and analyzed their association with outcome using the Glasgow Outcome Score—Extended (GOS-E) scale at discharge, 6 months, 1, 5, and 10 years following injury.

Results: Fifty-six pediatric patients with severe traumatic DAI were analyzed. The majority of the patients were >5 years of age and male. There were 2 mortalities. At discharge, 56% (30/54) of the surviving patients had unfavorable outcome. Sixty five percent (35/54) of surviving children were followed up to 10 years post-injury, and 71% (25/35) of them made a favorable recovery. Early fever and extensive DAI on MRI were associated with worse long-term outcomes.

Conclusion: We describe the long-term trajectory outcome of severe pediatric TBI patients with pure DAI. While this was a single institution study with a small sample size, the majority of the children survived. Over one-third of our surviving children were lost to follow-up. Of the surviving children who had follow-up for 10 years after injury, the majority of these children made a favorable recovery.

Systematic Review of Sex and Gender Effects in Traumatic Brain Injury: Equity in Clinical and Functional Outcomes

Background: Although traumatic brain injury (TBI) is a leading cause of death and disability in male and female patients worldwide, little is known about the effect of sex and gender on TBI outcomes.

Objectives: This systematic review summarizes the evidence on the effect of sex and gender on core TBI outcomes.

Methods: All English-language studies from six literature databases that addressed core outcomes in adults with TBI and included sex or gender, TBI severity, and age in their analyses were considered eligible. Two reviewers extracted data, and two reviewers assessed study quality using tools recommended by the National Institutes of Health. The results were sorted according to time post-injury, injury severity, gender equity ranking of the study's country of origin, and outcomes studied. The results from the included studies were grouped based on the approach taken in reporting their respective findings.

Results and Limitations: Of 172 articles assessed, 58 studies were selected, comprising 1, 265, 955 participants with TBI (67% male across all studies) of all injury severities. All studies were conducted in countries with a very high or high human development index, while the Gender Inequality Index (GII) varied. While the heterogeneity across studies limited any meaningful conclusions with respect to the role of sex and gender, we did observe that as gender equality ranking improved, differences between male and female participants in outcomes would diminish. Inclusion of social equity parameters in the studies was limited.

Conclusions and Implications: The non-uniform findings observed bring forth the need to develop and use a comprehensive and consistent methodology in the study of sex and gender post-TBI, incorporating social equity parameters to uncover the potential social underpinnings of gender effects on health and functional outcomes.

Systematic Review Registration: CRD42018098697.

Association of Lifetime History of Traumatic Brain Injury With Prescription Opioid Use and Misuse Among Adults

OBJECTIVE

To investigate associations of lifetime history of traumatic brain injury (TBI) with prescription opioid use and misuse among noninstitutionalized adults.

PARTICIPANTS

Ohio Behavioral Risk Factor Surveillance System (BRFSS) participants in the 2018 cohort who completed the prescription opioid and lifetime history of TBI modules (n = 3448).

DESIGN

Secondary analyses of a statewide population-based cross-sectional survey.

MAIN MEASURES

Self-report of a lifetime history of TBI using an adaptation of the Ohio State University TBI-Identification Method. Self-report of past year: (1) prescription pain medication use (ie, prescription opioid use); and (2) prescription opioid misuse, defined as using opioids more frequently or in higher doses than prescribed and/or using a prescription opioid not prescribed to the respondent.

RESULTS

In total, 22.8% of adults in the sample screened positive for a lifetime history of TBI. A quarter (25.5%) reported past year prescription opioid use, and 3.1% met criteria for prescription opioid misuse. A lifetime history of TBI was associated with increased odds of both past year prescription opioid use (adjusted odds ratio [AOR] = 1.52; 95% CI, 1.27-1.83; P < .01) and prescription opioid misuse (AOR = 1.65; 95% CI, 1.08-2.52; P < .05), controlling for sex, age, race/ethnicity, and marital status.

CONCLUSION

Results from this study support the "perfect storm" hypothesis-that persons with a history of TBI are at an increased risk for exposure to prescription opioids and advancing to prescription opioid misuse compared with those without a history of TBI. Routine screening for a lifetime history of TBI may help target efforts to prevent opioid misuse among adults.

Mild traumatic brain injury affects the features of migraine

BACKGROUND

Headache is one of the most common symptoms after concussion, and mild traumatic brain injury (mTBI) is a risk factor for chronic migraine (CM). However, there remains a paucity of data regarding the impact of mTBI on migraine-related symptoms and clinical course.

METHODS

Of 2161 migraine patients who participated in the American Registry for Migraine Research between February 2016 and March 2020, 1098 completed questions assessing history of TBI (50.8%). Forty-four patients reported a history of moderate to severe TBI, 413 patients reported a history of mTBI. Patients' demographics, headache symptoms and triggers, history of physical abuse, allodynia symptoms (ASC-12), migraine disability (MIDAS), depression (PHQ-2), and anxiety (GAD-7) were compared between migraine groups with (n = 413) and without (n = 641) a history of mTBI. Either the chi-square-test or Fisher's exact test, as appropriate, was used for the analyses of categorical variables. The Mann-Whitney test was used for the analyses of continuous variables. Logistic regression models were used to compare variables of interest while adjusting for age, gender, and CM.

RESULTS

A significantly higher proportion of patients with mTBI had CM (74.3% [307/413] vs. 65.8% [422/641], P = 0.004), had never been married or were divorced (36.6% [147/402] vs. 29.4% [187/636], P = 0.007), self-reported a history of physical abuse (24.3% [84/345] vs. 14.3% [70/491], P <  0.001), had mild to severe anxiety (50.5% [205/406] vs. 41.0% [258/630], P = 0.003), had headache-related vertigo (23.0% [95/413] vs. 15.9% [102/640], P = 0.009), and difficulty finding words (43.0% [174/405] vs. 32.9% [208/633], P <  0.001) in more than half their attacks, and headaches triggered by lack of sleep (39.4% [155/393] vs. 32.6% [198/607], P = 0.018) and reading (6.6% [26/393] vs. 3.0% [18/607], P = 0.016), compared to patients without mTBI. Patients with mTBI had significantly greater ASC-12 scores (median [interquartile range]; 5 [1-9] vs. 4 [1-7], P < 0.001), MIDAS scores (42 [18-85] vs. 34.5 [15-72], P = 0.034), and PHQ-2 scores (1 [0-2] vs. 1 [0-2], P = 0.012).

CONCLUSION

Patients with a history of mTBI are more likely to have a self-reported a history of physical abuse, vertigo, and allodynia during headache attacks, headaches triggered by lack of sleep and reading, greater headache burden and headache disability, and symptoms of anxiety and depression. This study suggests that a history of mTBI is associated with the phenotype, burden, clinical course, and associated comorbid diseases in patients with migraine, and highlights the importance of inquiring about a lifetime history of mTBI in patients being evaluated for migraine.