Traumatic Brain Injury-Related Emergency Department Visits, Hospitalizations, and Deaths - United States, 2007 and 2013

Liposomes as versatile agents for the management of traumatic and nontraumatic central nervous system disorders: drug stability, targeting efficiency, and safety

Various nanoparticle-based drug delivery systems for the treatment of neurological disorders have been widely studied. However, their inability to cross the blood-brain barrier hampers the clinical translation of these therapeutic strategies. Liposomes are nanoparticles composed of lipid bilayers, which can effectively encapsulate drugs and improve drug delivery across the blood-brain barrier and into brain tissue through their targeting and permeability. Therefore, they can potentially treat traumatic and nontraumatic central nervous system diseases. In this review, we outlined the common properties and preparation methods of liposomes, including thin-film hydration, reverse-phase evaporation, solvent injection techniques, detergent removal methods, and microfluidics techniques. Afterwards, we comprehensively discussed the current applications of liposomes in central nervous system diseases, such as Alzheimer's disease, Parkinson's disease, Huntington's disease, amyotrophic lateral sclerosis, traumatic brain injury, spinal cord injury, and brain tumors. Most studies related to liposomes are still in the laboratory stage and have not yet entered clinical trials. Additionally, their application as drug delivery systems in clinical practice faces challenges such as drug stability, targeting efficiency, and safety. Therefore, we proposed development strategies related to liposomes to further promote their development in neurological disease research.

Progressive hippocampal senescence and persistent memory deficits in traumatic brain Injury: A role of delayed testosterone

Cellular senescence is a stable, pro-inflammatory cell cycle arrest that has been recently implicated in the persistent memory deficits experienced with repetitive mild traumatic brain injury (rmTBI). Testosterone (T) treatment immediately following traumatic brain injury (TBI) mitigates cognitive deficits and cellular dysfunction known to induce cellular senescence. However, it has yet to be elucidated whether the therapeutic window for T treatment can be extended to a subacute time post-injury. This study examined the progression of hippocampal cellular senescence after rmTBI and evaluated the effects of subacute T on persistent memory deficits and cellular senescence post-injury. Changes in senescence-associated markers in the hippocampus were quantified at 5- and 9-weeks post-injury (WPI). An age-independent progressive increase in senescence-associated gene expression was observed for Cdkn2a, Cdkn1a, and p53 protein levels, along with a decrease in Sirt1 gene expression. Acute and persistent cognitive deficits were observed in the rmTBI rats as compared to sham rats. Serum T levels were significantly decreased at 4 WPI. Testosterone administration at 5 WPI ameliorated these persistent memory deficits. Moreover, subacute T treatment reduced rmTBI-induced levels of Cdkn2a 4 weeks post-treatment. This study indicates that rmTBI results in a progressive cellular senescence pathology that may contribute to the underlying mechanisms of persistent cognitive symptoms. Therapeutically targeting cellular senescence within this extended temporal window holds implications for patients dealing with the chronic cognitive ramifications of rmTBI.

Neural mechanisms associated with sleep-dependent enhancement of motor learning after brain injury

This study aimed to examine the improvement in performance and functional magnetic resonance imaging correlates of motor learning after a daytime nap versus a period of resting wakefulness among individuals with traumatic brain injury. A sample of 32 individuals with traumatic brain injury was randomly assigned to a Sleep (N = 17) or Wake (N = 15) group after a period of training on a motor sequential learning task. A 45-min nap opportunity was provided for the Sleep group, while the Wake group watched a documentary for 45 min. Performance at the end of training was compared with their performance after the nap or wake intervention. Before and after the intervention, the motor sequential learning task was completed in the magnetic resonance imaging scanner to examine the relationship between change in performance and neural activation. Participants in the Sleep group showed significant gains from the end of training to after the intervention, whereas the Wake group did not. The functional magnetic resonance imaging results showed that relative to the Wake group, the Sleep group showed significantly decreased activation post-intervention in the anterior cingulate/paracingulate, cerebellum, cuneus/precuneus, and inferior parietal lobule including angular and supramarginal gyri. Importantly, across both groups, increased task performance at post-intervention was associated with decreased activation in the anterior cingulate/paracingulate and cerebellum. This study demonstrated the enhancing effect of a nap on motor learning performance in a sample of individuals with traumatic brain injury, with patterns of neural activation suggesting that the sequence was more automatized in the Sleep group. Strategic placement of a nap after an intense period of motor learning in the medical rehabilitation setting may have important implications for maximizing recovery after traumatic brain injury.

Average Biomechanical Responses of the Human Brain Grouped by Age and Sex

Traumatic brain injuries (TBIs) occur from rapid head motion that results in brain deformation. Computational models are typically used to estimate brain deformation to predict risk of injury and evaluate the effectiveness of safety countermeasures. The accuracy of these models relies on validation to experimental brain deformation data. In this study, we create the first group-average biomechanical responses of the brain, including structure, material properties, and deformation response, by age and sex from 157 subjects. Subjects were sorted intro three age groups-young, mid-age, and older-and by sex to create group-average neuroanatomy, material properties, and brain deformation response to non-injurious loading using structural and specialized magnetic resonance imaging data. Computational models were also built using the group-average geometry and material properties for each of the six groups. The material properties did not depend on sex, but showed a decrease in shear stiffness in the older adult group. The brain deformation response also showed differences in the distribution of strain and a decrease in the magnitude of maximum strain in the older adult group. The computational models were simulated using the same non-injurious loading conditions as the subject data. While the models' strain response showed differences among the models, there were no clear relationships with age. Further studies, both modeling and experimental, with more data from subjects in each age group, are needed to clarify the mechanisms underlying the observed changes in strain response with age, and for computational models to better match the trends observed across the group-average responses.

The Application of MicroRNAs in Traumatic Brain Injury: Mechanism Elucidation and Clinical Translation

Traumatic brain injury (TBI) is a complex neurological disease caused by external forces impacting the head and is one of the leading causes of mortality and disability worldwide, exerting a significant impact on public health and socioeconomic conditions. Current research on TBI has focused primarily on assessing injury severity, determining clinical treatment, and improving patient prognosis. The timely and accurate diagnosis of TBI in clinical settings and the implementation of effective therapeutic strategies remain challenging. However, a deeper understanding of changes in gene expression and underlying molecular regulatory processes may alleviate this pressing issue. MicroRNAs (miRNAs), a class of short noncoding RNA molecules, play crucial roles in cellular physiology and pathology by regulating gene expression. With advancements in research, miRNAs have garnered increasing attention in TBI studies. This review summarizes the progress of miRNA research in TBI and explores the potential of miRNAs as diagnostic and prognostic markers and therapeutic targets for TBI.

Microglial NOX2 as a therapeutic target in traumatic brain injury: Mechanisms, consequences, and potential for neuroprotection

Traumatic brain injury (TBI) is a leading cause of long-term disability worldwide, with secondary injury mechanisms, including neuroinflammation and oxidative stress, driving much of its chronic pathology. While NADPH oxidase 2 (NOX2)-mediated reactive oxygen species (ROS) production is a recognized factor in TBI, the specific role of microglial NOX2 in perpetuating oxidative and inflammatory damage remains underexplored. Addressing this gap is critical, as current therapeutic approaches primarily target acute symptoms and fail to interrupt the persistent neuroinflammation that contributes to progressive neurodegeneration. Besides NOX, other ROS-generating enzymes, such as CYP1B1, COX2, and XO, also play crucial roles in triggering oxidative stress and neuroinflammatory conditions in TBI. However, this review highlights the pathophysiological role of microglial NOX2 in TBI, focusing on its activation following injury and its impact on ROS generation, neuroinflammatory signaling, and neuronal loss. These insights reveal NOX2 as a critical driver of secondary injury, linked to worsened outcomes, particularly in aged individuals where NOX2 activation is more pronounced. In addition, this review evaluates emerging therapeutic approaches targeting NOX2, such as GSK2795039 and other selective NOX2 inhibitors, which show potential in reducing ROS levels, limiting neuroinflammation, and preserving neurological functions. By highlighting the specific role of NOX2 in microglial ROS production and secondary neurodegeneration, this study advocates for NOX2 inhibition as a promising strategy to improve TBI outcomes by addressing the unmet need for therapies targeting long-term inflammation and neuroprotection. Our review highlights the potential of NOX2-targeted interventions to disrupt the cycle of oxidative stress and inflammation, ultimately offering a pathway to mitigate the chronic impact of TBI.

Otopathologic Patterns of Cellular Degeneration in the Peripheral Vestibular Organ Secondary to Head Trauma

OBJECTIVE

This study examined patterns of cellular and neural degeneration in the peripheral vestibular system following head trauma, comparing cases with and without skull/temporal bone fractures.

METHODS

We analyzed 26 temporal bones (17 cases) with head trauma with fractures (six cases, nine ears) and ones without fractures (11 cases, 17 ears). Appropriate age-matched control groups comprising temporal bones without temporal bone pathology were included for comparative purposes. Histopathological analyses included counts of Scarpa's ganglion cells (ScGCs) in the superior and inferior vestibular nerves (SVN and IVN), and counts of vestibular hair cells (HCs) in the utricle, saccule, lateral semicircular canal (LSCC), and posterior semicircular canal (PSCC). Mann-Whitney U tests were used for statistical analyses.

RESULTS

The group without fractures showed a significant reduction in total ScGCs (SVN + IVN) compared to controls (p = 0.040), with a pronounced decrease in the SVN (p = 0.014). Significant reductions in type I and type II HCs were observed in the utricle (p = 0.008 and p = 0.035) and in type I HCs in the LSCC (p = 0.037). In the group with fractures, only type I HCs in the utricle were significantly reduced (p = 0.038).

CONCLUSION

Head trauma without fractures is associated with more severe vestibular cell degeneration and greater loss of ganglion cells in the SVN in our specimens. These findings suggest that head trauma without fractures may pose a higher risk for vestibular cell damage compared with trauma with fractures.

LEVEL OF EVIDENCE

NA.

Relationship between language comprehension and chronic neurobehavioral symptoms in adults with mild traumatic brain injury

PRIMARY OBJECTIVES

Annually, millions of Americans sustain mild traumatic brain injuries (mTBI), and some may experience neurobehavioral symptoms (NBS), like slow processing speed that persist chronically or longer than 6 months post injury. In turn, cognitive processes like language comprehension may be compromised. This study investigates the relationship between NBS and language comprehension in individuals with mTBI history and low or high NBS.

METHODS & PROCEDURES

Thirty-one adults with mTBI and high (n = 13; female = 11) and low (n = 18; female = 10) NBS completed a language comprehension task in speeded and unspeeded conditions. Reduced language comprehension, as measured by slower response times (RTs) and reduced accuracy, was expected to be high compared to low NBS group, regardless of condition. Language comprehension correlates (e.g. cognition and general processing speed) were also measured.

MAIN OUTCOMES & RESULTS

Adults with high NBS showed reduced comprehension, measured by slower RTs in the unspeeded condition compared to low NBS. No difference in accuracy or errors produced was observed. Cognitive skills and processing speed are negatively correlated and predicted language comprehension task performance.

CONCLUSIONS

NBS and predictive factors specific to the individual are important to monitor post-mTBI, as they may affect language functioning.

Oral Supplementation of n-3 Polyunsaturated Fatty Acids (n-3-PUFA) Can Prevent TBI-Induced Visual, Motor, and Emotional Deficits in Mice

Traumatic brain injury (TBI) causes neuroinflammation and can generate long-term pathological consequences, including motor and visual impairments, cognitive deficits, and depression. In our previous study, we found that Fat1+-transgenic mice with higher endogenous n-3 polyunsaturated fatty acids (n-3 PUFA) were protected from post-TBI behavioral deficits and exhibited reduced levels of TBI-induced microglial activation, inflammatory factors, and sphingolipid ceramide, a lipid mediator of inflammation and cell death. This study's objective was to evaluate if feeding n-3 PUFA (EPA and docosahexaenoic acid, DHA 2:1) could restrict the elevation of ceramide in brain tissue and prevent TBI-mediated sensory-motor and behavioral deficits. Wildtype C57/BL6 mice were gavage pre-fed with PUFA (EPA: DHA = 2:1) at 500 mg/kg body weight/week for 2 weeks before and 4 weeks after exposure to left side focal cranial air-blast (50 psi) TBI or sham-blast (0-psi). Saline-gavaged mice served as controls. Following blast injury, various motor, visual, and behavioral tests were conducted, and brain tissues were collected for histological and biochemical assays. Lipidomics analysis confirmed a significant elevation of EPA in the plasma and brain tissue of PUFA-fed mice. TBI-Blast brain tissues were found to have elevated ceramide levels in control mice but not in PUFA-fed mice. Moreover, PUFA-fed mice demonstrated protection against motor impairment, photoreceptor dysfunction, depression, oculomotor nerve degeneration, and microglia activation in the optic tract. Our results demonstrate that EPA-mediated suppression of ceramide biosynthesis and neuroinflammatory factors in PUFA-fed mice is associated with significant protection against the visual, motor, and emotional deficits caused by TBI.

Molecular Pathway Changes Associated with Different Post-Conditioning Exercise Interventions After Experimental TBI

Traumatic brain injury (TBI) causes complex, time-dependent molecular and cellular responses, which include adaptive changes that promote repair and recovery, as well as maladaptive processes such as chronic inflammation that contribute to chronic neurodegeneration and neurological dysfunction. Hormesis is a well-established biological phenomenon in which exposure to low-dose toxins or stressors results in protective responses to subsequent higher-level stressors or insults. Hormetic stimuli show a characteristic U-shaped or inverted J-shaped dose-response curve, as well as being time and exposure-frequency dependent, similar to pre-conditioning and post-conditioning actions. Voluntary exercise interventions, before or after injury, appear to follow these general hormetic principles. But the molecular alterations associated with exercise interventions or more general hormetic responses have received only limited attention. In this study, we used a well-characterized mouse TBI model to assess the effects of different post-conditioning exercise-intervention paradigms on diverse molecular pathways, including neuroinflammation regulators, and post-traumatic neurological deficits. We generated high-throughput gene expression data and associated molecular pathway analyses to assess the potential molecular mechanisms associated with time- and duration-dependent voluntary exercise intervention, as well as time after treatment. Importantly, we also used newer analytical methods to more broadly assess the impact of exercise on diverse molecular pathways. TBI caused long-term changes in multiple neuroinflammation markers and chronic cognitive dysfunction. Notably, all delayed, post-conditioning exercise interventions reduced post-traumatic neuroinflammation and/or attenuated the related cognitive changes, albeit with different pathway specificity and effects magnitude. Exercise comprehensively reversed injury-associated effects in the hippocampus across both activated inflammatory and inhibited neuronal pathways, consistent with a return toward the noninjured, homeostatic state. In contrast, the cortex showed a less consistent pattern with more limited attenuation of inflammatory pathway activation and an amplification in the injury-dependent inhibition of select noninflammatory pathways, indicating less effective and potentially detrimental responses to exercise. Exercise intervention beginning 2 weeks after injury and lasting 2 weeks was less effective than exercise continuing for 4 weeks. Exercise initiated at a more delayed timepoint of 6 weeks after injury and continuing for 4 weeks was more effective than that during the acute phase. The delayed paradigm was also more effective than exercise initiated at 10 weeks after injury and continuing for 8 weeks, consistent with hormetic responses in other models and species. Overall, our study delineates regional and interventional parameters, as well as related molecular pathway changes, associated with post-conditioning exercise treatment, which may help inform future translational interventional strategies.

Evaluation of Older Adults in the Emergency Department Following a Fall

Falls are an important source of morbidity and mortality for older adults. The emergency department (ED) evaluation of an older patient who presents after a fall should include an assessment of events contributing to the acute fall, injuries sustained from it, as well as an underlying falls syndrome. ED measures and referrals to appropriate outpatient services on discharge can help ensure patients receive care and services that can help reduce future falls.

Changes in Resting-State Functional Connectivity and Cognitive-Affective Symptoms in Patients With Post-Concussion Syndrome Treated With N-Acetyl Cysteine

OBJECTIVE

Concussion accounts for more than 80% of people experiencing traumatic brain injury. Acute concussion is associated with characteristic cognitive and functional deficits that may persist for weeks to months. A subgroup of these patients (from 10% to 50%) have persistent symptoms referred to as chronic post-concussion syndrome (PCS). There are limited treatment options for these patients and the pathophysiology is poorly understood, though oxidative stress is thought to be a contributing factor. The purpose of this study was to evaluate whether an antioxidant, N -acetylcysteine (NAC), might be beneficial in patients with PCS.

SETTING

Outpatient medicine center.

PARTICIPANTS

Fifty patients with chronic PCS for at least 3 months post injury.

DESIGN

The patients with PCS were enrolled in this randomized unblinded clinical trial to receive the antioxidant NAC as a combination of daily oral and weekly intravenous infusions, or assigned to a waitlist control group where they would continue to receive standard of care.

MAIN MEASURES

Resting-state functional connectivity (FC) magnetic resonance imaging (rsFC-MRI) was performed pre and post either NAC or the waitlist period along with cognitive, emotional, and sensory symptom assessments.

RESULTS

The results demonstrated significant ( P < .05) improvements in symptoms as determined by the Rivermead Post-Concussion Symptoms Questionnaire, Spielberger State-Trait Anxiety Inventory, and Profile of Mood Scale in the PCS group receiving NAC as compared to patients receiving ongoing standard care. Importantly, there were significant ( P < .01) changes in FC in the NAC group, particularly in networks such as the default mode network, salience network, and executive control network. These changes in FC also correlated with improvements in symptoms.

CONCLUSIONS

In patients with chronic PCS, NAC treatment was associated with significant changes in resting state FC and improvement in a variety of symptoms, particularly cognitive and affective symptoms.

Predictors of participation over the 10 years after TBI in black individuals

BackgroundTraumatic brain injury (TBI) is a serious public health problem and is associated with an increased number of health comorbidities.ObjectiveThis study examined: (a) longitudinal trajectories of participation over the 10 years after TBI in a group of Black individuals, and (b) demographic and injury-related predictors of those trajectories.MethodThis study included 1,989 Black individuals in the national TBI Model Systems (TBIMS) Database, who had at least one of each Participation Assessment with Recombined Tools-Objective (PART-O) subscale scores at one or more follow-up time points (1, 2, 5, and 10 years after TBI).ResultsLower PART-O Productivity trajectories were observed among participants who were male (b = -.26, p = .001), were older at the time of injury (b = -.02, p < .001), had a lower education level (b = .06, p < .001), had public insurance coverage (b = .17, p = .009), and had longer posttraumatic amnesia (PTA) duration (b = -.28, p < .001). Lower PART-O Social trajectories emerged among participants who were older at the time of injury (b = -.02, p < .001), did not have a partner at the time of injury (b = .66, p < .001), had public insurance coverage (b = .19, p = .009), and had longer PTA duration (b = -.19, p = .001). Lower PART-O Out and About trajectories emerged among participants who were older at the time of injury (b = -.01, p = .018) and had a lower education level (b = .05, p < .001).ConclusionThe findings highlight the importance of understanding the strengths, risk factors, and unmet needs of this group, many of whom experience decreased community and social engagement after TBI.

Evaluation of Head Injury in the Emergency Department

This review summarizes the latest evidence in the evaluation of older adults presenting to the emergency department following head injury. The incidence of traumatic intracranial bleeding in older adults is rising. It is associated with significant morbidity and mortality. Early identification is critical to facilitate appropriate medical care. Evaluation of the older adult can be challenging due to frailty, delirium, and baseline cognitive and neurologic abnormalities. Clinical decision rules are helpful to identify patients who require advanced imaging. Warfarin slightly increases the risk of traumatic intracranial bleeding, and antiplatelet medications may also increase the risk.

Silent Struggles: Traumatic Brain Injuries and Mental Health in Law Enforcement

OBJECTIVE

To determine the prevalence of head injuries (HIs), posttraumatic stress disorder (PTSD), and depressive symptoms in law enforcement officers (LEOs) and (2) the association between HIs and psychological health conditions.

SETTING

County-level survey administered via Research Electronic Data Capture.

PARTICIPANTS

A total of 381 LEOs completed the survey (age = 43 ± 11 years; 40 [11%] females; time as LEO = 1-50 years, median = 15 years).

DESIGN

Cross-sectional study.

MAIN MEASURES

We examined the prevalence of HIs (the Ohio State University Traumatic Brain Injury Identification Method), PTSD (PTSD Checklist-Civilian [PCL-C]), and depressive symptoms (Patient Health Questionnaire-9 [PHQ-9]). We used Mann-Whitney U and chi-square analyses to compare PTSD and depressive symptoms between those with and without a HI history.

RESULTS

There were 282 (74%) participants who reported a lifetime history of 1 or more HIs; 116 (30%) sustained 1 or more HIs on the job. PCL-C scores ranged 17 to 85 (median = 27); 33 (10%) participants met or exceeded the clinical cutoff score of 50 to indicate a positive PTSD screening. Participants with a HI history (median = 29) had higher PCL-C scores than those with no HI history (median = 24; P < .001), but the proportion of participants who met the clinical cutoff for PTSD was not different between those with ( n = 28, 11%) and without ( n = 5, 5%) a HI history (X 2  = 2.52, P = .112, odds ratio = 2.18; 95% confidence interval, 0.82-5.83). PHQ-9 scores ranged 0 to 20 (median = 3); 124 (36%) participants reported mild or greater depressive symptoms. Participants with a HI history (median = 3) had higher depressive symptoms than those with no HI history (median = 2; P = .012). The proportion of participants with mild or greater depressive symptoms was higher among those with a HI history ( n = 99, 39%) than without ( n = 25, 27%; X 2  = 4.34, odds ratio = 1.74; 95% confidence interval, 1.03-2.93).

CONCLUSION

HIs are prevalent in LEOs, which may have consequences for their performance, well-being, and career longevity. PTSD and depressive symptoms are higher in those with a HI history, suggesting LEOs need better traumatic brain injuries and mental health resources.

Rural-urban disparities in hospitalisation for myocardial infarction in systemic lupus erythematosus in the USA

OBJECTIVE

To assess whether rural-urban disparities exist in people with SLE for hospitalisation with myocardial infarction (MI).

METHODS

We used the 2016-2019 US National Inpatient Sample data that contain all hospitalisation data. In people with a diagnosis of SLE, we assessed the multivariable adjusted ORs (aORs) to examine the association of rural patient residence with MI hospitalisation, while adjusting for demographics, payer, income, hospital characteristics and the Deyo-Charlson Comorbidity Index.

RESULTS

We found that the crude rates of patients hospitalised with MI per 100 000 area specific SLE hospitalisations were higher in rural versus urban residents with SLE, 2265 versus 1435 (p value<0.001). In the multivariable-adjusted model that accounted for demographics, insurance payer, household income, comorbidities and hospital characteristics including geographical location, we found that rural residence was associated with an aOR of 1.98 (95% CI, 1.71 to 2.29; reference category, urban residence) of MI hospitalisations in people with SLE. Other factors significantly associated with the risk of MI were male sex, Medicaid or private insurance, urban not teaching or urban teaching hospital, Midwest region and a private hospital control, either for profit or not for profit.

CONCLUSION

Rural residence doubled the risk of MI hospitalisation in people with SLE independent of demographics, payer status, social determinants of health and hospital characteristics. Our study highlights the disproportionate effect of rurality on health outcomes in people with SLE within the USA and a clear rural-urban gap disparity. Interventions to reduce this disparity are needed.

Effects of transcranial direct current stimulation on motor and cognitive function in paediatric brain damage: a systematic review and meta-analysis

PURPOSE

Transcranial direct current stimulation (tDCS) emerges as a secure therapy in paediatric brain damage rehabilitation. Our purpose is to acknowledge its evidence in motor and cognitive variables, examine correlations between tDCS effects and parameters, and identify associations between motor and cognitive outcomes.

METHODS

A systematic review and meta-analysis were conducted, registered in PROSPERO (CRD42023448441). 5 databases were consulted in September 2024. Randomised controlled trials evaluating tDCS effectiveness on motor or cognitive outcomes in paediatric brain injuries were included. Methodological quality was assessed using PEDro scale and ROB-2. Certainty of evidence was assessed by GRADE.

RESULTS

Nineteen studies were selected (447 participants). tDCS seems to be beneficial in gait (SMD: 0.83-0.90 (p < 0.0001)), balance (COP oscillations SMD: -0.51 - -1.13 (p < 0.02), PBS SMD: 0.48-0.56 (p < 0.0001)), functionality (SMD: 0.40 (p < 0.01)). Effects on cognition showed promising results. Effects in upper limb are controversial, due to fewer publications.

CONCLUSIONS

tDCS seems beneficial in motor and cognitive functions in paediatric brain damage. Motor and cognitive functions appears to be interconnected, so combined protocols could be an effective approach. Meta-analysis results are promising but may be considered carefully as few articles could be included. Further research is needed.

Association of Subacute Mild Traumatic Brain Injury Symptoms With Long-Term Persistent Symptoms, Functional Limitations, and Quality of Life

BACKGROUND AND OBJECTIVES

The objective was to evaluate the association of subacute postconcussion symptoms (with the total Rivermead Post-Concussion Questionnaire [RPQ] score) with persistent symptoms, functional limitations, and quality of life at 6 months in patients with mild traumatic brain injury (mTBI).

METHODS

This was a secondary analysis of the Transforming Research and Clinical Knowledge of Traumatic Brain Injury, which was a prospective cohort study of patients with TBI and admission Glasgow Coma Scale score between 13 and 15 at 18 US Level 1 trauma centers through 2014-2018. Participants were included in the study if presenting within 24 hours of external force trauma to the head and met the American Congress of Rehabilitation Medicine's criteria for TBI. Participants completed the RPQ, Glasgow Outcome Scale-Extended (GOSE), and Quality of Life after Brain Injury Overall Scale (QOLIBRI-OS). Primary outcomes were persistent symptoms (≥3 individual RPQ symptoms higher than preinjury level), incomplete recovery (GOSE score <8), and lower quality of life (QOLIBRI-OS score ≤51) at 6 months. Multivariable regression models were developed including RPQ clinical cutoffs at 2 weeks and 3 months and risk factors. Adjusted odds ratios (aORs) and 95% CI are reported for multivariable models. Receiver operating characteristic curves were built to identify discriminative ability of the cutoffs with area under the curve (AUC).

RESULTS

The age of the study cohort (n = 2,000) was 41.1 ± 17.3 years; 33% were female (n = 669), 67% male, 57% White (n = 1,141), and 20% Hispanic (n = 408). RPQ total score ≥14 was associated with higher odds of persistent symptoms (aOR 7.25, 95% CI 5.51-9.54), incomplete recovery (aOR 4.85, 95% CI 3.69-6.39), and lower quality of life (aOR 5.31, 95% CI 3.82-7.40) at 6 months compared with patients below the cutoff. AUC for RPQ total score ≥14 at 2 weeks was 0.76-0.81 across outcomes. RPQ total score ≥12 at 3 months was associated with higher odds of persistent symptoms (aOR 18.22, 95% CI 13.09-25.35), incomplete recovery (aOR 8.44, 95% CI 6.18-11.51), and lower quality of life (aOR 7.45, 95% CI 5.40-10.26) at 6 months compared with patients below the cutoff, with AUCs of 0.80-0.88 across outcomes.

DISCUSSION

Clinical cutoffs for a commonly used TBI symptom questionnaire had acceptable-to-excellent discrimination for 6-month outcomes and can be used by clinicians at 2 weeks after injury to identify patients at risk of chronic impairments and refer for targeted rehabilitation.

CLASSIFICATION OF EVIDENCE

This study provides Class III evidence that overall TBI symptoms at 2 weeks are predictive of 6-month clinical outcomes.

Trends in Hospitalization for Fall-Related Injuries in US Older Adults, 2001-2021

Introduction: Fall-related injuries are a major public health problem affecting ageing populations. Although previous studies have reported increasing hospitalization rates for fall-related injuries in United States older adults, recent trends in hospitalization for these injuries have not been examined. Thus, the present study aimed to examine nationwide trends in hospitalization after emergency department (ED) visits for fall-related injuries. Methods: The National Electronic Injury Surveillance System-All Injury Program was used to estimate hospitalizations after ED visits for fall-related injuries in adults ≥ 65 years between 2001 and 2021. Joinpoint regression software V.5.0.2 was used to examine the average annual percent change in age- and sex-adjusted hospitalization rates according to type of injury, body parts, and traumatic brain injuries. Results: A total of 704,875 ED visits for fall-related injuries occurred in US older adults between 2001 and 2021. Of those 26.5% (95% CI: 26.3, 26.6) were hospitalized. Overall, women represented 59.2% (95% CI: 59.0, 59.5) of the hospitalizations and fractures were the leading type of injury. By sex, hospitalization rates in women annually increased on average by 2.5% (95% CI: 2.0, 3.0) and in men by 4.2% (95% CI: 3.6, 4.9). Similarly, fall-related fracture rates in men increased annually on average by 2.5% (95% CI: 1.9, 3.2) and in women by 1.5% (95% CI: 1.0, 2.2) during the study period. Notably, the highest increase in hospitalization rates during the study period occurred among older adults with traumatic brain injuries. Conclusion: Hospitalizations for fall-related injuries significantly increased in US older adults over the past two decades. The present findings underscore the importance of implementing effective community-based programs to prevent fall-related injuries.

Resilient, engaged and connected (REC) study: protocol for a type 2 cluster-randomised trial of the Chicago Parent Program in prekindergarten in low-income urban and rural communities

BACKGROUND

Social, emotional and behavioural (SEB) problems are among the most common chronic disabilities affecting children growing up in poverty. They also have implications for children's school success as they affect essential social-emotional learning skills such as the ability to comply with rules, regulate emotions and get along with others. These skills are first learnt before kindergarten, in the context of a supportive, responsive and consistent parenting relationship. To date, school-based interventions to improve young children's SEB competence and learning have primarily targeted students and teachers. Yet, parents are central partners in promoting these skills. This study seeks to improve children's SEB competence and kindergarten readiness by strengthening parenting skills and parent engagement in early childhood education during prekindergarten (PreK). This hybrid type 2 effectiveness-implementation trial will rigorously evaluate the effects of an evidence-based parenting programme, the Chicago Parent Program (CPP), in PreK on children's SEB competence, kindergarten readiness, chronic school absenteeism and grade retention in urban and rural schools serving students from low-income families in Maryland.

METHODS

Using a cluster randomised design (n=30 schools, 840 parents; >90% low-income), we will examine the effects of CPP offered universally to PreK parents on parenting skills and parent engagement in children's education; children's SEB competence and kindergarten readiness; and chronic absence and grade retention in kindergarten. Schools will be stratified by rural versus urban district, then randomised to CPP or usual practice conditions. Data will be analysed using mixed effects regression models. Using the reach, effectiveness-adoption, implementation, maintenance (RE-AIM) framework and a mixed methods approach, we will assess CPP reach, efficacy, acceptability, adoption, implementation, cost-effectiveness and sustainability when offered in different formats (virtual vs in-person CPP groups) and contexts (urban vs rural). Schools will participate for 2 years with experimental schools offering CPP twice, once in virtual group format and once in an in-person group format (format randomised and counterbalanced). Data will be collected using multiple informants (parents, teachers, district administrative data) and methods (quantitative and qualitative data). Knowledge gained will inform schools in under-resourced urban and rural communities on sustainable, cost-effective strategies for strengthening parent-school connections and improving young children's SEB competence and academic success.

ETHICS AND DISSEMINATION

Ethics approval has been granted by Johns Hopkins University School of Medicine (protocol number 00428221) and the Baltimore City Public Schools (protocol number 2024-013). At the conclusion of the study, results will be summarised and shared with parents, teachers, school principals and district leaders for their perspectives on the outcomes. Final reports will be published in scientific journals and presented at professional meetings.

TRIAL REGISTRATION NUMBER

NCT06197997.

Implications and pathophysiology of neuroinflammation in pediatric patients with traumatic brain injury: an updated review

Traumatic Brain Injury (TBI) in children is a profound public health issue with the potential to disrupt cognitive, behavioral, and psychosocial development significantly. This review provides an updated examination of the role of neuroinflammation in pediatric TBI, emphasizing its dual impact on injury progression and recovery. Highlighted is the complex interplay of primary and secondary injury mechanisms, including the critical contributions of neuroinflammatory responses mediated by central and peripheral immune cells. Advances in biomarker identification and imaging techniques are discussed, showcasing how tools like diffusion tensor imaging (DTI) and positron emission tomography (PET) enhance our understanding of neuroinflammatory processes. The review also explores current therapeutic strategies targeting neuroinflammation, underscoring emerging treatments such as pharmacologic agents that modulate immune responses and novel therapies like stem cell interventions. This comprehensive review seeks to deepen the understanding of neuroinflammation's pathophysiological roles in pediatric TBI and propose directions for future clinical and research efforts.

Exploring Molecular Pathways in Exercise-Induced Recovery from Traumatic Brain Injury

Traumatic brain injury (TBI) is functional damage or brain injury due to external forces and is a leading cause of death and disability in children and adults. It causes disruption of the blood-brain barrier (BBB), infiltration of peripheral blood cells, oxidative stress, neuroinflammation and apoptosis, neural excitotoxicity, and mitochondrial dysfunction. Studies have shown that PE can be applied as a non-pharmacological therapy and effectively improve functional recovery from TBI. Recovery from TBI can benefit from both pre- or post-TBI exercise through various mechanisms for neurorepair and rehabilitation of behavior and cognition, including alleviation of TBI-induced oxidative stress, upregulation of heat-shock proteins, reduction of TBI-induced inflammation, promotion of secretion of neurotrophic factors to facilitate neural regeneration, suppression of TBI-induced apoptosis to reduce brain injury, and stabilization of mitochondrial function for better cellular function. This review article provides an overview of the effect of pre- and post-TBI exercise on recovery of neurofunctions and cognition following TBI, summarizes the potential regulatory networks and cellular and biological processes involved in recovery of brain functions, and outlines the molecular mechanisms underlying exercise-induced improvement of TBI, including regulation of gene expression and activation of heat-shock proteins and neurotrophic factors under different exercise schemes. These mechanisms involve TBI-induced oxidative stress, upregulation of heat-shock proteins, inflammation, secretion of neurotrophic factors, and TBI-induced apoptosis. Due to high heterogeneity in human TBI, the outcome of exercise intervention is affected by the injury type and severity of TBI. More studies are needed to investigate the application of various exercise approaches that fits TBI under different circumstances, and to elucidate the detailed pathogenesis mechanisms of TBI to develop more patient-tailored interventions.

Contribution of Extracranial Injuries to GOSE Scores after Traumatic Brain Injury TBI: A TRACK-Traumatic Brain Injury Study

The Glasgow Outcome Scale Extended (GOSE) is the most widely used outcome measure for hospital-based studies of traumatic brain injury (TBI). The GOSE may be administered several ways, the choice depending on the purpose of the research. In this investigation, we evaluated the effect of administering the GOSE to collect functional disability attributed to all injuries sustained (GOSE-All) or excluding the impact of extracranial injuries (GOSE-TBI). We examined the differences in reported disability between the two administration methods at 2 weeks, 3 months, 6 months, and 12 months after injury. Data are summarized from 2288 individuals who were enrolled in the prospective observational Transforming Research and Clinical Knowledge in TBI (TRACK-TBI) cohort study. The distribution of scores is summarized by time after injury, brain injury severity, and extracranial injury severity. Dichotomizing the GOSE varying ways, differences in the prevalence of unfavorable outcomes for GOSE-All versus GOSE-TBI range from none to 42 percentage points. Discrepancies in disability captured by GOSE-All and GOSE-TBI decrease with greater TBI severity, no serious extracranial injuries, and longer time post-injury. It is important for researchers, given the aims of their studies, to decide in advance whether GOSE classification should be based on the effects of all injuries sustained or excluding the effects of extracranial injuries so as to emphasize the effects of the brain injury, as well as how disability due to emotional consequences of injury and other circumstances will be scored. Instructions to the respondent and outcomes examiner need to be clear about what causes of disability are to be included. The TBI Common Data Elements should include information that reflects the method that was used to collect the GOSE data and data repositories should disclose which data collection method was used for a given study.

Traumatic Brain Injury Diagnostic Interview: Development, Interrater Reliability, and 2-Week Post-Injury Clinical Profiles

Because most traumatic brain injuries (TBIs) do not present with objective indicators (e.g., neuroimaging findings) to confirm the diagnosis, clinicians often rely on self- or observer-reporting of alteration of consciousness (AOC; e.g., loss of consciousness [LOC], amnesia, other signs of altered mental status), and symptoms to make diagnoses. Moreover, there is no universal agreement on signs and symptoms to sufficiently diagnose TBI, which leads to variability and ambiguity in how TBI is diagnosed in clinical and research settings. The lack of standardized procedures for the diagnosis of acute TBI is a major challenge that hampers the ability to evaluate and compare TBI studies and advance the science and treatment of TBI. We present a new semi-structured TBI Diagnostic Interview (TBI-DI), developed for prospective TBI research to collect injury information important to verifying eligibility for the diagnosis of TBI. Specifically, the TBI-DI collects patient (and/or witness) reports of head trauma, AOC (including LOC and amnesia), and TBI-related symptomology. We describe the protocol, interrater reliability of the TBI-DI items to the same audio-recorded interview, and observed injury characteristics for interviews conducted at 2 weeks post-injury. The sample comprised 335 interviews (320 self-reported, 10 informant-reported, and 5 both) collected on individuals with TBI who were prospectively recruited from 4 U.S. level 1 trauma centers from 2019 to 2023. Cohen's kappa was calculated to summarize interrater reliability n = 288 interviews. UpSet plots were created to illustrate the prevalence of distinct profiles of signs of AOC and symptom reporting. Overall, there was a near-perfect agreement between raters for all AOC descriptors (κ = 0.85-0.92) and symptom items (κ ranging from 0.92 to 0.99). We observed diverse profiles of AOC, with 45% manifesting witnessed LOC, post-traumatic amnesia, or other altered mental status. Patients (n = 325) self-reported 256 different combinations of the 14 acute symptoms included in the interview (most commonly experiencing headache, dizziness, fatigue, and difficulty concentrating). The TBI-DI and associated SOP appear well-suited for use in a multicenter prospective study of TBI. Future research should examine the stability of reporting by respondents and the alignment between interview and objective clinical information. The TBI-DI solicits diverse acute diagnostic information that, when combined with clinical information (including confounding factors) and objective injury indicators, may inform more rigorous scientific reporting and evidence-based TBI diagnostic practices.

Prevalence of Seizures in Hospitalizations with Traumatic Brain Injury: A U.S. Population-Based Study

In the United States, data on outcomes in adults hospitalized with traumatic brain injury (TBI) and concomitant seizures are limited. Here, we report on a feasibility analysis to understand the prevalence and consequences of concomitant seizures in patients with TBI. A retrospective database study was conducted using the National Inpatient Sample 2016-2020. Hospitalizations in patients (≥18 years of age) with TBI were assessed and stratified into groups either with or without concomitant seizures. All patient data were stratified by age, sex, ethnicity, and payer type. The primary outcome was the prevalence of seizures or epilepsy among hospitalizations for TBI. Other outcome variables recorded were mean charges, length of hospital stay, and case fatality. Overall, 1,591,575 hospitalizations with TBI were assessed over the study period. TBI prevalence remained relatively constant throughout the study period and was higher in men and those aged ≥65 years. Concomitant seizures were observed in 12.2% of all patients and were highest for men, the 45-64 years age group, and Black and Native Americans. Mean charges were significantly higher and length of hospital stay was significantly longer in TBI hospitalizations with seizures compared with those without seizures across all study years. No significant difference in case fatality between patients with seizures compared with those without seizures was observed. Data from this analysis showed differences in demographics and outcomes for TBI hospitalizations with versus without concomitant seizures, highlighting potential disparities in health care for patients experiencing seizures that warrant further research.

Age and pupil size: key predictors of mortality in traumatic brain injury patients with GCS 3

This study investigates the relationship between mortality and specific clinical factors in patients with severe traumatic brain injury (TBI) who present with a Glasgow Coma Scale (GCS) score of 3. Data from 161 adult patients were collected from the Chi-Mei Medical Center in Taiwan, spanning 2010 to 2019. The findings revealed an overall mortality rate of 44.10%, with significant predictors of mortality identified as age and pupil size. The Spearman correlation analysis showed that both age and pupil sizes were positively correlated with mortality rates. Multiple logistic regression confirmed age and left pupil size as strong predictors of mortality. Patients with GCS 3 and both unreactive pupils measuring 4 mm or more experienced the highest mortality rate of 68.39%, while those with pupils less than 4 mm had a lower mortality rate of 32.26%. The study determined optimal cut-off values for age and pupil size using ROC and AUC analysis, highlighting the significance of age in mortality predictions. These findings underscore the critical role of age and pupil size in the prognosis of TBI patients and provide valuable guidance for clinicians managing such cases.

Exploring Person-Centered Goals in Speech-Language Pathology Services for Mild Traumatic Brain Injury

PURPOSE

Person-centered goals represent meaningful and motivating aspirations of patients and help rehabilitation professionals shape treatment plans to meet individual needs. The purpose of this research note is to describe person-centered goals identified among individuals receiving speech-language pathology services after mild traumatic brain injury (mTBI) and to consider how goals might be informed by existing self-report measures and guide treatment planning.

METHOD

Using a retrospective chart review approach, we extracted person-centered goals of patients between the ages of 14 and 65 years who received care from a speech-language pathologist at an outpatient specialty concussion clinic between August 2019 and March 2020. Goals were coded according to impairment, activity, and participation domains; environmental setting; treatment domain; rehabilitative expectation (restorative or compensatory); as well as by alignment with items in a concussion symptom scale. Three reviewers independently coded goals, with discrepancies in ratings resolved through consensus. Data were analyzed descriptively.

RESULTS

In total, 59 patient charts met inclusion criteria. Mean patient age was 31.85 (SD = 17.31). Most goals were at the activity level (46%), followed by participation (32%), and impairment (22%). Return to productivity was central to patient goals, with almost half addressing return to school (49%) and 21% specifying return to work. By domain, goals were primarily cognitive in nature (62%), followed by communication (13%), emotional regulation (13%), or unspecified (12%). Almost all goals were restorative (86%). Just 37% of goals were represented on the symptom scale, as expected, those that were reflected cognitive needs.

CONCLUSION

Person-centered goals are not well captured by standard mTBI symptom scales, thus emphasizing a need for rehabilitation providers to use problem-focused interviewing, motivational interviewing, or other person-centered methods to identify personally relevant and meaningful goals in this population.

Predictors of healthy days at home: Benchmarking long-term outcomes in geriatric trauma

BACKGROUND

Quality benchmarking has recently evolved from a historical focus on short-term morbidity and mortality as the key metrics to assessing long-term outcomes. Long-term quality metrics have been shown to provide a more complete assessment of geriatric trauma care. Among these metrics, patients' average number of healthy days at home (HDAH) proports to be a useful administrative claims-based marker of patient functional status. Our goal was to determine the predictors of HDAH among injured older adults.

METHODS

Medicare inpatient claims (2014-2015) were used to identify all geriatric trauma patients. Patients' number of HDAH was measured from the date of discharge and calculated as the total sum of patients' time during that period less any time spent in the hospital or emergency department, step-down/rehabilitation/nursing care, home health, or after death within a 365-period after index admission. Controlling for demographic, injury severity, and hospital-level characteristics, multivariable regression analyses were performed to identify the factors associated with increased HDAH.

RESULTS

We included 772,109 geriatric trauma patients. The mean age was 82.15 years (SD, 8.49 years), 68.3% were female, and 91.6% were White. The median HDAH was 351 days (interquartile range, 351-355 days). After adjusted analysis, age, Black race, Charlson Comorbidity Index (CCI), and care at a level 3/nontrauma center were associated with fewer HDAH within 365 days after discharge.

CONCLUSION

This study suggests that higher level trauma centers provide more HDAH after index admission for injured older adults. Future studies should focus on correlating HDAH with more granular but less readily accessible quality of life metrics.

LEVEL OF EVIDENCE

Prognostic and Epidemiological; Level III.

Implantation of MSC spheroid-derived 3D decellularized ECM enriched with the MSC secretome ameliorates traumatic brain injury and promotes brain repair

Traumatic brain injury (TBI) presents substantial clinical challenges, as existing treatments are unable to reverse damage or effectively promote brain tissue regeneration. Although implantable biomaterials have been proposed to support tissue repair by mitigating the adverse microenvironment in injured brains, many fail to replicate the complex composition and architecture of the native extracellular matrix (ECM), resulting in only limited therapeutic outcomes. This study introduces an innovative approach by developing a mesenchymal stem cell (MSC) spheroid-derived three-dimensional (3D) decellularized ECM (dECM) that is enriched with the MSC-derived matrisome and secretome, offering a promising solution for TBI treatment and brain tissue regeneration. Proteomic and cytokine array analyses revealed that 3D dECM retained a diverse array of MSC spheroid-derived matrisome proteins and secretome components, which are crucial for replicating the complexity of native ECM and the therapeutic capabilities of MSCs. These molecules were found to underlie the observed effects of 3D dECM on immunomodulation, proneuritogenesis, and proangiogenesis in our in vitro functional assays. Implantation of 3D dECM into TBI model mice effectively mitigated postinjury tissue damage and promoted brain repair, as evidenced by a reduced brain lesion volume, decreased cell apoptosis, alleviated neuroinflammation, reduced glial scar formation, and increased of neuroblast recruitment to the lesion site. These outcomes culminated in improved motor function recovery in animals, highlighting the multifaceted therapeutic potential of 3D dECM for TBI. In summary, our study elucidates the transformative potential of MSC spheroid-derived bioactive 3D dECM as an implantable biomaterial for effectively mitigating post-TBI neurological damage, paving the way for its broader therapeutic application.

Patient and Hospital Factors Associated With Hospital Course for Patients With Mild Traumatic Brain Injury

OBJECTIVE

To characterize variation in the treatment of patients with mild traumatic brain injury (mTBI) who were reasonable candidates for hospitalization, we investigated patient-level associations with inpatient admission and hospital-level associations with length of stay (LOS). We further investigated whether patients treated at high-LOS hospitals were more likely to experience home discharge.

SETTING

Patients were retrospectively identified from the ACS TQIP dataset.

PARTICIPANTS

A total of 122 406 patients with mTBI were included.

DESIGN

We performed hierarchical logistic regression to investigate associations of patient-level variables with inpatient admission. Among hospitalized patients, a hierarchical linear regression was constructed for associations with LOS, including hospitals as a random effects term. Based on random effects coefficients, hospitals were classified as high-LOS outliers or non-outliers.

MAIN MEASURES

Univariable comparisons on facility characteristics were performed. Patients were propensity score matched across hospital outlier status, and a multivariable logistic regression for associations with discharge to home was performed.

RESULTS

The median age was 63 years (interquartile range [IQR], 42-77 years), and 111 306 (91%) patients experienced inpatient admission. Uninsured status was associated with lower odds of inpatient admission (odds ratio [OR], 0.71; 95% confidence interval [CI], 0.65-0.76; P < .001). After excluding very low-volume hospitals, 80 258 admitted patients were treated across 469 hospitals, and 98 were designated as high-LOS outliers. These were more likely to be Level 1 trauma centers (76% vs. 26%; P < .001). After matching, patients treated at high-LOS outlier hospitals were less likely to experience home discharge (OR, 0.89; 95% CI, 0.85-0.93; P < .001). This effect was amplified for patients identifying as non-White, non-Black, non-Hispanic other races (P = .003).

CONCLUSIONS

Inpatient admission after mTBI varies by insurance status, with uninsured patients less likely to be admitted. There is significant interhospital variation in LOS, with Level 1 trauma centers more likely to be high-LOS outliers. Despite their longer LOS, patients treated at outlier hospitals experienced lower odds of home discharge.

Association of Traumatic Meningeal Enhancement on MRI With Clinical Recovery in Patients With Traumatic Brain Injury

BACKGROUND AND OBJECTIVES

Traumatic meningeal enhancement (TME) can be observed on MRI of patients with acute traumatic brain injury (TBI) and reflects abnormal contrast extravasation into the meninges. Resolution of TME occurs over time, but TME can persist for weeks, suggesting incomplete meningeal repair. This study's objectives were to describe TME's prevalence, severity, and evolution over time and to investigate TME's association with other imaging findings, blood-based biomarkers commonly associated with TBI, and incomplete recovery.

METHODS

Patients with suspected TBI presenting within 48 hours of injury to Suburban Hospital or Washington Hospital Center were prospectively enrolled between 2010 and 2019, received MRI, and underwent optional blood collection at baseline and follow-up visits at 1 week, 30 days, 90 days, and 1 year. Independent trained raters blinded to patient details scored for the presence and severity of TME on postcontrast MRI. Neuroimaging findings on CT and MRI, other than TME, were extracted from neuroradiology reports. Plasma biomarker levels (total tau [t-tau]; neurofilament light chain [NfL]; glial fibrillary acidic protein [GFAP]; ubiquitin C-terminal hydrolase-1 [UCH-L1]) were assessed with single-molecule array kits. Incomplete recovery was defined as a Glasgow Outcome Scale-Extended (GOSE) score <7 at 30-90-day follow-up. Factors associated with recovery were assessed through multivariable logistic regression analysis controlled for confounding variables.

RESULTS

Of 675 patients (male/female/neither 68%/31%/1%; median [interquartile range] age: 45 [28-58] years; Glasgow Coma Scale score 15 [15-15]), 359 (53%) were positive for TME at baseline (16 [6-25] hours after injury). At 30-90-day follow-up, TME remained absent in 117 (37%), resolved in 139 (45%), and persisted in 56 (18%). Acute TME had a high positive predictive value (PPV) for acute TBI-related findings on CT (87.7%) and MRI (86.1%). One-way analysis of covariance demonstrated significant associations between baseline TME and CT for plasma biomarker levels (F(df): t-tau = 19.328 (2); NfL = 20.458 (2); GFAP = 78.662 (2); UCH-LI = 46.680 (2)). Patients with persistent TME were more likely (odds ratio 3.809; 95% CI 1.703-8.519; p = 0.001) to have GOSE score <7.

DISCUSSION

TME was prevalent at baseline, with high PPV for other neuroimaging findings, but was not associated with recovery. TME's persistence was independently associated with incomplete recovery, suggesting that the meninges' failure to repair may be a mediator of recovery after TBI.

TRIAL REGISTRATION INFORMATION

ClinicalTrials.gov NCT01132937.

Long-Term Brain Health Outcomes in Females With a History of Contact Sports: A Cross-Sectional Survey Analysis

OBJECTIVE

To assess whether female sex is associated with higher lifetime concussion risk and if years of contact sport participation and/or concussion history are associated with negative long-term cognitive and psychiatric difficulties in females compared with males.

DESIGN

Cross-sectional survey.

SETTING

ResearchMatch, a national health-based volunteer registry.

PARTICIPANTS

A total of 330 participants (111 females) with contact sport exposure.

INTERVENTIONS

Participants reported lifetime concussion history, age of first exposure, and duration of contact sport exposure.

MAIN OUTCOME MEASURES

Lifetime concussion history, depressive symptoms (PHQ-9), anxiety symptoms (GAD-7), and cognitive symptoms (BC-CCI).

RESULTS

Of 330 participants (N = 111 females), 57.1% of females reported at least one concussion. Females had fewer years of contact sport exposure than males (6.0 ± 4.5 vs 8.5 ± 8.9 years; P < 0.001). Age of first exposure was similar between sexes (females: 11.7 ± 8.9 years; males: 11.5 ± 5.3 years; P = 0.779). Female sex was not associated with a positive lifetime concussion history (OR = 1.13; 95% CI, 0.66-1.93; P = 0.662). Total years of contact sport exposure did not predict lifetime concussion history in females (OR = 1.02; 95% CI, 0.94-1.11; P = 0.667) but did in males (OR = 1.05; 95% CI, 1.01-1.10; P = 0.020). Increased lifetime concussions predicted increased late-life depressive, anxiety, and cognitive symptoms in both sexes.

CONCLUSIONS

Female sex was not associated with a higher likelihood of having a lifetime concussion history. Total years of contact sport exposure did not predict lifetime concussion risk in females but did in males. Increased lifetime concussions were associated with higher late-life depressive, anxiety, and cognitive symptoms in both sexes.

CLINICAL RELEVANCE

These findings highlight the importance of considering sex-specific differences in assessing long-term cognitive and psychiatric risks in former athletes.

Deep learning modelling of structural brain MRI in chronic head and neck pain after mild TBI

ABSTRACT

Chronic headache is a common complication after mild traumatic brain injury (mTBI), which affects close to 70 million individuals annually worldwide. This study aims to test the utility of a unique, early predictive magnetic resonance imaging (MRI)-based classification model using structural brain MRI scans, a rarely used approach to identify high-risk individuals for post-mTBI chronic pain. We recruited 227 patients with mTBI after a vehicle collision, between March 30, 2016 and December 30, 2019. T1-weighted brain MRI scans from 128 patients within 72 hours postinjury were included and served as input for a pretrained 3D ResNet-18 deep learning model. All patients had initial assessments within the first 72 hours after the injury and performed follow-ups for 1 year. Chronic pain was reported in 43% at 12 months postinjury; remaining 57% were assigned to the recovery group. The best results were achieved for the axial plane with an average accuracy of 0.59 and an average area under the curve (AUC) of 0.56. Across the model's 8 folds. The highest performance across folds reached an AUC of 0.78, accuracy of 0.69, and recall of 0.83. Saliency maps highlighted the right insula, bilateral ventromedial prefrontal cortex, and periaqueductal gray matter as key regions. Our study provides insights at the intersection of neurology, neuroimaging, and predictive modeling, demonstrating that early T1-weighted MRI scans may offer useful information for predicting chronic head and neck pain. Saliency maps may help identify brain regions linked to chronic pain, representing an initial step toward targeted rehabilitation and early intervention for patients with mTBI to enhance clinical outcomes.

Acute Comparison of Mild-Gain Hearing Aid Approaches in an Adult With Mild Traumatic Brain Injury and Long-Term Effects of Mild-Gain Amplification on Speech Perception in Noise and Self-Reported Hearing-Related Disability, Hyperacusis, and Quality of Life

OBJECTIVE

This report documents the effects of hearing treatment in an adult with a history of mild traumatic brain injury (mTBI) and normal peripheral hearing acuity.

DESIGN

This report details a case study of a 26-year-old female with a history of mTBI.

STUDY SAMPLE

A 26-year-old female with a history of mTBI presented with auditory symptoms including tinnitus, hyperacusis, listening fatigue, and speech-in-noise (SIN) difficulties despite diagnostic audiological findings showing normal peripheral auditory function and suprathreshold SIN performance within the normal range. The patient was fit with premium-level receiver-in-the-canal (RIC) hearing aids (HAs) using several different mild-gain fitting approaches involving wide dynamic range compression (WDRC) or linearized gain. A combination of objective and subjective methods was utilized to guide clinical decision making on the fitting approach and to verify/validate treatment outcomes.

RESULTS

Despite no difference in acutely aided SIN performance between the WDRC or linearized fitting approaches, the patient expressed a clear preference for the HA fitting approach involving application of 2-10 dB of shaped linearized gain > 1.5 kHz for soft, medium, and loud input levels (with greatest gain applied at 3-4 kHz). These settings were preferred in terms of loudness and sound quality even compared to the WDRC fitting approaches previously reported in literature. This fitting approach was verified and validated by SIN testing showing improved performance in the aided condition, as well as high levels of self-reported benefit and satisfaction, reduction in self-reported hearing handicap, reduction in sound sensitivity, and enhanced quality of life with HAs.

CONCLUSIONS

Results add to the growing body of evidence supporting the benefits of mild-gain HAs for adults with mTBI and self-reported SIN deficits despite normal hearing acuity. Results also support the importance of using a combination of measures (e.g., SIN testing, patient report, outcome questionnaires) to guide the HA fitting process and to verify/validate treatment outcomes. Although findings were derived from a single case study and should be interpreted with caution, the patient's preference for a shaped linearized mild-gain approach is noteworthy. There exists a lack of clinical guidelines and prescriptive fitting methodology for fitting HAs in mTBI adults with SIN difficulty despite normal peripheral hearing acuity. Future research should systematically compare WDRC versus linearized gain approaches of fitting in this population to develop a clinical methodology for HA fitting and optimize outcomes in this special subpopulation.

Neighborhood Deprivation and Recovery Following Traumatic Brain Injury Among Older Adults

OBJECTIVE

Understanding the extent to which neighborhood impacts recovery following traumatic brain injury (TBI) among older adults could spur targeting of rehabilitation and other services to those living in more disadvantaged areas. The objective of the present study was to determine the extent to which neighborhood disadvantage influences recovery following TBI among older adults.

Setting and Participants: Community-dwelling Medicare beneficiaries aged ≥65 years hospitalized with TBI 2010-2018.

DESIGN AND MAIN MEASURES

In this retrospective cohort study, the Area Deprivation Index (ADI) was used to assess neighborhood deprivation by linking it to 9-digit beneficiary zip codes. We used national-level rankings to divide the cohort into the top 10% (highest neighborhood disadvantage), middle 11-90%, and bottom 10% (lowest neighborhood disadvantage). Recovery was operationalized as days at home, calculated by subtracting days spent in a care environment or deceased from monthly follow-up over the year post-TBI.

RESULTS

Among 13,747 Medicare beneficiaries with TBI, 1713 (12.7%) were in the lowest decile of ADI rankings and 1030 (7.6%) were in the highest decile of ADI rankings. Following covariate adjustment, beneficiaries in neighborhoods with greatest disadvantage [rate ratio (RtR) 0.96; 95% confidence interval (CI) 0.94, 0.98] and beneficiaries in middle ADI percentiles (RtR 0.98; 95% CI 0.97, 0.99) had fewer days at home per month compared to beneficiaries in neighborhoods with lowest disadvantage.

CONCLUSION

This study provides evidence that neighborhood is associated with recovery from TBI among older adults and highlights days at home as a recovery metric that is responsive to differences in neighborhood disadvantage.

Contextual Determinants of Health Disparities in Utilization of Community-Based Rehabilitation Services Among Medicare Fee-for-Service Beneficiaries With Traumatic Brain Injury

OBJECTIVE

To examine the association between contextual social determinants of health (SDoH) and receipt of first outpatient or home health (HH) rehabilitation visit after hospital discharge among older adults with traumatic brain injury (TBI) in Texas.

SETTING

Community following hospital discharge.

PARTICIPANTS

19 117 patients aged 66 and older hospitalized for a TBI from January 1, 2014, and discharged up to December 31, 2018, who returned home within 90 days from discharge.

DESIGN

Retrospective cohort study using 100% Texas Medicare claims data.

MAIN MEASURES

Contextual-level SDoH (eg, neighborhood ethno-racial identity make-up, socioeconomic position, and residential context) from the 2022 American Community Survey (zip-code level) and the 2023 County Health Rankings; HH and Outpatient Rehabilitation Services (eg, physical therapy, occupational therapy, speech/language therapy, and behavioral health [eg, psychology, neuropsychology, social work]). Fine-Gray competing risk models were conducted.

RESULTS

Patients living in areas with higher median household incomes (Hazard ratio, HR = 0.92; 95% Confidence Interval, 95% CI: 0.87-0.97) and higher unemployment rate (HR = 0.98; 95% CI: 0.97-0.99) had decreased likelihood of having a HH visit upon return to community; those with higher uninsured rates (HR = 0.78; 95% CI: 0.70-0.87) and in rural areas (HR = 0.83; 95% CI: 0.76-0.92) had decreased likelihood of having an outpatient visit. In contrast, Food Environment Index (HR = 1.08; 95% CI: 1.05-1.11) increased the likelihood of having a HH visit while a higher percentage with severe housing problems (HR = 1.34; 95% CI: 1.22-1.46) increased the likelihood of an outpatient visit. When treating either outpatient or HH visits as a competing event, contextual-level SDoH was associated with a decreased likelihood of an outpatient visit but an increased likelihood of a HH visit.

CONCLUSIONS

Disparities exist in access to rehabilitation following community discharge, based on contextual-level SDoH, indicating the need to improve access to rehabilitation services for persons with TBI living in communities with greater social needs.

Concordance of Traumatic Brain Injury Symptoms, Evaluation, and Diagnosis Between Teens and Parents: Data From the National Health Interview Survey-Teen

PURPOSE

To investigate differences in teen-reported and parent-reported lifetime prevalence estimates of traumatic brain injury (TBI) symptoms, TBI evaluation, and TBI diagnosis among a nationally representative sample of teenagers aged 12-17 years old and their parents.

METHODS

Parent-reported data from the 2021 to 2022 National Health Interview Survey linked with teen-reported data from the National Health Interview Survey-Teen July 2021-December 2022 (n = 1,153) were analyzed. Lifetime prevalence estimates for TBI symptoms (e.g., selected symptoms as a result of a blow or jolt to the head), history of evaluation by health professional for TBI (i.e., TBI evaluation), and TBI diagnosis stratified by sociodemographic characteristics and reporter type were produced, and z-tests were conducted to test for differences. Concordance measures were calculated to assess agreement between teen and parent survey responses to TBI measures.

RESULTS

Lifetime prevalence of TBI symptoms varied by reporter type across all sociodemographic characteristics with teen-report consistently producing higher estimates. Estimates of TBI evaluation varied by reporter type only among older teens, non-Hispanic teens, and teens who participated in sports; there was no difference for TBI diagnosis. Percent agreement between the 2 reporters ranged from 73% to 95%, prevalence-adjusted bias-adjusted kappa ranged from 0.45 to 0.90, and Cohen's kappa ranged from 0.22 to 0.63.

DISCUSSION

There was general agreement for observable outcomes TBI evaluation and TBI diagnosis, but discordance existed in reports of TBI symptoms. These findings suggest that youth self-report of TBI symptoms may enhance surveillance efforts.

Nasal anti-CD3 monoclonal antibody ameliorates traumatic brain injury, enhances microglial phagocytosis and reduces neuroinflammation via IL-10-dependent Treg-microglia crosstalk

Neuroinflammation plays a crucial role in traumatic brain injury (TBI), contributing to both damage and recovery, yet no effective therapy exists to mitigate central nervous system (CNS) injury and promote recovery after TBI. In the present study, we found that nasal administration of an anti-CD3 monoclonal antibody ameliorated CNS damage and behavioral deficits in a mouse model of contusional TBI. Nasal anti-CD3 induced a population of interleukin (IL)-10-producing regulatory T cells (Treg cells) that migrated to the brain and closely contacted microglia. Treg cells directly reduced chronic microglia inflammation and regulated their phagocytic function in an IL-10-dependent manner. Blocking the IL-10 receptor globally or specifically on microglia in vivo abrogated the beneficial effects of nasal anti-CD3. However, the adoptive transfer of IL-10-producing Treg cells to TBI-injured mice restored these beneficial effects by enhancing microglial phagocytic capacity and reducing microglia-induced neuroinflammation. These findings suggest that nasal anti-CD3 represents a promising new therapeutic approach for treating TBI and potentially other forms of acute brain injury.

Tufm lactylation regulates neuronal apoptosis by modulating mitophagy in traumatic brain injury

Lactates accumulation following traumatic brain injury (TBI) is detrimental. However, whether lactylation is triggered and involved in the deterioration of TBI remains unknown. Here, we first report that Tufm lactylation pathway induces neuronal apoptosis in TBI. Lactylation is found significantly increased in brain tissues from patients with TBI and mice with controlled cortical impact (CCI), and in neuronal injury cell models. Tufm, a key factor in mitophagy, is screened and identified to be mostly lactylated. Tufm is detected to be lactylated at K286 and the lactylation inhibits the interaction of Tufm and Tomm40 on mitochondria. The mitochondrial distribution of Tufm is then inhibited. Consequently, Tufm-mediated mitophagy is suppressed while mitochondria-induced neuronal apoptosis is increased. In contrast, the knockin of a lactylation-deficient TufmK286R mutant in mice rescues the mitochondrial distribution of Tufm and Tufm-mediated mitophagy, and improves functional outcome after CCI. Likewise, mild hypothermia, as a critical therapeutic method in neuroprotection, helps in downregulating Tufm lactylation, increasing Tufm-mediated mitophagy, mitigating neuronal apoptosis, and eventually ameliorating the outcome of TBI. A novel molecular mechanism in neuronal apoptosis, TBI-initiated Tufm lactylation suppressing mitophagy, is thus revealed.

Identifying Growth Hormone Deficiency in Brain-Injured Patients: The Quality of Life Scale-99

Traumatic brain injury (TBI) is frequently associated with hypopituitarism. The hypothalamic-pituitary axis appears to be susceptible to the same forces that cause injury to the parenchyma of the brain. Following even a mild TBI (mTBI), patients may suffer transient or permanent decreases in anterior pituitary hormones, including somatotropin (growth hormone [GH]), gonadotropins (luteinizing hormone and follicle-stimulating hormone), thyrotropin, and adrenocorticotropic hormone, with the most frequent long-term deficiency being GH deficiency (GHD). GHD is common after mTBI and is often the cause of persistent post-concussive symptoms a year or more post-injury. GHD is known to cause physical and cognitive fatigue, cognitive inefficiency, metabolic changes, and a range of psychological symptoms. Confusing the picture is that some symptoms of GHD are also common to brain injury itself. To facilitate the detection of GHD when comorbid with TBI, we utilized a new symptom inventory, the Quality-of-Life Scale-99 (QoLS-99), and administered it to a cohort of chronic TBI subjects with and without GHD, distinguished using the insulin tolerance test (ITT). Between 2018 and 2023, 371 patients completed the QoLS-99, of which 263 underwent GH testing with the ITT. Of these 263 patients, 136 (52%) were diagnosed with GHD. A retrospective comparison of QoLS-99 scores found that loss of libido (p < 0.006), a reliance on sleep aids (p < 0.011), and feeling overweight (p < 0.015) were the strongest univariate predictors of GHD. Most survey items did not elicit a significant difference in response between the GHD groups, and for those that did, effect sizes were mild to moderate. Still, initial findings demonstrate strong predictive value in a subset of survey items (i.e., GHD symptoms) that are most discriminating in the sample of patients with TBI. A multivariate prediction model using this subset of questions was able to differentiate GHD status in patients with TBI, correctly identifying 88% of GHD cases with a 37% false positive rate. Based on these findings, we recommend that clinicians inquire about libido, insomnia, and body image as potential markers for GHD. Furthermore, given the amenability of patients with GHD to growth hormone replacement therapy, we strongly encourage clinicians and basic scientists to develop interventions for the large and underserved population of patients with TBI with comorbid GHD.

Trends of Mortality due to Traumatic Brain Injury in the USA: A Comprehensive Analysis of CDC WONDER Data from 1999 to 2020

Traumatic brain injury (TBI) poses a significant public health challenge in the United States, with diverse causes and outcomes. Understanding the trends in TBI-related mortality is crucial for effective prevention and intervention strategies. This comprehensive analysis utilized data from the Centers for Disease Control and Prevention's Wide-ranging Online Data for Epidemiologic Research (CDC WONDER) database, covering the period from 1999 to 2020. Cause-of-death records were examined using the 10th Edition of the International Classification of Diseases and Related Health Problems diagnostic code S06 for TBI-related fatalities. Mortality rates were calculated per 100,000 individuals, adjusted for age and urban/rural status. Joinpoint Regression analysis was employed to identify significant trends over time. Between 1999 and 2020, 1,218,667 TBI-related deaths occurred, with varying mortality rates across demographic groups and geographic regions. Within the overall population, the highest annual average mortality rates were observed in the non-Hispanic (NH) American Indian or Alaska Native cohort, followed by NH white, NH black or African American, Hispanic or Latino, and NH Asian or Pacific Islander groups. Overall, there was an initial decrease in mortality rate from 1999 to 2012, followed by a subsequent significant increase. Males consistently exhibited higher mortality rates than females across all age groups. Disparities were also observed based on race/ethnicity, with NH American Indian or Alaska Native populations showing the highest mortality rates. Regional variations were evident, with the southern region consistently exhibiting the highest mortality rates. Evolving trends in TBI-related mortality in the United States highlight the need for targeted interventions, particularly in high-risk demographic groups and regions.

Impact of Post-Traumatic Epilepsy on Mental Health and Multidimensional Outcome and Quality of Life: An NIDILRR TBIMS Study

Traumatic brain injury (TBI) and subsequent post-traumatic epilepsy (PTE) often impair daily activities and mental health (MH), which contribute to long-term TBI-related disability. PTE also affects driving capacity, which impacts functional independence, community participation, and satisfaction with life (SWL). However, studies evaluating the collective impact of PTE on multidimensional outcomes are lacking. Thus, we generated a model to investigate how PTE after moderate-to-severe (ms)TBI affects TBI-associated impairments, limits activities and participation, and influences SWL. Of 5108 participants with msTBI enrolled into the National Institute for Disability, Independent Living, and Rehabilitation Research TBI Model Systems between 2010 and 2018 and with seizure-event data available at year-1 post-TBI, 1214 had complete outcome data and 1003 had complete covariate data used for analysis. We constructed a conceptual framework illustrating hypothesized interrelationships between year-1 PTE, driving status, functional independence measure (FIM), depression and anxiety, as well as year-2 participation, and SWL. We performed univariate and multivariable linear and logistic regressions. A covariate-adjusted structural equation model (SEM), using the lavaan package (R), assessed the conceptual framework's suitability in establishing PTE links with outcomes 1-2 years post-injury. Multiple parameters were evaluated to assess SEM fit. Year-1 PTE was correlated with year-1 FIM motor (standardized coefficient, βstd = -0.112, p = 0.007) and showed a trend level association with year-1 FIM cognition (βstd = -0.070, p = 0.079). Individuals with year-1 PTE were less likely to drive independently at year 1 (βstd = -0.148, p < 0.001). In addition, FIM motor (βstd = 0.323, p < 0.001), FIM cognition (βstd = 0.181, p = 0.012), and anxiety (βstd = -0.135, p = 0.024) influenced driving status. FIM cognition was associated with year-1 depression (βstd = 0.386, p < 0.001) and year-1 anxiety (βstd = 0.396, p < 0.001), whereas year-1 FIM motor (βstd = 0.186, p = 0.003), depression (βstd = -0.322, p = 0.011), and driving status (βstd = 0.233, p < 0.001) directly affected year-2 objective life participation metrics. Moreover, year-1 depression (βstd = -0.382, p = 0.001) and year-2 participation (βstd = 0.160, p < 0.001) had direct effects on year-2 SWL. SWL was influenced indirectly by year-1 variables, including functional impairment, anxiety, and driving status-factors that impacted year-2 participation directly or indirectly, and consequently year-2 SWL, forming a complex relationship with year-1 PTE. A sensitivity analysis SEM showed that the number of MH disorders was associated with participation and SWL (p < 0.001), and this combined MH variable was directly related to driving status (p < 0.02). Developing PTE during year-1 after msTBI affects multiple aspects of life. PTE effects extend to motor and cognitive abilities, driving capabilities, and indirectly, to life participation and overall SWL. The implications underscore the crucial need for effective PTE management strategies during the first year post-TBI to minimize the adverse impact on factors influencing multidimensional year-2 participation and SWL outcomes. Addressing transportation barriers is warranted to enhance the well-being of those with PTE and msTBI, emphasizing a holistic approach. Further research is recommended for SEM validation studies, including testing causal inference pathways that might inform future prevention and treatment trials.

Cognitive, Behavioral, and Functional Outcomes of Suspected Mild Traumatic Brain Injury in Community-Dwelling Older Persons Without Mild Cognitive Impairment or Dementia

BACKGROUND

Traumatic brain injury is associated with greater risk and earlier onset of dementia.

OBJECTIVE

This study investigated whether later-life changes in subjective cognition and behavior - potential markers of Alzheimer disease - could be observed in cognitively unimpaired older persons with a history of suspected mild traumatic brain injury (smTBI) earlier in life and whether changes in cognition and behavior mediated the link between smTBI and daily function.

METHODS

Data for 1392 participants from the Canadian Platform for Research Online to Investigate Health, Quality of Life, Cognition, Behaviour, Function, and Caregiving in Aging were analyzed. A validated self-reported brain injury screening questionnaire was used to determine the history of smTBI. Outcomes were measured using the Everyday Cognition scale (for subjective cognitive decline [SCD]), Mild Behavioral Impairment (MBI) Checklist, and Standard Assessment of Global Everyday Activities (for function). Inverse probability of treatment weighted logistic and negative binomial regressions were used to model smTBI (exposure) associations with SCD and MBI statuses, and Everyday Cognition-II and MBI Checklist total scores, respectively. Mediation analyses were conducted using bootstrapping.

RESULTS

History of smTBI was linked to higher odds of SCD (odds ratio = 1.45, 95% confidence interval: [1.14-1.84]) or MBI (odds ratio = 1.75, 95% confidence interval: [1.54-1.98]), as well as 24% (95% confidence interval: [18%-31%]) higher Everyday Cognition-II and 52% (95% confidence interval: [41%-63%]) higher MBI Checklist total scores. Finally, SCD and MBI mediated approximately 45% and 56%, respectively, of the association between smTBI history and poorer function, as indicated by higher Standard Assessment of Global Everyday Activities total scores.

CONCLUSIONS

smTBI at any point in the life course is linked to poorer cognition and behavior even in community-dwelling older persons without MCI or dementia. Older persons with smTBI may benefit from early dementia risk assessment using tools that measure changes in cognition and behavior. Interventions for declining cognition and behavior may also be beneficial in this population to address functional impairment.

Mechanisms of Injury for Traumatic Brain Injury Among U.S. Military Service Members Before and During the COVID-19 Pandemic

OBJECTIVE

To understand the mechanisms of injury and demographic risk factors associated with traumatic brain injury (TBI) patients among active and reserve service members in the U.S. Military before and during the COVID-10 pandemic.

METHODS

Active and reserve service members diagnosed with an incident TBI from January 2019 through September 2021 were selected. Traumatic brain injury patients diagnosed before March 1, 2020 were categorized as pre-COVID (PC), and patients diagnosed on or after March 1, 2020 were categorized as the intra-COVID (IC) group, aligning closely with the date when the World Health Organization officially proclaimed the pandemic. We determined the frequency of causes of injuries associated with TBI separate by sex, age, occupation, and TBI severity. In addition, we conducted multivariate logistic regression analyses to assess the demographic risk factors associated with TBI severity during the PC and IC eras.

RESULTS

Our cohort included 48,562 TBI patients: 22,819 (47.0%) diagnosed during the PC era and 25,743 (53.0%) diagnosed during the IC era. The major mechanisms of injury within our TBI cohort were being struck by/against objects, falls/slips/trips, and motor vehicle traffic accidents before and during the pandemic. The most common causes of TBI were not impacted by COVID, but motor vehicle accidents did increase during the IC era. The mechanisms of injury associated with TBI differed by TBI severity: being struck by or against an object caused more mild and moderate TBI; motor vehicle accidents caused more severe TBI; and firearms was a major cause of penetrating TBI. In addition, the percentage of severe TBI because of firearms rose sharply during the IC era. Further, women were more likely to be diagnosed with mild TBI compared to men.

CONCLUSION

Military leaders should consider how different causes of injury are associated with differing TBI severities and how certain demographic groups were vulnerable to specific TBI severities when developing injury prevention programs.

A double-blind randomized trial of hyperbaric oxygen for persistent symptoms after brain injury

In this double-blind randomized trial, adults with persistent symptoms following non-stroke brain injury received 40 hyperbaric oxygen (HBO2) sessions or 40 sham sessions over 12 weeks. Three months later, all were offered 40 unblinded HBO2 sessions. Participants completed the Neurobehavioral Symptom Inventory (NSI) at baseline, 13 weeks (after 40 chamber sessions), 6 months, 9 months (after the second chamber series), and 12 months, with prime outcome at 13 weeks, and additional questionnaires, neuropsychological tests, and functional measures. We enrolled 49 participants and analyzed 47 due to drop-out/exclusion (26 males, 40 with traumatic brain injury). Baseline NSI was 35.9 ± 15.8 in the HBO2 group (n = 26) and 30.7 ± 16.9 in the sham group (n = 21) (p = 0.28). Mean 13-week change scores were 10.6 ± 10.6 (HBO2 group) and 3.6 ± 5.9 (sham group) (mean difference 7.0, 95% CI 1.7-12.3, p = 0.01). The HBO2 group improved on measures of olfaction, anxiety, sleep difficulties, and vestibular complaints. Both groups reported improvements in depression, headaches, PTSD symptoms, physical quality of life, and degree to which difficulties interfere with daily life. With an additional 40 HBO2 sessions, the original HBO2 group reported additional improvements on NSI at 12 months. Only 15 original sham participants completed the second chamber series, limiting conclusions from that data.

Machine learning using random forest to differentiate between blow and fall situations of head trauma

Blunt head trauma is a common occurrence in forensic practice. Interpreting the origin of craniocerebral injuries can be a challenging process, particularly when it comes to distinguishing between falls or inflicted blows. The objective of this study was to develop a predictive model using an innovative Random Forest (RF) classification approach to differentiate injuries caused by falls from those caused by blows. The study examined 65 cases of blunt head trauma over the age of 18 resulting from a fall or an inflicted blow. A preliminary univariate logistic regression analysis followed by RF classification was performed. The presence of a depressed fracture and the lateralisation on the left-sided of cranial vault fractures, as well as extra-axial bleeding, in particular an extra-dural haematoma, were indicative of inflicted blows. The RF classification provided a simple predictive model with an accuracy rate of 78% to identify the most relevant injury criteria for distinguishing between falls and assault situations involving blows.

Effect of statins on neurological functional outcomes in critically ill adult patients with traumatic brain injury: a systematic review and meta-analysis

BACKGROUND

Statins are considered a promising therapy in traumatic brain injury (TBI) because of their role in mediating inflammatory injury and other endothelial properties. Whether they can improve patient outcomes is unknown.

OBJECTIVES

To evaluate the effect of statins in critically ill patients with TBI.

DESIGN

Systematic review and meta-analysis of randomised controlled trials.

ELIGIBILITY CRITERIA

Trials of adult patients with acute moderate or severe TBI.

METHODS

We searched Medline, Embase, Cochrane Central and Web of Science databases for trials comparing the use of any statin with placebo or other interventions. Our primary outcome was the Glasgow Outcome Scale (GOS or GOS extended); secondary outcomes were mortality, intensive care unit (ICU) and hospital length of stay. We used inverse variance random-effects models to calculate risk ratios (RR) and weighted mean differences. We assessed the risk of bias of trials using the Cochrane risk of bias assessment tool and the presence of statistical heterogeneity using the I2 index. Levels of evidence for summary effect measures were evaluated using Grading of Recommendations Assessment, Development and Evaluation methodology.1 RESULTS: Of the 2418 retrieved records, 7 trials met our eligibility criteria. Three studied simvastatin, and four studied atorvastatin. The duration of the intervention ranged from 2 to 10 days, and outcomes were assessed between ICU discharge and 6 months. Five trials were considered at high risk of bias. We observed no statistically significant association between statins and the GOS (RR 0.42; 95% CI, 0.14 to 1.22; two trials; n=84, I2=0%; very low certainty) or mortality (RR 0.59; 95% CI, 0.25 to 1.44; three trials; n=160, I2=0%; very low certainty). No significant effect was observed for ICU length of stay, while hospital length of stay was evaluated in one trial showing shorter duration.

CONCLUSION

We found no conclusive evidence supporting the use of statins in critically ill adult patients with TBI at this time. Nevertheless, the trials were limited, and wide confidence intervals resulted in significant uncertainty of the findings. A potential benefit cannot be ruled out, underscoring the need for a larger, well-designed trial.

PROSPERO REGISTRATION NUMBER

CRD42023421227.

Lactate dehydrogenase is the Achilles' heel of Lyme disease bacterium Borreliella burgdorferi

As a zoonotic pathogen, the Lyme disease bacterium Borreliella burgdorferi has evolved unique metabolic pathways, some of which are specific and essential for its survival and thus present as ideal targets for developing new therapeutics. B. burgdorferi dispenses with the use of thiamin as a cofactor and relies on lactate dehydrogenase (BbLDH) to convert pyruvate to lactate for balancing NADH/NAD + ratios. This report first demonstrates that BbLDH is a canonical LDH with some unique biochemical and structural features. A loss-of-function study then reveals that BbLDH is essential for B. burgdorferi survival and infectivity, highlighting its therapeutic potential. Drug screening identifies four previously unknown LDH inhibitors with minimal cytotoxicity, two of which inhibit B. burgdorferi growth. This study provides mechanistic insights into the function of BbLDH in the pathophysiology of B. burgdorferi and lays the groundwork for developing genus-specific metabolic inhibitors against B. burgdorferi and potentially other tick-borne pathogens as well.

Mortality trends of traumatic brain injuries in the adult population of the United States: a CDC WONDER analysis from 1999 to 2020

BACKGROUND

Traumatic Brain Injury (TBI) is a critical public health issue in the United States, contributing significantly to morbidity, mortality, and healthcare costs. Accounting for a substantial proportion of injury-related deaths and disabilities, TBI impacts a wide demographic, with particularly high incidence rates among young and elderly populations. Despite earlier declines, recent years have seen an uptick in TBI-related fatalities. This study aimed to evaluate the patterns and geographical disparities in mortality related to TBI among the adult population in the United States.

METHODS

We examined the death certificates sourced from the Centers for Disease Control and Prevention Wide-Ranging Online Data for Epidemiologic Research (CDC WONDER) database to identify adults in whom TBI was documented as an underlying or contributing cause of death between 1999 and 2020. Age-adjusted mortality rates (AAMRs) per 100,000 individuals and annual percent change (APC) were computed and stratified based on year, gender, race/ethnicity, and geographic region.

RESULTS

Between 1999 and 2020, 1,026,185 TBI-related deaths occurred among adults aged ≥ 25 years. The AAMR remained stable from 22.2 in 1999 to 22.3 in 2007, followed by an insignificant decline to 21.5 in 2010, and a steeper significant subsequent increase to 24.6 in 2020. Men had consistently higher AAMR than women from 1999 (men: 35.6; women: 11.1) to 2020 (men: 38.8; women: 11.9). The 85 + years age group had the highest AAMR 118.5 trailed by 75-84-year age group at 53.2. American Indian or Alaska Native adults had the highest AAMR (31.9) followed by White (24.4). South had the highest AAMR (25.3), followed by West (22.7). Non-metropolitan areas consistently had higher mortality rates compared to metropolitan areas.

CONCLUSIONS

Following a brief period of stability in TBI-related mortality from 1999 to 2010, there has been a subsequent increase of 1.3% per year in mortality till 2020. Notable geographic and demographic disparities persist, underscoring the need for further research and precise health policy interventions to better understand and address these differences.