The relationship of family income to the incidence, external causes, and outcomes of serious brain injury, San Diego County, California

Racial Disparities in Employment Status After Moderate/Severe Traumatic Brain Injuries in Southeast Michigan

OBJECTIVE

To examine the progress made in recent decades by assessing the employment rates of Black and non-Hispanic White (NHW) patients after traumatic brain injury (TBI), controlling for pre-TBI employment status and education status.

DESIGN

Retrospective analysis in a cohort of patients treated in Southeast Michigan at major trauma centers in more recent years (February 2010 to December 2019).

SETTING

Southeastern Michigan Traumatic Brain Injury Model System (TBIMS): 1 of 16 TBIMSs across the United States.

PARTICIPANTS

NHW (n=81) and Black (n=188) patients with moderate/severe TBI (N=269).

INTERVENTION

Not applicable.

MAIN OUTCOME MEASURES

Employment status, which is separated into 2 categories: student plus competitive employment and noncompetitive employment.

RESULTS

In 269 patients, NHW patients had more severe initial TBI, measured by percentage brain computed tomography with compression causing >5-mm midline shift (P<.001). Controlling for pre-TBI employment status, we found NHW participants who were students or had competitive employment prior to TBI had higher rates of competitive employment at 2-year (P=.03) follow-up. Controlling for pre-TBI education status, we found no difference in competitive and noncompetitive employment rates between NHW and Black participants at all follow-up years.

CONCLUSIONS

Black patients who were students or had competitive employment before TBI experience worse employment outcomes than their NHW counterparts after TBI at 2 years post TBI. Further research is needed to understand better the factors driving these disparities and how social determinants of health affect these racial differences after TBI.

Exploring the Social Determinants of Health and Health Disparities in Traumatic Brain Injury: A Scoping Review

Traumatic brain injury (TBI) is a global health concern, that can leave lasting physical, cognitive, and/or behavioral changes for many who sustain this type of injury. Because of the heterogeneity of this population, development of appropriate intervention tools can be difficult. Social determinants of health (SDoH) are factors that may impact TBI incidence, recovery, and outcome. The purpose of this study is to describe and analyze the existing literature regarding the prevailing SDoH and health disparities (HDs) associated with TBI in adults. A scoping review, guided by the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) framework was used to explore three electronic databases-PubMed, Medline, and CINAHL. Searches identified peer-reviewed empirical literature addressing aspects of SDoH and HDs related to TBI. A total of 123 records were identified and reduced to 27 studies based on inclusion criteria. Results revealed race/ethnicity was the most commonly reported SDoH impacting TBI, followed by an individual's insurance status. Health disparities were noted to occur across the continuum of TBI, including TBI risk, acute hospitalization, rehabilitation, and recovery. The most frequently reported HD was that Whites are more likely to be discharged to inpatient rehabilitation compared to racial/ethnic minorities. Health disparities associated with TBI are most commonly associated with the race/ethnicity SDoH, though insurance status and socioeconomic status commonly influence health inequities as well. The additional need for evidence related to the impact of other, lesser researched, SDoH is discussed, as well as clinical implications that can be used to target intervention for at-risk groups using an individual's known SDoH.

Area-Level Socioeconomic Inequalities in Intracranial Injury-Related Hospitalization in Korea: A Retrospective Analysis of Data From Korea National Hospital Discharge Survey 2008-2015

BACKGROUND

Although inequality in traumatic brain injury (TBI) by individual socioeconomic status (SES) exists, interventions to modify individual SES are difficult. However, as interventions for area-based SES can affect the individual SES, monitoring or public health intervention can be planned. We analyzed the effect of area-based SES on hospitalization for TBI and revealed yearly inequality trends to provide a basis for health intervention.

METHODS

We included patients who were hospitalized due to intracranial injuries (ICIs) between 2008 and 2015 as a measure of severe TBI with data provided by the Korea National Hospital Discharge Survey. Area-based SES was synthesized using the 2010 census data. We assessed inequalities in ICI-related hospitalization rates using the relative index of inequality and the slope index of inequality for the periods 2008-2009, 2010-2011, 2012-2013, and 2014-2015. We analyzed the trends of these indices for the observation period by age and sex.

RESULTS

The overall relative indices of inequality for each 2-year period were 1.82 (95% confidence interval, 1.5-2.3), 1.97 (1.6-2.5), 2.01 (1.6-2.5), and 2.01 (1.6-2.5), respectively. The overall slope indices of inequality in each period were 38.74 (23.5-54.0), 36.75 (21.7-51.8), 35.65 (20.7-50.6), and 43.11 (27.6-58.6), respectively. The relative indices of inequality showed a linear trend for men (P = 0.006), which was most evident in the ≥ 65-year age group.

CONCLUSION

Inequality in hospitalization for ICIs by area-based SES tended to increase during the observation period. Practical preventive interventions and input in healthcare resources for populations with low area-based SES are likely needed.

Factors associated with follow-up care after pediatric concussion: A longitudinal population-based study in Alberta, Canada

BACKGROUND

Concussion is a common injury in children and adolescents. Current best practice guidelines indicate that recovery should be supervised through recurrent follow-up visits. A more detailed understanding of the system-level and individual factors that are associated with follow-up care is a critical step towards increasing evidence-based practice. The objective of this study was to identify predisposing, enabling, and need-based factors associated with follow-up care after pediatric concussion.

MATERIALS AND METHODS

A retrospective population-based cohort study was conducted using linked, province-wide administrative health data for all patients <18 years of age with a diagnosis of concussion, other specified injuries of the head, unspecified injury of head, or post-concussion syndrome (PCS) between April 1, 2004 and March 31, 2018 in Alberta, Canada. The association between predisposing, enabling, and need-based factors and the receipt of follow-up care within a defined episode of care (EOC) was analyzed using logistic regression models for the entire cohort and for EOC that began with a concussion diagnosis. Predisposing factors included age and sex. Enabling factors included the community type of patient residence, area-based socioeconomic status (SES), and visit year. Need-based factors included where the EOC began (outpatient vs. emergency settings) and history of previous concussion-related EOC.

RESULTS

194,081 EOCs occurred during the study period but only 13% involved follow-up care (n = 25,461). Males and adolescents were more likely to receive follow-up care. Follow-up was less likely among patients who lived in remote communities or in areas of lower SES, while EOCs beginning in 2011 or later were more likely to involve follow-up care. Patients whose EOC began in outpatient settings, had more than one EOC, or a diagnosis of concussion were more likely to receive follow-up care.

CONCLUSION

Follow-up care for pediatric concussion has increased over time and is associated with patient age and sex, history of concussion-related EOC, where a patient lives (community type and area-based SES), and when and where the index visit occurs. A better understanding of which children are more likely to receive follow-up care, as well as how and when they do, is an important step in aligning practice with follow-up guidelines.

Cranial Nerve Stimulation for Olfaction (Cranial Nerve 1)

Like sensory maps in other systems, the sense of smell has an organizational structure based on converging projections of olfactory receptor neurons containing unique odorant receptors onto the olfactory bulb in synaptic aggregations termed glomeruli. This organizational structure provides the potential for electrical stimulation and restoration of smell. Prior animal and human studies support the feasibility of an olfactory stimulation device, encouraging ongoing work in development of olfactory implants.

Factors Associated With Phantom Odor Perception Among US Adults: Findings From the National Health and Nutrition Examination Survey

Importance

Phantom odor perception can be a debilitating condition. Factors associated with phantom odor perception have not been reported using population-based epidemiologic data.

Objective

To estimate the prevalence of phantom odor perception among US adults 40 years and older and identify factors associated with this condition.

Design, Setting, and Participants

In this cross-sectional study with complex sampling design, 7417 adults 40 years and older made up a nationally representative sample from data collected in 2011 through 2014 as part of the National Health and Nutrition Examination Survey.

Exposures

Sociodemographic characteristics, cigarette and alcohol use, head injury, persistent dry mouth, smell function, and general health status.

Main Outcomes and Measures

Phantom odor perception ascertained as report of unpleasant, bad, or burning odor when no actual odor exists.

Results

Of the 7417 participants in the study, 52.8% (3862) were women, the mean (SD) age was 58 (12) years, and the prevalence of phantom odor perception occurred in 534 participants, which was 6.5% of the population (95% CI, 5.7%-7.5%). Phantom odor prevalence varied considerably by age and sex. Women 60 years and older reported phantom odors less commonly (7.5% [n = 935] and 5.5% [n = 937] among women aged 60-69 years and 70 years and older, respectively) than younger women (9.6% [n = 1028] and 10.1% [n = 962] among those aged 40-49 years and 50-59 years, respectively). The prevalence among men varied from 2.5% (n = 846) among men 70 years and older to 5.3% (n = 913) among men 60 to 69 years old. Phantom odor perception was 60% (n = 1602) to 65% (n = 2521) more likely among those with an income-to-poverty ratio of less than 3 compared with those in the highest income-to-poverty ratio group (odds ratio [OR], 1.65; 95% CI, 1.06-2.56; and OR, 1.60; 95% CI, 1.01-2.54 for income-to-poverty ratio <1.5 and 1.5-2.9, respectively). Health conditions associated with phantom odor perception included persistent dry mouth (OR, 3.03; 95% CI, 2.17-4.24) and history of head injury (OR, 1.74; 95% CI, 1.20-2.51).

Conclusions and Relevance

An age-related decline in the prevalence of phantom odor perception is observed in women but not in men. Only 11% (n = 64) of people who report phantom odor perception have discussed a taste or smell problem with a clinician. Associations of phantom odor perception with poorer health and persistent dry mouth point to medication use as a potential explanation. Prevention of serious head injuries could have the added benefit of reducing phantom odor perception.

Socioeconomic Status Affects Outcomes After Severity-Stratified Traumatic Brain Injury

BACKGROUND

Socioeconomic status (SES) and race have been shown to increase the incidence of being afflicted by a traumatic brain injury (TBI) resulting in worse posthospitalization outcomes. The goal of this study was to determine the effect disparities have on in-hospital mortality, discharge to inpatient rehabilitation, hospital length of stay (LOS), and TBI procedures performed stratified by severity of TBI.

METHODS

This was a retrospective cohort study of patients with closed head injuries using the National Trauma Data Bank (2012-2015). Multivariate logistic/linear regression models were created to determine the impact of race and insurance status in groups graded by head Abbreviated Injury Scale (AIS).

RESULTS

We analyzed 131,461 TBI patients from NTDB. Uninsured patients experienced greater mortality at an AIS of 5 (odds ratio [OR] = 1.052, P = 0.001). Uninsured patients had a decreased likelihood of being discharged to inpatient rehabilitation with an increasing AIS beginning from an AIS of 2 (OR = 0.987, P = 0.008) to an AIS of 5 (OR = 0.879, P < 0.001). Black patients had an increased LOS as their AIS increased from an AIS of 2 (0.153 d, P < 0.001) to 5 (0.984 d, P < 0.001) with the largest discrepancy in LOS occurring at an AIS of 5.

CONCLUSIONS

Disparities in race and SES are associated with differences in mortality, LOS, and discharge to inpatient rehabilitation. Patients with more severe TBI have the greatest divergence in treatment and outcome when stratified by race and ethnicity as well as SES.

Loss to Follow-Up and Social Background in an Inception Cohort of Patients With Severe Traumatic Brain Injury: Results From the PariS-TBI Study

OBJECTIVES

To assess determinants of loss to follow-up (FU) at 2 time points of an inception traumatic brain injury (TBI) cohort.

DESIGN AND PARTICIPANTS

The PariS-TBI study consecutively included 504 adults with severe TBI on the accident scene (76% male, mean age 42 years, mean Glasgow Coma Scale 5). No exclusion criteria were used.

MAIN MEASURE

Loss to FU at 1 and 4 years was defined among survivors as having no outcome data other than survival status.

RESULTS

Among 257 1-year survivors, 118 (47%) were lost to FU at 1 year and 98 (40%) at 4 years. Main reasons for loss to FU were impossibility to achieve contact (109 at 1 year, 52 at 4 years) and refusal to participate (respectively 5 and 24). At 1 year, individuals not working preinjury or with nonaccidental traumas were more often lost to FU in univariate and multivariable analyses. At 4 years, loss to FU was significantly associated with preinjury alcohol abuse and unemployment. Relationship with injury severity was not significant.

CONCLUSIONS

Socially disadvantaged persons are underrepresented in TBI outcome research. It could result in overestimation of outcome and biased estimates of sociodemographic characteristics' effects. These persons, particularly unemployed individuals, require special attention in clinical practice.

Posttraumatic olfactory dysfunction

Impairment of smell may occur following injury to any portion of the olfactory tract, from nasal cavity to brain. A thorough understanding of the anatomy and pathophysiology combined with comprehensively obtained history, physical exam, olfactory testing, and neuroimaging may help to identify the mechanism of dysfunction and suggest possible treatments. Although most olfactory deficits are neuronal mediated and therefore currently unable to be corrected, promising technology may provide novel treatment options for those most affected. Until that day, patient counseling with compensatory strategies and reassurance is essential for the maintenance of safety and QoL in this unique and challenging patient population.

Factors affecting the likelihood of presentation to the emergency department of trauma patients after discharge

STUDY OBJECTIVE

We determine the rate at which trauma patients re-present to the emergency department (ED) after discharge from the hospital and determine whether re-presentation is related to race, insurance, and socioeconomic factors such as neighborhood income level.

METHODS

Trauma patients admitted to a Level I trauma center between January 1, 1997, and December 31, 2007, were identified with the hospital's trauma registry. These patients were linked to administrative data to obtain information about re-presentation to the hospital. Neighborhood income was obtained with census block data; multiple imputation was implemented to account for missing income data. Logistic regression analysis was used to determine the predictors of re-presentation.

RESULTS

There were 6,675 patients who were included in the study. A total of 886 patients (13.3%) returned to the ED within 30 days of discharge from the hospital. Uninsured patients (odds ratio [OR]=1.64; 95% confidence interval [CI] 1.30 to 2.06) and publicly insured patients (OR=1.60; 95% CI 1.20 to 2.14) were more likely to re-present to the ED than those with commercial insurance. Residing in a neighborhood with a median household income less than $20,000 was associated with a higher odds of re-presentation (OR=1.77; 95% CI 1.37 to 2.29). Only 13.2% of patients who came to the ED were readmitted to the hospital.

CONCLUSION

A substantial number of trauma patients return to the ED within 30 days of being discharged, but only a small proportion of these patients required readmission. Re-presentation is associated with being uninsured or underinsured and with lower neighborhood income level.

Incidence and descriptive epidemiologic features of traumatic brain injury in King County, Washington

OBJECTIVE

Traumatic brain injury (TBI) is a major cause of disability among US children. Our goal was to obtain population-based data on TBI incidence rates.

METHODS

We conducted surveillance through a stratified random sample of hospital emergency departments in King County, Washington, to identify children 0 to 17 years of age with medically treated TBIs during an 18-month study period in 2007-2008. Additional cases were identified through hospital admission logs and the medical examiner's office. For a sample of nonfatal cases, parents were interviewed to verify TBIs, and medical record data on severity and mechanisms were obtained.

RESULTS

The estimated incidence of TBIs in this setting was 304 cases per 100,000 child-years. The incidence was highest for preschool-aged children and lowest for children aged 5 to 9 years. Rates were uniformly higher for boys than for girls; there was a larger gender gap at older ages. Falls were the main mechanism of injury, especially among preschool-aged children, whereas being struck by or against an object and motor vehicle-related trauma were important contributors for older children. Approximately 97% of TBI cases were mild, although moderate/severe TBI incidence increased with age.

CONCLUSIONS

TBIs led to many emergency department visits involving children, but a large majority of the cases were clinically mild. Incidence rates for King County were well below recent national estimates but within the range reported in previous US studies. Because mechanisms of injury varied greatly according to age, prevention strategies almost certainly must be customized to each age group for greatest impact.

Regional economic levels and adverse events linked to intrauterine devices

OBJECTIVE

To explore the relationship between macro-economic indicators and incidences of adverse events linked to intrauterine devices (IUDs).

METHODS

Data on IUD-associated adverse events were collected from a cohort study conducted between September 2005 and December 2006. Regional economic data were from the 2006 National Economic and Social Development Statistical Bulletins and Statistical Yearbooks of various regions. A total of 20,220 IUD users in 236 towns in Jiangsu, Shanghai, Guangdong, Anhui, Sichuan, and Chongqing provinces in China were included in this study. Linear correlation and regression analyses were used to analyze the relationships between regional income and total incidences of adverse events, incidences of mild adverse events, and incidences of severe adverse events.

RESULTS

Incidences of total adverse events and mild adverse events were positively correlated with regional economic level (rs= 0.336, p < 0.05; rs= 0.272, p < 0.05), while incidences of severe adverse events were not correlated with regional economic level.

CONCLUSIONS

The positive relationship between regional economic level and reported IUD-associated mild adverse events likely reflects income-related disparities in women seeking care and receiving treatment for mild adverse events. This points to a need to improve both public health education and the quality of health services, particularly in poorer areas.

Race affects mortality after moderate to severe traumatic brain injury

BACKGROUND

Traumatic brain injury (TBI) is the most common cause of death and disability in trauma patients, affecting over 1 million Americans per year. Minorities are at disproportionate risk for TBI, and they account for nearly half of all brain injury hospitalizations. Little is known regarding racial disparities in TBI patients. The objective of this study was to investigate the association of race on mortality in patients with moderate to severe isolated TBI.

METHODS

The Los Angeles County Trauma System database, consisting of admissions from five Level I and eight Level II trauma centers, was queried for all patients with isolated moderate to severe TBI admitted between 1998 and 2005. Demographics and mortality were compared between races: Asian, African American, Hispanic, White, and Other. Multivariate logistic regression was used to determine the relationship between race and mortality.

RESULTS

A total of 17,977 (23.8% female, 76.2% male) severe TBI patients were evaluated. Of this study population, 7.1% were Asian, 13.5% were African American, 42.3% were Hispanic, 32.5% were White, and 4.7% where classified as Other. Overall, Asians (adjusted Odds Ratio [AOR] 1.4; 95% CI: 1.14-1.71, P = 0.001) had a significantly higher risk in mortality when compared with Whites. Surprisingly, neither African Americans (AOR 1.02; 95% CI: 0.87-1.2, P = 0.82), nor Hispanics (AOR 1.00; 95% CI: 0.89-1.13, P > 0.9) were at increased risk of death compared to their White counterparts.

CONCLUSION

This data supports the hypothesis that race may play a role in mortality in moderate to severe TBI. However, only Asians were at higher risk for death.

Counting heads: estimating traumatic brain injury in New South Wales

The public health problem of head injuries contributes to considerable morbidity in the community and is the commonest cause of death in young adult Australians. However, estimating the incidence of head injury has been difficult, and has varied between countries and over time. This paper critically appraises the methodological issues contributing to head injury/brain injury incidence estimates, in particular case definition, differing data sources, and methods of case ascertainment. The most appropriate definition from a methodological service provider perspective is one which clearly distinguishes between potential and actual brain injury. The results from a study which used the most accurate methods have been extrapolated to NSW, and reduce the estimated brain injury incidence in NSW from a reported 392 to 180 per 100,000 incident cases per year. This revised estimate implies that in 1990 there will be about 10,500 new cases of traumatic brain injury, of which an estimated 400 will result in serious physical or mental disability. These estimates were originally calculated to enable the development of an appropriate level of health service provision for brain-injured persons through the NSW Brain Injury Program.

Identification and characteristics of vaccine refusers

Background

This study evaluated the utility of immunization registries in identifying vaccine refusals among children. Among refusers, we studied their socioeconomic characteristics and health care utilization patterns.

Methods

Medical records were reviewed to validate refusal status in the immunization registries of two health plans. Racial, education, and income characteristics of children claiming refusal were collected based on the census tract of each child. Health care utilization was identified using both electronic medical record and insurance claims. Within the immunization registries of two HMOs in the study, some providers use refusal and medical contraindication interchangeably, and some providers tend to always use "ever refusal." Therefore, we combined medical contraindication and refusal together and treated them all as "refusal" in this study.

Results

The immunization registry, compared to chart review, had negative predictive values of 85–92% and 90–97% for 2- and 6-year olds, and positive predictive values of only 52–74% and 59–62% to identify vaccine refusals. Refusers were more likely to reside in well-educated, higher income areas than non-refusers. Refusers had not opted out of health care system and continued, although less frequently for the age 2 and under group, to use services.

Conclusion

Without enhancements to immunization registries, identifying children with immunization refusal would be time consuming. Since communities where refusers live are well educated, interventions should target these communities to communicate vaccine adverse events and consequences of vaccine preventable diseases.

Racial disparities in long-term functional outcome after traumatic brain injury

OBJECTIVE

Ethnic disparities have been demonstrated in several diseases, but not in trauma. We hypothesized that access to acute rehabilitation and long-term functional outcomes among traumatic brain injury (TBI) patients are influenced by patient race and ethnicity.

METHODS

Patients with severe TBI (Abbreviated Injury Scale [AIS] score, 3-5) who were discharged alive from initial hospitalization were recruited from an urban Level I trauma center (1998-2005). Functional outcome was measured 6 to 12 months after injury using the Glasgow Outcome Scale-Extended (GOSE) score, and classified as good recovery (GOSE score, 7 and 8) or moderate to severe disability (GOSE score, 1-6). Ethnic minorities (n = 114) were compared with non-Hispanic Whites (NHW, n = 230). Logistic regression was used to measure the association between ethnicity and functional outcome while controlling for age, gender, Injury Severity Score (ISS), head AIS score, Glasgow Coma Scale (GCS) score, discharge disposition, and insurance.

RESULTS

Minority and NHW groups had similar ISS, GCS score, and head AIS score. Ethnic minorities were less likely to be insured (uninsured, 66% vs. 31%, p < 0.001), but were equally likely to be placed in a rehabilitation facility upon trauma center discharge (47% vs. 42%, p = 0.417). Minority patients were more likely to have moderate to severe disability at follow-up (74% vs. 61%; adjusted odds ratio [OR], 2.17; 95% confidence interval [CI], 1.27-3.69). The relationship between ethnicity and functional outcome became insignificant when insurance was taken into account (OR, 1.52; 95% CI, 0.81-2.72).

CONCLUSION

Despite equal access to acute rehabilitation, ethnic minorities have significantly worse long-term functional outcomes after TBI, which is related to lack of health insurance.

Ethnic disparities exist in trauma care

BACKGROUND

An estimated 5.3 million people in the United States live with permanent disability related to traumatic brain injury (TBI). Access to rehabilitation after TBI is important in minimizing these disabilities. Ethnic disparities in access to health care have been documented in other diseases, but have not been studied in trauma care. We hypothesized that access to rehabilitation after TBI is influenced by race or ethnicity.

METHODS

Retrospective analysis of the National Trauma Data Bank patients with severe blunt TBI (head abbreviated injury score 3-5, n = 58,729) who survived the initial hospitalization was performed. Placement into rehabilitation after discharge was studied in three groups: non-Hispanic white (NHW 77%), African American (14%), and Hispanic (9%). The two minority groups were compared with NHW patients using logistic regression to control for differences in age, gender, overall injury severity (injury severity score), TBI severity (head abbreviated injury score and Glasgow Coma Scale score), associated injuries, and insurance status.

RESULTS

The three groups were similar in injury severity score, TBI severity, and associated injuries. After accounting for differences in potential confounders, including injury severity and insurance status, minority patients were 15% less likely to be placed in rehabilitation (odds ratio 0.85, 95% confidence interval 0.8-0.9, p < 0.0001).

CONCLUSIONS

Ethnic minority patients are less likely to be placed in rehabilitation than NHW patients are, even after accounting for insurance status, suggesting existence of systematic inequalities in access. Such inequalities may have a disproportionate impact on long-term functional outcomes of African American and Hispanic TBI patients, and suggest the need for an in-depth analysis of this disparity at a health policy level.

Ethnic differences in rehabilitation placement and outcome after TBI

OBJECTIVE

To determine whether race/ethnicity and proficiency with the English language influence access to rehabilitation services, and ultimately outcome after traumatic brain injury (TBI).

DESIGN

A retrospective correlational investigation.

SETTING AND PARTICIPANTS

Postrehabilitation outpatients with blunt TBI. A total of 476 patients were examined 6 months postinjury, of which 109 (23%) were Hispanics, and of those 42 were predominantly Spanish speaking.

MAIN OUTCOME MEASURES

Access to rehabilitation services, Glasgow Outcome Scale-Extended.

RESULTS

Insurance, age, and injury severity had the greatest influence on receipt of rehabilitation services; however, higher rates of severe disability were found among Hispanics and Spanish speakers than non-Hispanic whites and non-Hispanic English speakers, respectively.

CONCLUSIONS

Insurance status has a larger influence on receipt of rehabilitation services than ethnicity or proficiency with the English language, but language proficiency is a significant predictor of severe disability.

Functional Outcome in TBI I: Neuropsychological, Emotional, and Behavioral Mediators

Literature exists to suggest that the severity of traumatic brain injury (TBI) is positively associated with the severity of functional impairment. However, potential mediators of this relationship have not been studied systematically. In the present study, we evaluated a model hypothesized to explain the relationship between TBI severity and functional impairment in 87 patients with moderate-to-severe TBI, studied longitudinally. Using structural equation modeling, we found that only neuropsychological status (but not emotional or behavioral difficulties) consistently mediated the relationship between TBI severity and functional outcome at 12-months post-injury. These findings suggest that, of the factors examined here, neurocognitive compromise plays the most prominent role in mediating post-TBI adaptive functioning in moderate-to-severe TBI, which has important implications for post-injury interventions.

Race and productivity outcome after traumatic brain injury: influence of confounding factors

OBJECTIVE

Investigate the impact of race on productivity outcome after traumatic brain injury (TBI) and evaluate the influence of confounding factors on this relationship.

DESIGN

Inception cohort of 1083 adults with TBI for whom 1-year productivity follow-up data were available.

RESULTS

Univariable logistic regression indicated that race was a significant predictor of productivity outcome after TBI. African Americans were 2.76 times more likely to be nonproductive than whites and other racial minorities were 1.92 times more likely to be nonproductive than whites. Multivariable logistic regression analyses revealed that the effect of race on employability was influenced by confounds with preinjury productivity, education level, and cause of injury. After adjustment for other predictors, African Americans were 2.00 times more likely to be nonproductive than whites and other racial minorities were 2.08 times more likely to be nonproductive than whites. The multivariable logistic regression model with all predictors except race accounted for 39% of the variability in productivity outcome (R2-Nagelkerke=0.39), whereas the full logistic regression model including race accounted for 41% of the variability in productivity outcome (R2-Nagelkerke=0.41); a difference of only 2%.

CONCLUSION

Any effect of race on productivity is significantly influenced by confounding with preinjury productivity, education level, and cause of injury.

Social deprivation and adult head injury: a national study

OBJECTIVES

To establish the association between measures of social deprivation, mechanisms of injury, patterns of care, and outcome following closed head injury.

METHODS

All Scottish adult A&E attendees with closed head injury (AIS Head > or =3) between July 1996 and December 2000 were studied.

RESULTS

Trauma was more common in individuals from more deprived areas. Within the trauma population head injury was relatively more common in patients from deprived areas; these individuals were more likely to sustain an isolated head injury as a result of an assault. Admission GCS was higher and normal physiology (as assessed by the RTS) was more common in individuals from more deprived areas. Recorded co-morbidity was similar between the two groups with the exception of a history of alcohol or substance abuse which was more common among patients from more deprived areas. Similar proportions of patients from more deprived and less deprived areas were transferred to the Regional Neurosurgical Centre. For patients who were transferred directly from A&E, time to neurosurgical theatre was similar for both groups. Length of hospital and ITU stay was less in patients from more deprived areas. After adjusting for known predictors of outcome using logistic regression analysis, there was no significant difference in mortality between patients from more deprived and less deprived areas.

CONCLUSIONS

Residing in a more deprived area is not associated with increased mortality from head injury among adults in Scotland. It is associated with different patterns of injury and a different process of care following presentation to hospital.

Socioeconomic inequalities in injury: critical issues in design and analysis

Injuries continue to place a tremendous burden on the public's health and rates vary widely among different groups in the population. Increasing attention has recently been given to the effects of socioeconomic status (SES) as a determinant of health among both individuals and communities. However, relatively few studies have focused on the influence of SES and injuries. Furthermore, those that have, and the other injury studies that have included measures of SES in their analysis, have varying degrees of conceptual and methodological rigor in their use of this measure. Recent advances in data linkage and analytic techniques have, however, provided new and improved methods to assess the relationship between SES and injuries. This review summarizes the relevant literature on SES and injuries, with particular attention to study design, and the measurement and interpretation of SES. We found that increasing SES has a strong inverse association with the risk of both homicide and fatal unintentional injuries, although the results for suicide were mixed. However, the relationship between SES and nonfatal injuries was less consistent than for fatal injuries. We offer potential explanatory mechanisms for the relationship between SES and injuries and make recommendations for future research in this area.

Traumatic brain injury in older adults

Traumatic brain injury (TBI) is a serious health risk for older adults, and the consequences of TBI range from full recovery to death. For many who survive, there is a legacy of cognitive, physical, and emotional disability. Falls are the major cause of head injury in older adults. There are many risk factors including pre-existing brain disease, other diseases, and, sometimes, iatrogenic factors. Efforts directed at prevention are of great importance. Outcome studies indicate that outcome is generally worse for older people than for younger people with similar injuries, but older individuals also deserve aggressive rehabilitation directed at the best possible recovery. This review will discuss the symptoms and syndromes that commonly result from TBI with comments about treatment.

Olfactory dysfunction in patients with head trauma

OBJECTIVE

There are few reports about following up olfactory acuity of the patients who have post-traumatic olfactory dysfunction. In this study, we studied about patients with post-traumatic olfactory dysfunction for a short period under a treatment.

METHODS

The olfactory function of 27 patients with head trauma was studied. The olfactory acuities of all the patients were examined using olfactory tests before the treatment, and 18 patients were examined again after the treatment. Olfactory functions were evaluated in 26 patients by T&T olfactometry and in 27 patients by Alinamin test. All of the patients were treated with a local injection of suspended steroid solution into the nasal mucosa [J Otolaryngol Jpn 102 (1999) 1175].

RESULTS

Before the treatment, 16 patients (61.5%) presented anosmia, five patients (19.2%) presented severe hyposmia, three patients (11.5%) presented moderate hyposmia, and two patients (7.7%) presented mild hyposmia. Eighteen cases (69.2%) were negative for the Alinamin test and eight cases (30.8%) were positive. The improvement rates of recognition and detection thresholds by T&T olfactometry were 35.3 and 23.5%, respectively.

CONCLUSION

Olfactory dysfunction caused by head trauma can be recovered to a limited degree in some cases by the local injection of steroid within the relatively short period from the start of the therapy.

Brain injury in the Commonwealth of Virginia: an analysis of Central Registry data, 1988-1993

Cumulative data from the Virginia Brain Injury Central Registry, which maintains information on persons presenting to the emergency rooms for evaluation and treatment of head trauma, were analysed for fiscal years 1988-1993. Persons age 40 years and younger represented almost 80% of all head injuries presenting to Virginia emergency rooms. Age-adjusted incidence rates were greatest for children under age 6 years (237/100,000 persons-years), and least for persons age 40-69 years (56/100,000 person-years). Head injuries occurred 1.4 times more frequently in males than females, and male mortality rates were 1.6 times greater. Falls exceeded motor vehicle accidents as the most common cause of head trauma after fiscal year 1989 followed by assaults and sports/recreation-related injuries. Head injuries were most common in May through October, and early mortality rates increased progressively with age. Findings are contrasted with prior demographic and epidemiological studies limited to persons hospitalized following moderate to severe head trauma.

Is magnitude of co-payment effect related to income? Using census data for health services research

This study: (1) describes and evaluates a method for estimating household income using home addresses in conjunction with census data, and (2) uses this method in a study designed to determine if the introduction of copayments caused primary care office visit rates to decrease more for lower income enrollees than for higher income enrollees of a large health maintenance organization (HMO). Each step in the process of linking income estimates for small census units (block groups) to specific home addresses is described and the validity and precision of these estimates is assessed through comparisons of estimated income with self-reported income for residents of the Puget Sound area of Washington state. Although subject to considerable measurement error, this approach provided valid income estimates. This method was then used to estimate the incomes of over 20,000 households of HMO enrollees in a controlled study of the relationship between copayment effect on visit rates and enrollee income. Copayments were found to have a similar effect on higher and lower income enrollees.

Outcome following physical trauma: a comparative approach

This study aimed to examine physical and psychosocial changes after injury in a range of trauma patients. Three groups were selected for comparison purposes: severely head-injured patients, patients with major trauma, and those with minor trauma (n = 102). Outcomes were assessed by questionnaires and inventories administered to a family member or friend of the trauma survivor, approximately 1 year post-injury. Severely head-injured patients were reported to have the greatest degree of difficulty in self-care and mobility, and in community living skills, followed by other major trauma patients and then minor trauma patients. Severely head-injured patients also had relatively more frequent reports of behavioural changes than the other two groups. None the less, more than half of the major trauma group were reported to act differently after the accident. The relative frequency of adverse outcomes in the major trauma group was greater than expected and should be the focus of further research.

Blood alcohol tests, prevalence of involvement, and outcomes following brain injury

We collected data on all residents of San Diego County, California who were hospitalized for or died from a brain injury in 1981. The objectives were to assess the frequency of blood alcohol concentration (BAC) testing and the associations of BAC prevalence with the external cause of the brain injury and case outcome. We found that high BAC levels were most frequent among brain-injured subjects between the ages of 25 and 44 and among those subjects involved in motor vehicle crashes and assaults. Contrary to expectations, injury severity and hospital mortality were inversely related to BAC level, controlling for other predictors. We believe that these inverse associations might be due to differential rates of BAC testing by severity. Among brain-injured survivors with more severe injuries, however, we found that BAC level was positively associated with the prevalence of physician-diagnosed neurological impairment at discharge and with the length of hospitalization.