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1.  Cognitive Performance in Late Adolescence and the Subsequent Risk of Subdural Hematoma: An Observational Study of a Prospective Nationwide Cohort 
PLoS Medicine  2011;8(12):e1001151.
Anna and Peter Nordström analyzed a prospective nationwide cohort of 440,742 Swedish men and found that reduced cognitive function in young adulthood was associated with increased risk of subdural hematoma later in life, whereas a higher level of education and physical fitness were associated with a decreased risk.
There are few identified risk factors for traumatic brain injuries such as subdural hematoma (SDH). The aim of the present study was to investigate whether low cognitive performance in young adulthood is associated with SDH later in life. A second aim was to investigate whether this risk factor was associated with education and physical fitness.
Methods and Findings
Word recollection, logical, visuospatial, and technical performances were tested at a mean age of 18.5 years in a prospective nation-wide cohort of 440,742 men. An estimate of global intelligence was calculated from these four tests. Associations between cognitive performance, education, physical fitness, and SDH during follow-up were explored using Cox regression analyses. During a median follow-up of 35 years, 863 SDHs were diagnosed in the cohort. Low global intelligence was associated with an increased risk of SDH during follow-up (hazard ratio [HR]: 1.33, per standard deviation decrease, 95% CI = 1.25–1.43). Similar results were obtained for the other measures of cognitive performance (HR: 1.24–1.33, p<0.001 for all). In contrast, a high education (HR: 0.27, comparing more than 2 years of high school and 8 years of elementary school, 95% CI = 0.19–0.39), and a high level of physical fitness (HR: 0.76, per standard deviation increase, 95% CI = 0.70–0.83), was associated with a decreased risk of suffering from a SDH.
The present findings suggest that reduced cognitive function in young adulthood is strongly associated with an increased risk of SDH later in life. In contrast, a higher level of education and a higher physical fitness were associated with a decreased risk of SDH.
Please see later in the article for the Editors' Summary
Editors' Summary
Every year, about 10 million people worldwide sustain a traumatic brain injury that needs medical attention or that proves fatal. Such injuries occur when the head is suddenly hit or jolted or when an object such as a bullet pierces the skull and enters the brain. Motor vehicle accidents are responsible for many traumatic brain injuries, but falls, assaults, and military action can also cause these serious injuries. The symptoms of a traumatic brain injury, which may not appear until many days after the injury, include loss of consciousness, headaches, dizziness, and nausea. Affected individuals can experience changes in their memory, concentration, or ability to think clearly (“cognitive” changes) and can have behavioral or emotional problems. Although the initial brain damage caused by trauma cannot be reversed, immediate medical treatment is essential to prevent further injury occurring. In particular, patients need to be monitored for “subdural hematoma,” a common outcome of traumatic brain injury in which blood from ruptured vessels collects between the brain and the skull. Subdural hematoma puts pressure on the brain and has to be removed surgically to prevent further brain damage.
Why Was This Study Done?
Not everyone who has a traumatic brain injury develops subdural hematoma. If the factors that increase a person's risk of developing subdural hematoma could be identified, it might be possible to devise public-health interventions that would reduce the incidence of subdural hematomas. In this prospective population-based analysis, the researchers investigate whether low cognitive performance in early adulthood is associated with subdural hematoma later in life. Impaired cognitive functioning is sometimes recorded as a symptom of subdural hematoma but the researchers hypothesize that these cognitive deficits might have been present before the traumatic head injury that led to subdural hematoma. Low cognitive performance is associated with a reduced ability to compare objects and patterns (perceptual speed) and with impaired judgment, planning, and risk behavior (executive functions), so low cognitive performance might increase a person's risk of having an accident that results in a head injury and subdural hematoma.
What Did the Researchers Do and Find?
The researchers calculated a global intelligence score for 440,742 male Swedish military conscripts (average age 18.5 years) from cognitive tests completed by the men between 1969 and 1978. They obtained information about diagnoses of subdural hematoma up to 40 years later among these men from medical records, and then used several statistical approaches to look for associations between cognitive performance, education (recorded during conscription assignment), physical fitness (measured during conscription assignment), and subsequent subdural hematoma. During the follow-up period, 863 subdural hematomas were diagnosed among the men. Conscripts with a low global intelligence score in early adulthood were more likely to develop subdural hematoma during later life than those with a high score. Specifically, when the men were divided into five groups (quintiles) on the basis of their global intelligence score, men with a score in the lowest quintile were more than twice as likely to develop subdural hematoma as those with a score in the highest quintile. By contrast, men who had had more than 2 years high school education were much less likely to develop subdural hematoma than those who had only had 8 years of elementary school education. A high level of physical fitness in early adulthood also reduced the risk of subdural hematoma.
What Do These Findings Mean?
These findings suggest that low cognitive function in early adulthood is associated with subdural hematoma later in life, whereas high levels of education and physical fitness is associated with a decreased risk of subdural hematoma. Because this study was observational, these findings do not prove that low cognitive performance, low education level, or low physical fitness is causally linked to subdural hematoma. Other unidentified factors (confounders) shared by people with these characteristics might actually be responsible for the observed association between these factors and subdural hematoma. For example, poorly educated people might work in more hazardous environments than those who attended high school. However, if these findings can to be confirmed in other large studies, an exploration of the mechanistic basis of the associations reported here might eventually inform the development of public-health interventions designed to reduce the occurrence of subdural hematoma.
Additional Information
Please access these Web sites via the online version of this summary at
The US National Institute of Neurological Disorders and Stroke provides detailed information about traumatic brain injury (in English and Spanish)
The US Centers for Disease Control and Prevention also provides detailed information about traumatic brain injury
The UK National Health Service Choices website has an article about severe head injury that includes a personal story about a head injury sustained in a motor vehicle accident, and an article about subdural hematoma
MedlinePlus provide links to further resources on traumatic brain injury and information on subdural hematoma; it also provides an interactive tutorial on traumatic brain injury (available in English and Spanish)
The UK charity Headway, which works to improve life after brain injury, has a collection of personal stories about brain injury
PMCID: PMC3246434  PMID: 22215989
2.  Risk of Violent Crime in Individuals with Epilepsy and Traumatic Brain Injury: A 35-Year Swedish Population Study 
PLoS Medicine  2011;8(12):e1001150.
Seena Fazel and colleagues report findings from a longitudinal follow-up study in Sweden that evaluated the risks of violent crime subsequent to hospitalization for epilepsy, or traumatic brain injury. The researchers control for familial confounding with sibling controls. The analyses call into question an association between epilepsy and violent crime, although they do suggest that there may be a relationship between traumatic brain injury and violent crime.
Epilepsy and traumatic brain injury are common neurological conditions, with general population prevalence estimates around 0.5% and 0.3%, respectively. Although both illnesses are associated with various adverse outcomes, and expert opinion has suggested increased criminality, links with violent behaviour remain uncertain.
Methods and Findings
We combined Swedish population registers from 1973 to 2009, and examined associations of epilepsy (n = 22,947) and traumatic brain injury (n = 22,914) with subsequent violent crime (defined as convictions for homicide, assault, robbery, arson, any sexual offense, or illegal threats or intimidation). Each case was age and gender matched with ten general population controls, and analysed using conditional logistic regression with adjustment for socio-demographic factors. In addition, we compared cases with unaffected siblings.
Among the traumatic brain injury cases, 2,011 individuals (8.8%) committed violent crime after diagnosis, which, compared with population controls (n = 229,118), corresponded to a substantially increased risk (adjusted odds ratio [aOR] = 3.3, 95% CI: 3.1–3.5); this risk was attenuated when cases were compared with unaffected siblings (aOR = 2.0, 1.8–2.3). Among individuals with epilepsy, 973 (4.2%) committed a violent offense after diagnosis, corresponding to a significantly increased odds of violent crime compared with 224,006 population controls (aOR = 1.5, 1.4–1.7). However, this association disappeared when individuals with epilepsy were compared with their unaffected siblings (aOR = 1.1, 0.9–1.2). We found heterogeneity in violence risk by age of disease onset, severity, comorbidity with substance abuse, and clinical subgroups. Case ascertainment was restricted to patient registers.
In this longitudinal population-based study, we found that, after adjustment for familial confounding, epilepsy was not associated with increased risk of violent crime, questioning expert opinion that has suggested a causal relationship. In contrast, although there was some attenuation in risk estimates after adjustment for familial factors and substance abuse in individuals with traumatic brain injury, we found a significantly increased risk of violent crime. The implications of these findings will vary for clinical services, the criminal justice system, and patient charities.
Please see later in the article for the Editors' Summary
Editors' Summary
News stories linking mental illness (diseases that appear primarily as abnormalities of thought, feeling or behavior) with violence frequently hit the headlines. But what about neurological conditions—disorders of the brain, spinal cord, and nerves? People with these disorders, which include dementia, Parkinson's disease, and brain tumors, often experience stigmatization and discrimination, a situation that is made worse by the media and by some experts suggesting that some neurological conditions increase the risk of violence. For example, many modern textbooks assert that epilepsy—a neurological condition that causes repeated seizures or fits—is associated with increased criminality and violence. Similarly, various case studies have linked traumatic brain injury—damage to the brain caused by a sudden blow to the head—with an increased risk of violence.
Why Was This Study Done?
Despite public and expert perceptions, very little is actually known about the relationship between epilepsy and traumatic brain injury and violence. In particular, few if any population-based, longitudinal studies have investigated whether there is an association between the onset of either of these two neurological conditions and violence at a later date. This information might make it easier to address the stigma that is associated with these conditions. Moreover, it might help scientists understand the neurobiological basis of violence, and it could help health professionals appropriately manage individuals with these two disorders. In this longitudinal study, the researchers begin to remedy the lack of hard information about links between neurological conditions and violence by investigating the risk of violent crime associated with epilepsy and with traumatic brain injury in the Swedish population.
What Did the Researchers Do and Find?
The researchers used the National Patient Register to identify all the cases of epilepsy and traumatic brain injury that occurred in Sweden between 1973 and 2009. They matched each case (nearly 23,000 for each condition) with ten members of the general population and retrieved data on all convictions for violent crime over the same period from the Crime Register. They then linked these data together using the personal identification numbers that identify Swedish residents in national registries. 4.2% of individuals with epilepsy had at least one conviction for violence after their diagnosis, but only 2.5% of the general population controls did. That is, epilepsy increased the absolute risk of a conviction for violence by 1.7%. Using a regression analysis that adjusted for age, gender, and various socio-demographic factors, the researchers calculated that the odds of individuals with epilepsy committing a violent crime were 1.5 times higher than for general population controls (an adjusted odds ratio [aOR] of 1.5). The strength of this association was reduced when further adjustment was made for substance abuse, and disappeared when individuals with epilepsy were compared with their unaffected siblings (a sibling control study). Similarly, 8.8% of individuals with traumatic brain injury were convicted of a violent crime after their diagnosis compared to only 3% of controls, giving an aOR of 3.3. Again, the strength of this association was reduced when affected individuals were compared to their unaffected siblings (aOR = 2.0) and when adjustment was made for substance abuse (aOR = 2.3).
What Do These Findings Mean?
Although some aspects of this study may have affected the accuracy of its findings, these results nevertheless challenge the idea that there are strong direct links between epilepsy and violent crime. The low absolute rate of violent crime and the lack of any association between epilepsy and violent crime in the sibling control study argue against a strong link, a potentially important finding given the stigmatization of epilepsy. For traumatic brain injury, the reduced association with violent crime in the sibling control study compared with the general population control study suggests that shared familial features may be responsible for some of the association between brain injury and violence. As with epilepsy, this finding should help patient charities who are trying to reduce the stigma associated with traumatic brain injury. Importantly, however, these findings also suggest that some groups of patients with these conditions (for example, patients with head injuries who abuse illegal drugs and alcohol) would benefit from being assessed for their risk of behaving violently and from appropriate management.
Additional Information
Please access these websites via the online version of this summary at
This study is further discussed in a PLoS Medicine Perspective by Jan Volavka
The US National Institute of Neurological Disorders and Stroke provides detailed information about traumatic brain injury and about epilepsy (in English and Spanish)
The UK National Health Service Choices website provides information about severe head injury, including a personal story about a head injury sustained in a motor vehicle accident, and information about epilepsy, including personal stories about living with epilepsy
Healthtalkonline has information on epilepsy, including patient perspectives
MedlinePlus provide links to further resources on traumatic brain injury and on epilepsy (available in English and Spanish)
PMCID: PMC3246446  PMID: 22215988
3.  The effect of traumatic brain injury on the health of homeless people 
We sought to determine the lifetime prevalence of traumatic brain injury and its association with current health conditions in a representative sample of homeless people in Toronto, Ontario.
We surveyed 601 men and 303 women at homeless shelters and meal programs in 2004–2005 (response rate 76%). We defined traumatic brain injury as any self-reported head injury that left the person dazed, confused, disoriented or unconscious. Injuries resulting in unconsciousness lasting 30 minutes or longer were defined as moderate or severe. We assessed mental health, alcohol and drug problems in the past 30 days using the Addiction Severity Index. Physical and mental health status was assessed using the SF-12 health survey. We examined associations between traumatic brain injury and health conditions.
The lifetime prevalence among homeless participants was 53% for any traumatic brain injury and 12% for moderate or severe traumatic brain injury. For 70% of respondents, their first traumatic brain injury occurred before the onset of homelessness. After adjustment for demographic characteristics and lifetime duration of homelessness, a history of moderate or severe traumatic brain injury was associated with significantly increased likelihood of seizures (odds ratio [OR] 3.2, 95% confidence interval [CI] 1.8 to 5.6), mental health problems (OR 2.5, 95% CI 1.5 to 4.1), drug problems (OR 1.6, 95% CI 1.1 to 2.5), poorer physical health status (–8.3 points, 95% CI –11.1 to –5.5) and poorer mental health status (–6.0 points, 95% CI –8.3 to –3.7).
Prior traumatic brain injury is very common among homeless people and is associated with poorer health.
PMCID: PMC2553875  PMID: 18838453
4.  Who gets post-concussion syndrome? An emergency department-based prospective analysis 
The objective of this study was to determine who gets post-concussion syndrome (PCS) after mild traumatic brain injury or head injury.
Patients presented within an hour of mild traumatic brain injury (mTBI). Written informed consent was obtained from all patients, who then provided detailed answers to surveys at the time of injury as well as at 1 week and 1 month follow-up. Statistical analyses were performed using JMP 11.0 for the Macintosh.
The most commonly reported symptoms of PCS at first follow-up were headache (27%), trouble falling asleep (18%), fatigue (17%), difficulty remembering (16%), and dizziness (16%). Furthermore, only 61% of the cohort was driving at 1 week follow-up, compared to 100% prior to the injury.
Linear regression analysis revealed the consumption of alcohol prior to head injury, the mechanism of head injury being a result of motor vehicle collision (MVC) or fall, and the presence of a post-injury headache to be significantly associated with developing PCS at 1 week follow-up, while the occurrence of a seizure post-injury or having an alteration in consciousness post-injury was significantly associated with developing PCS at 1 month follow-up. On multivariate regression analysis, the presence of a headache post-injury was the most robust predictor, retaining statistical significance even after controlling for age, gender, and presence of loss of consciousness (LOC), alteration of consciousness (AOC), post-traumatic amnesia (PTA), seizure, or vomiting.
The results of this prospective study suggest that headache right after the head injury, an alteration of consciousness after the head injury, and alcohol consumption prior to the head injury are significant predictors of developing PCS, which occurs with equal frequency in men and women. Early identification of those who are at risk of developing PCS would diminish the burden of the injury and could potentially reduce the number of missed work and school days.
PMCID: PMC4306054  PMID: 25635191
Post-concussion syndrome; Mild traumatic brain injury; Emergency department
To compare the prevalence of co-morbid depression between patients with chronic primary headache syndromes and chronic post-traumatic headaches.
A prospective cross-sectional analysis of all patients presenting sequentially to a community-based general neurology clinic during a 2-year period for evaluation of chronic headache pain was conducted. Headache diagnosis was determined according to the International Headache Society’s Headache Classification criteria. Depression was determined through a combination of scores on the clinician administered Hamilton Rating Scale for Depression and patients’ self-report. An additional group of patients who suffered traumatic brain injuries (TBI) but did not develop post-traumatic headaches was included for comparison.
A total of 83 patients were included in the study: 45 with chronic primary headaches (24 with chronic migraine headaches, 21 with chronic tension headaches), 24 with chronic post-traumatic headaches, and 14 with TBI but no headaches. Depression occurred less frequently among those with chronic post-traumatic headaches (33.3%) compared to those with chronic migraine (66.7%) and chronic tension (52.4%) headaches (Chi-Square = 7.68; df = 3; p = 0.053), and did not significantly differ from TBI patients without headaches. A multivariate logistic regression model using depression as the outcome variable and including headache diagnosis, gender, ethnicity, and alcohol and illicit substance use was statistically significant (Chi-Square = 27.201; df = 10; p < 0.01) and identified primary headache (migraine and tension) diagnoses (Score = 7.349; df = 1; p = 0.04) and female gender (Score = 15.281; df = 1; p < 0.01) as significant predictor variables. The overall model accurately predicted presence of co-morbid depression in 74.7% of the cases.
Co-morbid depression occurs less frequently among patients with chronic post-traumatic headaches and TBI without headaches than among those with chronic primary headaches.
PMCID: PMC4326262  PMID: 24066406
chronic pain; depression; headache
6.  Are boys and girls that different? An analysis of traumatic brain injury in children 
Emergency Medicine Journal : EMJ  2012;30(8):675-678.
The Phillips Report on traumatic brain injury (TBI) in Ireland found that injury was more frequent in men and that gender differences were present in childhood. This study determined when gender differences emerge and examined the effect of gender on the mechanism of injury, injury type and severity and outcome.
A national prospective, observational study was conducted over a 2-year period. All patients under 17 years of age referred to a neurosurgical service following TBI were included. Data on patient demographics, events surrounding injury, injury type and severity, patient management and outcome were collected from ‘on-call’ logbooks and neurosurgical admissions records.
342 patients were included. Falls were the leading cause of injury for both sexes. Boys’ injuries tended to involve greater energy transfer and involved more risk-prone behaviour resulting in a higher rate of other (non-brain) injury and a higher mortality rate. Intentional injury occurred only in boys. While injury severity was similar for boys and girls, significant gender differences in injury type were present; extradural haematomas were significantly higher in boys (p=0.014) and subdural haematomas were significantly higher in girls (p=0.011). Mortality was 1.8% for girls and 4.3% for boys.
Falls were responsible for most TBI, the home is the most common place of injury and non-operable TBI was common. These findings relate to all children. Significant gender differences exist from infancy. Boys sustained injuries associated with a greater energy transfer, were less likely to use protective devices and more likely to be injured deliberately. This results in a different pattern of injury, higher levels of associated injury and a higher mortality rate.
PMCID: PMC3717585  PMID: 22962053
Trauma; paediatric injury; epidemiology; Trauma, head; accident prevention
7.  Gait and Glasgow Coma Scale scores can predict functional recovery in patients with traumatic brain injury☆ 
Neural Regeneration Research  2012;7(25):1978-1984.
Fifty-one patients with mild (n = 14), moderate (n = 10) and severe traumatic brain injury (n = 27) received early rehabilitation. Level of consciousness was evaluated using the Glasgow Coma Score. Functional level was determined using the Glasgow Outcome Score, whilst mobility was evaluated using the Mobility Scale for Acute Stroke. Activities of daily living were assessed using the Barthel Index. Following Bobath neurodevelopmental therapy, the level of consciousness was significantly improved in patients with moderate and severe traumatic brain injury, but was not greatly influenced in patients with mild traumatic brain injury. Mobility and functional level were significantly improved in patients with mild, moderate and severe traumatic brain injury. Gait recovery was more obvious in patients with mild traumatic brain injury than in patients with moderate and severe traumatic brain injury. Activities of daily living showed an improvement but this was insignificant except for patients with severe traumatic brain injury. Nevertheless, complete recovery was not acquired at discharge. Multiple regression analysis showed that gait and Glasgow Coma Scale scores can be considered predictors of functional outcomes following traumatic brain injury.
PMCID: PMC4298893  PMID: 25624828
brain injury; traumatic brain injury; rehabilitation; early rehabilitation; function; prognosis; Glasgow Coma Scale; Glasgow Outcome Scale; functional level; neural regeneration
8.  Gender Differences in Awareness and Outcomes During Acute Traumatic Brain Injury Recovery 
Journal of Women's Health  2014;23(7):573-580.
Background: Recent literature on traumatic brain injury (TBI), though mixed when reporting outcomes, seems collectively to suggest possible gender advantage for women in postinjury recovery, especially in executive functions. Hormonal neuroprotection, through female reproductive hormones, is often proposed as an underlying factor in these results. We explored potential gender differences in an aspect of executive functions, self-awareness (SA), which is often impaired after TBI, limits patient effort in critical rehabilitation, and increases caregiver burden.
Methods: Within a prospective survey, repeated-measures design, 121 patients with moderate or severe TBI undergoing acute rehabilitation in a Level 1 trauma center, a family member or caregiver informant, and a treating clinician were asked to complete the Patient Competency Rating Scale (PCRS) and the Frontal Systems Behavior Scale (FrSBe) at admission and discharge.
Results: Although overall, women and men with TBI showed generally similar levels of SA, women had significantly better awareness of their injury-related deficits at acute rehabilitation discharge, even when controlling for age, education, and injury severity.
Conclusions: Mixed findings in this study mirror the pattern of results that dominate the published literature on gender and TBI. Gender differences in executive dysfunction may not be as large or robust as some researchers argue. In addition, complex interplays of socialization, gender-role expectations, naturally occurring male and female ability differences, and differences in access to postinjury rehabilitation are understudied potential moderators.
PMCID: PMC4089016  PMID: 24932911
9.  Gender differences in patients with dizziness and unsteadiness regarding self-perceived disability, anxiety, depression, and its associations 
It is known that anxiety and depression influence the level of disability experienced by persons with vertigo, dizziness or unsteadiness. Because higher prevalence rates of disabling dizziness have been found in women and some studies reported a higher level of psychiatric distress in female patients our primary aim was to explore whether women and men with vertigo, dizziness or unsteadiness differ regarding self-perceived disability, anxiety and depression. Secondly we planned to investigate the associations between disabling dizziness and anxiety and depression.
Patients were recruited from a tertiary centre for vertigo and balance disorders. Participants rated their global disability as mild, moderate or severe. They filled out the Dizziness Handicap Inventory and the two subscales of the Hospital Anxiety Depression Scale (HADS). The HADS was analysed 1) by calculating the median values, 2) by estimating the prevalence rates of abnormal anxiety/depression based on recommended cut-off criteria. Mann-Whitney U-tests, Chi-square statistics and odds ratios (OR) were calculated to compare the observations in both genders. Significance values were adjusted with respect to multiple comparisons.
Two-hundred and two patients (124 women) mean age (standard deviation) of 49.7 (13.5) years participated. Both genders did not differ significantly in the mean level of self-perceived disability, anxiety, depression and symptom severity. There was a tendency of a higher prevalence of abnormal anxiety and depression in men (23.7%; 28.9%) compared to women (14.5%; 15.3%). Patients with abnormal depression felt themselves 2.75 (95% CI: 1.31-5.78) times more severely disabled by dizziness and unsteadiness than patients without depression. In men the OR was 8.2 (2.35-28.4). In women chi-square statistic was not significant. The ORs (95% CI) of abnormal anxiety and severe disability were 4.2 (1.9-8.9) in the whole sample, 8.7 (2.5-30.3) in men, and not significant in women.
In men with vertigo, dizziness or unsteadiness emotional distress and its association with self-perceived disability should not be underestimated. Longitudinal surveys with specific pre-defined co-variables of self-perceived disability, anxiety and depression are needed to clarify the influence of gender on disability, anxiety and depression in patients with vertigo, dizziness or unsteadiness.
PMCID: PMC3352112  PMID: 22436559
10.  Predicting Outcome after Traumatic Brain Injury: Development and International Validation of Prognostic Scores Based on Admission Characteristics 
PLoS Medicine  2008;5(8):e165.
Traumatic brain injury (TBI) is a leading cause of death and disability. A reliable prediction of outcome on admission is of great clinical relevance. We aimed to develop prognostic models with readily available traditional and novel predictors.
Methods and Findings
Prospectively collected individual patient data were analyzed from 11 studies. We considered predictors available at admission in logistic regression models to predict mortality and unfavorable outcome according to the Glasgow Outcome Scale at 6 mo after injury. Prognostic models were developed in 8,509 patients with severe or moderate TBI, with cross-validation by omission of each of the 11 studies in turn. External validation was on 6,681 patients from the recent Medical Research Council Corticosteroid Randomisation after Significant Head Injury (MRC CRASH) trial. We found that the strongest predictors of outcome were age, motor score, pupillary reactivity, and CT characteristics, including the presence of traumatic subarachnoid hemorrhage. A prognostic model that combined age, motor score, and pupillary reactivity had an area under the receiver operating characteristic curve (AUC) between 0.66 and 0.84 at cross-validation. This performance could be improved (AUC increased by approximately 0.05) by considering CT characteristics, secondary insults (hypotension and hypoxia), and laboratory parameters (glucose and hemoglobin). External validation confirmed that the discriminative ability of the model was adequate (AUC 0.80). Outcomes were systematically worse than predicted, but less so in 1,588 patients who were from high-income countries in the CRASH trial.
Prognostic models using baseline characteristics provide adequate discrimination between patients with good and poor 6 mo outcomes after TBI, especially if CT and laboratory findings are considered in addition to traditional predictors. The model predictions may support clinical practice and research, including the design and analysis of randomized controlled trials.
Ewout Steyerberg and colleagues describe a prognostic model for the prediction of outcome of traumatic brain injury using data available on admission.
Editors' Summary
Traumatic brain injury (TBI) causes a large amount of morbidity and mortality worldwide. According to the Centers for Disease Control, for example, about 1.4 million Americans will sustain a TBI—a head injury—each year. Of these, 1.1 million will be treated and released from an emergency department, 235,000 will be hospitalized, and 50,000 will die. The burden of disease is much higher in the developing world, where the causes of TBI such as traffic accidents occur at higher rates and treatment may be less available.
Why Was This Study Done?
Given the resources required to treat TBI, a very useful research tool would be the ability to accurately predict on admission to hospital what the outcome of a given injury might be. Currently, scores such as the Glasgow Coma Scale are useful to predict outcome 24 h after the injury but not before.
Prognostic models are useful for several reasons. Clinically, they help doctors and patients make decisions about treatment. They are also useful in research studies that compare outcomes in different groups of patients and when planning randomized controlled trials. The study presented here is one of a number of analyses done by the IMPACT research group over the past several years using a large database that includes data from eight randomized controlled trials and three observational studies conducted between 1984 and 1997. There are other ongoing studies that also seek to develop new prognostic models; one such recent study was published in BMJ by a group involving the lead author of the PLoS Medicine paper described here.
What Did the Researchers Do and Find?
The authors analyzed data that had been collected prospectively on individual patients from the 11 studies included in the database and derived models to predict mortality and unfavorable outcome at 6 mo after injury for the 8,509 patients with severe or moderate TBI. They found that the strongest predictors of outcome were age, motor score, pupillary reactivity, and characteristics on the CT scan, including the presence of traumatic subarachnoid hemorrhage. A core prognostic model could be derived from the combination of age, motor score, and pupillary reactivity. A better score could be obtained by adding CT characteristics, secondary problems (hypotension and hypoxia), and laboratory measurements of glucose and hemoglobin. The scores were then tested to see how well they predicted outcome in a different group of patients—6,681 patients from the recent Medical Research Council Corticosteroid Randomisation after Significant Head Injury (MRC CRASH) trial.
What Do These Findings Mean?
In this paper the authors show that it is possible to produce prognostic models using characteristics collected on admission as part of routine care that can discriminate between patients with good and poor outcomes 6 mo after TBI, especially if the results from CT scans and laboratory findings are added to basic models. This paper has to be considered together with other studies, especially the paper mentioned above, which was recently published in the BMJ (MRC CRASH Trial Collaborators [2008] Predicting outcome after traumatic brain injury: practical prognostic models based on large cohort of international patients. BMJ 336: 425–429.). The BMJ study presented a set of similar, but subtly different models, with specific focus on patients in developing countries; in that case, the patients in the CRASH trial were used to produce the models, and the patients in the IMPACT database were used to verify one variant of the models. Unfortunately this related paper was not disclosed to us during the initial review process; however, during PLoS Medicine's subsequent consideration of this manuscript we learned of it. After discussion with the reviewers, we took the decision that the models described in the PLoS Medicine paper are sufficiently different from those reported in the other paper and as such proceeded with publication of the paper. Ideally, however, these two sets of models would have been reviewed and published side by side, so that readers could easily evaluate the respective merits and value of the two different sets of models in the light of each other. The two sets of models are, however, discussed in a Perspective article also published in PLoS Medicine (see below).
Additional Information.
Please access these Web sites via the online version of this summary at
This paper and the BMJ paper mentioned above are discussed further in a PLoS Medicine Perspective article by Andrews and Young
The TBI Impact site provides a tool to calculate the scores described in this paper
The CRASH trial, which is used to validate the scores mentioned here, has a Web site explaining the trial and its results
The R software, which was used for the prognostic analyses, is freely available
The MedlinePlus encyclopedia has information on head injury
The WHO site on neurotrauma discusses head injury from a global perspective
The CDC's National Center for Injury Prevention and Control gives statistics on head injury in the US and advice on prevention
PMCID: PMC2494563  PMID: 18684008
11.  Sex Differences in Alcohol Misuse and Estimated Blood Alcohol Concentrations Among Emergency Department Patients: Implications for Brief Interventions 
The objective was to assess the relationship between alcohol use and misuse and patient sex among emergency department (ED) patients by comparing self-reported estimates of quantity and frequency of alcohol use; estimated blood alcohol concentrations (eBACs) when typically drinking, and during heavy episodic drinking (binging); and alcohol misuse severity, to understand sex differences in alcohol use and misuse for this population.
The authors surveyed a random sample of non-intoxicated, sub-critically ill or injured, 18 to 64 year-old English- or Spanish-speaking patients on randomly selected dates and times at two EDs during July 2009 and August 2009. Participants self-administered a questionnaire about their self-reported alcohol use during a typical month within the past 12 months, and the Alcohol Use Disorders Identification Test (AUDIT). Using the formulae by Matthews and Miller, sex-specific eBACs were calculated for participants according to their reported weight and the number of reported alcoholic drinks consumed on days when typically drinking, and on days of heavy episodic (binge) drinking (≥ 5 drinks/occasion for men, ≥ 4 drinks for women). Sex-specific alcohol misuse severity levels (low-risk, harmful, hazardous, and dependence) were calculated using AUDIT scores. Wilcoxon rank-sum and Pearson’s chi-square tests were used to compare outcomes by sex. Negative binomial regression was used to assess the relationship between sex and the number of drinks consumed on a typical day, the number of days spent drinking and binging, and estimated AUDIT scores. Logistic regression was used to assess the outcome of the presence of binging according to sex. Multinomial logistic regression was used to compare by sex the percentage of days spent drinking and binging in one month, eBACs when typically drinking and when binging, and AUDIT at-risk drinking levels. Incidence rate ratios (IRRs) and adjusted odds ratios (AORs) with 95% confidence intervals (CIs) were estimated. All models were adjusted for patient demographic characteristics.
Of the 513 participants, 52.1% were women, 55.8% were white non-Hispanic, and their median age was 34 years (IQR 25 to 46 years). Men reported greater mean alcohol consumption than women when typically drinking (4.3 vs. 3.3 drinks per day; p < 0.001), and during heavy episodic drinking (8.6 vs. 5.3/drinks per occasion; p < 0.001). Men spent more days drinking (IRR 1.41, 95% CI = 1.19 to 1.65) and engaging in heavy episodic drinking (IRR 1.68, 95% CI = 1.31 to 2.17) than women. Additionally, men were more likely to engage in heavy episodic drinking (AOR 1.72, 95% CI = 1.16 to 2.56) than women. However, the mean eBACs for men and women were similar when typically drinking (0.05 vs. 0.06; p < 0.13) and during heavy episodic drinking (0.13 vs. 0.12; p < 0.13). Mean AUDIT scores were greater for men than women (7.5 vs. 5.3; p < 0.001), although alcohol misuse severity levels were similar between men and women (24.4% vs. 26.6% for hazardous, 2.8% vs. 2.2% for harmful, and 6.5% vs. 3.4% for dependence; p < 0.38).
Although men drink more than women, women have similar eBACs with comparable levels of alcohol misuse. Women may benefit from recognizing that they are reaching similar levels of intoxication compared to men. Addressing these differences and possible health implications in future ED brief interventions may induce changes in problematic alcohol use among women.
PMCID: PMC3424395  PMID: 22849748
12.  BMI and Risk of Serious Upper Body Injury Following Motor Vehicle Crashes: Concordance of Real-World and Computer-Simulated Observations 
PLoS Medicine  2010;7(3):e1000250.
Shankuan Zhu and colleagues use computer crash simulations, as well as real-world data, to evaluate whether driver obesity is associated with greater risk of body injury in motor vehicle crashes.
Men tend to have more upper body mass and fat than women, a physical characteristic that may predispose them to severe motor vehicle crash (MVC) injuries, particularly in certain body regions. This study examined MVC-related regional body injury and its association with the presence of driver obesity using both real-world data and computer crash simulation.
Methods and Findings
Real-world data were from the 2001 to 2005 National Automotive Sampling System Crashworthiness Data System. A total of 10,941 drivers who were aged 18 years or older involved in frontal collision crashes were eligible for the study. Sex-specific logistic regression models were developed to analyze the associations between MVC injury and the presence of driver obesity. In order to confirm the findings from real-world data, computer models of obese subjects were constructed and crash simulations were performed. According to real-world data, obese men had a substantially higher risk of injury, especially serious injury, to the upper body regions including head, face, thorax, and spine than normal weight men (all p<0.05). A U-shaped relation was found between body mass index (BMI) and serious injury in the abdominal region for both men and women (p<0.05 for both BMI and BMI2). In the high-BMI range, men were more likely to be seriously injured than were women for all body regions except the extremities and abdominal region (all p<0.05 for interaction between BMI and sex). The findings from the computer simulation were generally consistent with the real-world results in the present study.
Obese men endured a much higher risk of injury to upper body regions during MVCs. This higher risk may be attributed to differences in body shape, fat distribution, and center of gravity between obese and normal-weight subjects, and between men and women.
Please see later in the article for the Editors' Summary
Editors' Summary
Worldwide, accidents involving motor vehicles kill 1.2 million people and injure as many as 50 million people every year. Collisions between motor vehicles, between vehicles and stationary objects, or between vehicles and pedestrians are responsible for one in 50 deaths and are the 11th leading cause of death globally. Many factors contribute to the risk of motor traffic accidents and the likelihood of subsequent injury or death. These risk factors include vehicle design, vehicle speeds, road design, driver impairment through, for example, alcohol use, and other driver characteristics such as age. Faced with an ever-increasing death toll on their roads, many countries have introduced lower speed limits, mandatory seat belt use, and greater penalties for drunk driving to reduce the carnage. Road design and traffic management initiatives have also been introduced to try to reduce the incidence of road traffic accidents and cars now include many features that provide protection in crashes for their occupants such as airbags and crumple zones.
Why Was This Study Done?
Although these measures have reduced the number of crashes and casualties, a better understanding of the risk factors associated with motor vehicle crashes is needed to deal with this important public-health problem. Another major public-health problem is obesity—having excess body fat. Obesity increases the risk of heart disease and diabetes but also contributes to the severity of motor vehicle crash injuries. Men with a high body mass index (an individual's weight in kilograms divided by height in meters squared; a BMI of 30 or more indicates obesity) have a higher risk of death after a motor vehicle accident than men with a normal BMI (18.5–24.9). This association between death and obesity is not seen in women, however, possibly because men and women accumulate fat on different parts of their body and the resultant difference in body shape could affect how male and female bodies move during traffic collisions and how much protection existing car safety features afford them. In this study, therefore, the researchers investigated how driver obesity affects the risk of serious injuries in different parts of the body following real and simulated motor vehicle crashes in men and women.
What Did the Researchers Do and Find?
The researchers extracted data about injuries and BMIs for nearly 11,000 adult men and women who were involved in a frontal motor vehicle collision between 2001 and 2005 from the Crashworthiness Data System of the US National Automotive Sampling System. They then used detailed statistical methods to look for associations between specific injuries and driver obesity. The researchers also constructed computer models of obese drivers and subjected these models to simulated crashes. Their analysis of the real-world data showed that obese men had a substantially higher risk of injury to the upper body (the head, face, chest, and spine) than men with a normal weight. Serious injury in the abdominal region was most likely at low and high BMIs for both men and women. Finally, obese men were more likely to be seriously injured than obese women for all body regions except the extremities and the abdominal region. The researchers' computer simulations confirmed many of these real-world findings.
What Do These Findings Mean?
These findings suggest that obese men have a higher risk of injury, particularly to their upper body, from motor vehicle crashes than men with a normal body weight or than obese women. The researchers suggest that this higher risk may be attributed to differences in body shape, fat distribution, and center of gravity between obese and normal weight individuals and between men and women. These findings, although limited by missing data, suggest that motor vehicle safety features should be adjusted to take into account the ongoing obesity epidemic. Currently, two-thirds of people in the US are overweight or obese, yet a crash test dummy with a normal BMI is still used during the design of car cabins. Finally, although more studies are needed to understand the biomechanical responses of the human body during vehicle collisions, the findings in this study could aid the identification of groups of people at particularly high risk of injury or death on the roads who could then be helped to reduce their risk.
Additional Information
Please access these Web sites via the online version of this summary at
Wikipedia has a page on traffic collision (note that Wikipedia is a free online encyclopedia that anyone can edit; available in several languages)
The World Health Organization has information about road traffic injuries as a public-health problem; its World report on road traffic injury prevention is available in several languages
The US Centers for Disease Control and Prevention provides detailed information about overweight and obesity (in several languages)
MedlinePlus provides links to further resources about obesity (in English and Spanish)
The US National Automotive Sampling System Crashworthiness Data System contains detailed data on thousands of US motor vehicle crashes
PMCID: PMC2846859  PMID: 20361024
13.  Gender Differences in Survival among Adult Patients Starting Antiretroviral Therapy in South Africa: A Multicentre Cohort Study 
PLoS Medicine  2012;9(9):e1001304.
Morna Cornell and colleagues investigate differences in mortality for HIV-positive men and women on antiretroviral therapy in South Africa.
Increased mortality among men on antiretroviral therapy (ART) has been documented but remains poorly understood. We examined the magnitude of and risk factors for gender differences in mortality on ART.
Methods and Findings
Analyses included 46,201 ART-naïve adults starting ART between January 2002 and December 2009 in eight ART programmes across South Africa (SA). Patients were followed from initiation of ART to outcome or analysis closure. The primary outcome was mortality; secondary outcomes were loss to follow-up (LTF), virologic suppression, and CD4+ cell count responses. Survival analyses were used to examine the hazard of death on ART by gender. Sensitivity analyses were limited to patients who were virologically suppressed and patients whose CD4+ cell count reached >200 cells/µl. We compared gender differences in mortality among HIV+ patients on ART with mortality in an age-standardised HIV-negative population.
Among 46,201 adults (65% female, median age 35 years), during 77,578 person-years of follow-up, men had lower median CD4+ cell counts than women (85 versus 110 cells/µl, p<0.001), were more likely to be classified WHO stage III/IV (86 versus 77%, p<0.001), and had higher mortality in crude (8.5 versus 5.7 deaths/100 person-years, p<0.001) and adjusted analyses (adjusted hazard ratio [AHR] 1.31, 95% CI 1.22–1.41). After 36 months on ART, men were more likely than women to be truly LTF (AHR 1.20, 95% CI 1.12–1.28) but not to die after LTF (AHR 1.04, 95% CI 0.86–1.25). Findings were consistent across all eight programmes. Virologic suppression was similar by gender; women had slightly better immunologic responses than men. Notably, the observed gender differences in mortality on ART were smaller than gender differences in age-standardised death rates in the HIV-negative South African population. Over time, non-HIV mortality appeared to account for an increasing proportion of observed mortality. The analysis was limited by missing data on baseline HIV disease characteristics, and we did not observe directly mortality in HIV-negative populations where the participating cohorts were located.
HIV-infected men have higher mortality on ART than women in South African programmes, but these differences are only partly explained by more advanced HIV disease at the time of ART initiation, differential LTF and subsequent mortality, and differences in responses to treatment. The observed differences in mortality on ART may be best explained by background differences in mortality between men and women in the South African population unrelated to the HIV/AIDS epidemic.
Please see later in the article for the Editors' Summary.
Editors' Summary
About 34 million people (most living in low- and middle-income countries) are currently infected with HIV, the virus that causes AIDS. HIV destroys CD4 lymphocytes and other immune system cells, leaving infected individuals susceptible to other infections. Early in the AIDS epidemic, most HIV-infected people died within 10 years of becoming infected. Then, in 1996, antiretroviral therapy (ART)—cocktails of drugs that keep HIV in check—became available. For people living in affluent countries, HIV/AIDS became a chronic condition. However, ART was expensive and, for people living in poorer countries, HIV/AIDS remained a fatal illness. In 2003, this situation was declared a global emergency, and governments and international agencies began to implement plans to increase ART coverage in resource-limited countries. Since then, ART programs in these countries have grown rapidly. In South Africa, for example, about 52% of the 3.14 million adults in need of ART were receiving an ART regimen recommended by the World Health Organization by the end of 2010.
Why Was This Study Done?
The outcomes of ART programs in resource-limited countries need to be evaluated thoroughly so that these programs can be optimized. One area of concern to ART providers is that of gender differences in survival among patients receiving treatment. In sub-Saharan Africa, for example, men are more likely to die than women while receiving ART. This gender difference in mortality may arise because men initiating ART in many African ART programs have more advanced HIV disease than women (early ART initiation is associated with better outcomes than late initiation) or because men are more likely to be lost to follow-up than women (failure to continue treatment is associated with death). Other possible explanations for gender differentials in mortality on ART include gender differences in immunologic and virologic responses to treatment (increased numbers of immune system cells and reduced amounts of virus in the blood, respectively). In this multicenter cohort study, the researchers examine the size of, and risk factors for, gender differences in mortality on ART in South Africa by examining data collected from adults starting ART at International Epidemiologic Databases to Evaluate AIDS South Africa (IeDEA-SA) collaboration sites.
What Did the Researchers Do and Find?
The researchers analyzed data collected from 46,201 ART-naïve adults who started ART between 2002 and 2009 in eight IeDEA-SA ART programs. At ART initiation, men had a lower CD4 count on average and were more likely to have advanced HIV disease than women. During the study, after allowing for factors likely to affect mortality such as HIV disease stage at initiation, men on ART had a 31% higher risk of dying than women. Men were more likely to be lost to follow-up than women, but men and women who were lost to follow-up were equally likely to die. Women had a slightly better immunological response to ART than men but virologic suppression was similar in both genders. Importantly, in analyses of mortality limited to individuals who were virologically suppressed at 12 months and to patients who had a good immunological response to ART, men still had a higher risk of death than women. However, the gender differences in mortality on ART were smaller than the gender differences in age-standardized mortality in the HIV-negative South African population.
What Do These Findings Mean?
These analyses show that among South African patients initiating ART between 2002 and 2009, men were more likely to die than women but that this gender difference in mortality on ART cannot be completely explained by gender differences in baseline characteristics, loss to follow-up, or virologic and/or immunologic responses. Instead, the observed gender differences in mortality can best be explained by background gender differences in mortality in the whole South African population. Because substantial amounts of data were missing in this study (for example, HIV disease stage was not available for all the patients), these findings need to be interpreted cautiously. Moreover, similar studies need to be done in other settings to investigate whether they are generalizable to the South African national ART program and to other countries. If confirmed, however, these findings suggest that the root causes of gender differences in mortality on ART may be unrelated to HIV/AIDS or to the characteristics of ART programs.
Additional Information
Please access these Web sites via the online version of this summary at
Information is available from the US National Institute of Allergy and Infectious Diseases on HIV infection and AIDS
Information on the treatment of HIV/AIDS in South Africa is available from the Southern African HIV Clinicians Society
NAM/aidsmap provides basic information about HIV/AIDS and summaries of recent research findings on HIV care and treatment
Information is available from Avert, an international AIDS charity on many aspects of HIV/AIDS, including information on HIV/AIDS treatment and care, and on HIV/AIDS in South Africa (in English and Spanish)
WHO provides information about universal access to AIDS treatment (in several languages); its 2010 ART guidelines can be downloaded
Information about the IeDEA-SA collaboration is available
The Treatment Action Campaign provides information on antiretroviral therapy and South African HIV statistics
Patient stories about living with HIV/AIDS are available through Avert; the nonprofit website Healthtalkonline also provides personal stories about living with HIV, including stories about taking anti-HIV drugs and the challenges of anti-HIV drugs
PMCID: PMC3433409  PMID: 22973181
14.  Traumatic brain injury among men in an urban homeless shelter: observational study of rates and mechanisms of injury 
CMAJ Open  2014;2(2):E69-E76.
Little empiric research has investigated the interrelationship between homelessness and traumatic brain injury. The objectives of this study were to determine the rate, mechanisms and associated outcomes of traumatic brain injury among men in an urban homeless shelter.
We recruited participants from an urban men’s shelter in Toronto, Ontario. Researchers administered the Brain Injury Screening Questionnaire, a semistructured interview screening tool for brain injury. Demographic information and detailed histories of brain injuries were obtained. Participants with positive and negative screening results were compared, and the rates and mechanisms of injury were analyzed by age group.
A total of 111 men (mean age 54.2 ± standard deviation 11.5 yr; range 27–81 yr) participated. Nearly half (50 [45%]) of the respondents had a positive screening result for traumatic brain injury. Of these, 73% (35/48) reported experiencing their first injury before adulthood (< 18 yr), and 87% (40/46) reported a first injury before the onset of homelessness. Among those with a positive screening result, 33 (66%) reported sustaining at least one traumatic brain injury by assault, 22 (44%) by sports or another recreational activity, 21 (42%) by motor vehicle collision and 21 (42%) by a fall. A positive screening result was significantly associated with a lifetime history of arrest or mental illness and a parental history of substance abuse.
Multiple mechanisms contributed to high rates of traumatic brain injury within a sample of homeless men. Assault was the most common mechanism, with sports and recreation, motor vehicle collisions and falls also being reported frequently by the participants. Injury commonly predated the onset of homelessness, with most participants experiencing their first injury in childhood. Additional research is needed to understand the complex interactions among homelessness, traumatic brain injury, mental illness and substance use.
PMCID: PMC4084748  PMID: 25077132
15.  Psychosocial interventions for the prevention of disability following traumatic physical injury 
Traumatic physical injury can result in many disabling sequelae including physical and mental health problems and impaired social functioning.
To assess the effectiveness of psychosocial interventions in the prevention of physical, mental and social disability following traumatic physical injury.
Search methods
The search was not restricted by date, language or publication status. We searched the following electronic databases; Cochrane Injuries Group Specialised Register, CENTRAL (The Cochrane Library 2009, Issue 1), MEDLINE (Ovid SP), EMBASE (Ovid SP), PsycINFO (Ovid SP), Controlled Trials metaRegister (, AMED (Allied & Complementary Medicine), ISI Web of Science: Social Sciences Citation Index (SSCI), PubMed. We also screened the reference lists of all selected papers and contacted authors of relevant studies. The latest search for trials was in February 2008.
Selection criteria
Randomised controlled trials that consider one or more defined psychosocial interventions for the prevention of physical disability, mental health problems or reduced social functioning as a result of traumatic physical injury. We excluded studies that included patients with traumatic brain injury (TBI).
Data collection and analysis
Two authors independently screened the titles and abstracts of search results, reviewed the full text of potentially relevant studies, independently assessed the risk of bias and extracted data.
Main results
We included five studies, involving 756 participants. Three studies assessed the effect of brief psychological therapies, one assessed the impact of a self-help booklet, and one the effect of collaborative care. The disparate nature of the trials covering different patient populations, interventions and outcomes meant that it was not possible to pool data meaningfully across studies. There was no evidence of a protective effect of brief psychological therapy or educational booklets on preventing disability. There was evidence from one trial of a reduction in both post-traumatic stress disorder (PTSD) and depressive symptoms one month after injury in those who received a collaborative care intervention combined with a brief psycho-educational intervention, however this was not retained at follow up. Overall mental health status was the only disability outcome affected by any intervention. In three trials the psychosocial intervention had a detrimental effect on the mental health status of patients.
Authors’ conclusions
This review provides no convincing evidence of the effectiveness of psychosocial interventions for the prevention of disability following traumatic physical injury. Taken together, our findings cannot be considered as supporting the provision of psychosocial interventions to prevent aspects of disability arising from physical injury. However, these conclusions are based on a small number of disparate trials with small to moderate sample sizes and are therefore necessarily cautious. More research, using larger sample sizes, and similar interventions and patient populations to enable pooling of results, is needed before these findings can be confirmed.
PMCID: PMC3428876  PMID: 19821365
Depression [prevention & control]; Disabled Persons [psychology]; Interpersonal Relations; Mental Disorders [prevention & control]; Pamphlets; Psychotherapy [methods]; Randomized Controlled Trials as Topic; Self Care [methods]; Social Support; Stress Disorders, Post-Traumatic [prevention & control]; Wounds and Injuries [psychology]; Humans
16.  Gender equality in couples and self-rated health - A survey study evaluating measurements of gender equality and its impact on health 
Men and women have different patterns of health. These differences between the sexes present a challenge to the field of public health. The question why women experience more health problems than men despite their longevity has been discussed extensively, with both social and biological theories being offered as plausible explanations. In this article, we focus on how gender equality in a partnership might be associated with the respondents' perceptions of health.
This study was a cross-sectional survey with 1400 respondents. We measured gender equality using two different measures: 1) a self-reported gender equality index, and 2) a self-perceived gender equality question. The aim of comparison of the self-reported gender equality index with the self-perceived gender equality question was to reveal possible disagreements between the normative discourse on gender equality and daily practice in couple relationships. We then evaluated the association with health, measured as self-rated health (SRH). With SRH dichotomized into 'good' and 'poor', logistic regression was used to assess factors associated with the outcome. For the comparison between the self-reported gender equality index and self-perceived gender equality, kappa statistics were used.
Associations between gender equality and health found in this study vary with the type of gender equality measurement. Overall, we found little agreement between the self-reported gender equality index and self-perceived gender equality. Further, the patterns of agreement between self-perceived and self-reported gender equality were quite different for men and women: men perceived greater gender equality than they reported in the index, while women perceived less gender equality than they reported. The associations to health were depending on gender equality measurement used.
Men and women perceive and report gender equality differently. This means that it is necessary not only to be conscious of the methods and measurements used to quantify men's and women's opinions of gender equality, but also to be aware of the implications for health outcomes.
PMCID: PMC3167759  PMID: 21871087
gender equality; health; index; gender differences
17.  Incidence of self-reported brain injury and the relationship with substance abuse: findings from a longitudinal community survey 
BMC Public Health  2010;10:171.
Traumatic or serious brain injury (BI) has persistent and well documented adverse outcomes, yet 'mild' or 'moderate' BI, which often does not result in hospital treatment, accounts for half the total days of disability attributed to BI. There are currently few data available from community samples on the incidence and correlates of these injuries. Therefore, the study aimed to assess the 1) incidence of self-reported mild (not requiring hospital admission) and moderate (admitted to hospital)) brain injury (BI), 2) causes of injury 3) physical health scores and 4) relationship between BI and problematic alcohol or marijuana use.
An Australian community sequential-cohort study (cohorts aged 20-24, 40-44 and 60-64 years at wave one) used a survey methodology to assess BI and substance use at baseline and four years later.
Of the 7485 wave one participants, 89.7% were re-interviewed at wave two. There were 56 mild (230.8/100000 person-years) and 44 moderate BI (180.5/100000 person-years) reported between waves one and two. Males and those in the 20-24 year cohort had increased risk of BI. Sports injury was the most frequent cause of BI (40/100) with traffic accidents being a greater proportion of moderate (27%) than mild (7%) BI. Neither alcohol nor marijuana problems at wave one were predictors of BI. BI was not a predictor of developing substance use problems by wave two.
BI were prevalent in this community sample, though the incidence declined with age. Factors associated with BI in community samples differ from those reported in clinical samples (e.g. typically traumatic brain injury with traffic accidents the predominate cause). Further, detailed evaluation of the health consequences of these injuries is warranted.
PMCID: PMC2860359  PMID: 20350327
18.  Patterns of Gender Equality at Workplaces and Psychological Distress 
PLoS ONE  2013;8(1):e53246.
Research in the field of occupational health often uses a risk factor approach which has been criticized by feminist researchers for not considering the combination of many different variables that are at play simultaneously. To overcome this shortcoming this study aims to identify patterns of gender equality at workplaces and to investigate how these patterns are associated with psychological distress. Questionnaire data from the Northern Swedish Cohort (n = 715) have been analysed and supplemented with register data about the participants' workplaces. The register data were used to create gender equality indicators of women/men ratios of number of employees, educational level, salary and parental leave. Cluster analysis was used to identify patterns of gender equality at the workplaces. Differences in psychological distress between the clusters were analysed by chi-square test and logistic regression analyses, adjusting for individual socio-demographics and previous psychological distress. The cluster analysis resulted in six distinctive clusters with different patterns of gender equality at the workplaces that were associated to psychological distress for women but not for men. For women the highest odds of psychological distress was found on traditionally gender unequal workplaces. The lowest overall occurrence of psychological distress as well as same occurrence for women and men was found on the most gender equal workplaces. The results from this study support the convergence hypothesis as gender equality at the workplace does not only relate to better mental health for women, but also more similar occurrence of mental ill-health between women and men. This study highlights the importance of utilizing a multidimensional view of gender equality to understand its association to health outcomes. Health policies need to consider gender equality at the workplace level as a social determinant of health that is of importance for reducing differences in health outcomes for women and men.
PMCID: PMC3541387  PMID: 23326404
19.  Resilience after Hurricane Katrina among pregnant and postpartum women 
Although disaster causes distress, many disaster victims do not develop long-term psychopathology. Others report benefits after traumatic experiences (post-traumatic growth). The objective of this study was to examine demographic and hurricane-related predictors of resilience and post-traumatic growth.
222 pregnant southern Louisiana women were interviewed, and 292 postpartum women completed interviews at delivery and eight weeks later. Resilience was measured by scores lower than a non-affected population, using the Edinburgh Depression Scale and the Post-Traumatic Stress Checklist (PCL). Post-traumatic growth was measured by questions about perceived benefits of the storm. Women were asked about their experience of the hurricane, addressing danger, illness/injury, and damage. Chi-square tests and log-Poisson models were used to calculate associations and relative risks (RR) for demographics, hurricane experience, and mental health resilience and perceived benefit.
35% of pregnant and 34% of the postpartum women were resilient from depression, while 56% and 49% were resilient from post-traumatic stress disorder. Resilience was most likely among white women, older women, and women who had a partner. A greater experience of the storm, particularly injury/illness or danger, was associated with lower resilience. Experiencing damage due to the storm was associated with increased report of some perceived benefits.
Many pregnant and postpartum women are resilient from the mental health consequences of disaster, and perceive benefits after a traumatic experience. Certain aspects of experiencing disaster reduce resilience, but may increase perceived benefit.
PMCID: PMC2822707  PMID: 20123173
resilience; depression; postpartum; pregnancy; disaster; post-traumatic stress disorder
20.  Do Men and Women Report Their Sexual Partnerships Differently? Evidence from Kisumu, Kenya 
It is generally believed that men and women misreport their sexual behaviors, which undermines the ability of researchers, program designers and health care providers to assess whether these behaviors compromise individuals’ sexual and reproductive health.
Data on 1,299 recent sexual partnerships were collected in a 2007 survey of 1,275 men and women aged 18–24 and living in Kisumu, Kenya. Chi-square and t tests were used to examine how sample selection bias and selective partnership reporting may result in gender differences in reported sexual behaviors. Correlation coefficients and kappa statistics were calculated in further analysis of a sample of 280 matched marital and nonmarital couples to assess agreement on reported behaviors.
Even after adjustment for sample selection bias, men reported twice as many partnerships as women (0.5 vs. 0.2), as well as more casual partnerships. However, when selective reporting was controlled for, aggregate gender differences in sexual behaviors almost entirely disappeared. In the matched-couples sample, men and women exhibited moderate to substantial levels of agreement for most relationship characteristics and behaviors, including type of relationship, frequency of sex and condom use. Finally, men and women tended to agree about whether men had other nonmarital partners, but disagreed about women’s nonmarital partners.
Both sample selection bias and selective partnership reporting can influence the level of agreement between men’s and women’s reports of sexual behaviors. Although men report more casual partners than do women, accounts of sexual behavior within reported relationships are generally reliable.
PMCID: PMC3383815  PMID: 22227625
21.  Psychiatric Diagnoses and Neurobehavioral Symptom Severity Among OEF/OIF VA Patients with Deployment-Related Traumatic Brain Injury: A Gender Comparison 
Traumatic brain injury (TBI) has substantial negative implications for the post-deployment adjustment of Veterans who served in Operation Enduring Freedom (OEF) and Operation Iraqi Freedom (OIF); however, most research on Veterans has focused on males. This study investigated gender differences in psychiatric diagnoses and neurobehavioral symptom severity among OEF/OIF Veterans with deployment-related TBI.
This population-based study examined psychiatric diagnoses and self-reported neurobehavioral symptom severity from administrative records for 12,605 United States OEF/OIF Veterans evaluated as having deployment-related TBI. Men (n = 11,951) and women (n = 654) who were evaluated to have deployment-related TBI during a standardized comprehensive TBI evaluation in Department of Veterans Affairs (VA) facilities were compared on the presence of psychiatric diagnoses and severity of neurobehavioral symptoms.
Posttraumatic stress disorder (PTSD) was the most common psychiatric condition for both genders, although women were less likely than men to have a PTSD diagnosis. In contrast, relative to men, women were 2 times more likely to have a depression diagnosis, 1.3 times more likely to have a non-PTSD anxiety disorder, and 1.5 times more likely to have PTSD with comorbid depression. Multivariate analyses indicated that blast exposure during deployment may account for some of these differences. Additionally, women reported significantly more severe symptoms across a range of neurobehavioral domains.
Although PTSD was the most common condition for both men and women, it is also critical for providers to identify and treat other conditions, especially depression and neurobehavioral symptoms, among women Veterans with deployment-related TBI.
PMCID: PMC3132395  PMID: 21724143
traumatic brain injury; Veterans; women; gender; psychiatric conditions; neurobehavioral symptoms; post-deployment adjustment
22.  Cognitive Improvement after Mild Traumatic Brain Injury Measured with Functional Neuroimaging during the Acute Period 
PLoS ONE  2015;10(5):e0126110.
Functional neuroimaging studies in mild traumatic brain injury (mTBI) have been largely limited to patients with persistent post-concussive symptoms, utilizing images obtained months to years after the actual head trauma. We sought to distinguish acute and delayed effects of mild traumatic brain injury on working memory functional brain activation patterns < 72 hours after mild traumatic brain injury (mTBI) and again one-week later. We hypothesized that clinical and fMRI measures of working memory would be abnormal in symptomatic mTBI patients assessed < 72 hours after injury, with most patients showing clinical recovery (i.e., improvement in these measures) within 1 week after the initial assessment. We also hypothesized that increased memory workload at 1 week following injury would expose different cortical activation patterns in mTBI patients with persistent post-concussive symptoms, compared to those with full clinical recovery. We performed a prospective, cohort study of working memory in emergency department patients with isolated head injury and clinical diagnosis of concussion, compared to control subjects (both uninjured volunteers and emergency department patients with extremity injuries and no head trauma). The primary outcome of cognitive recovery was defined as resolution of reported cognitive impairment and quantified by scoring the subject’s reported cognitive post-concussive symptoms at 1 week. Secondary outcomes included additional post-concussive symptoms and neurocognitive testing results. We enrolled 46 subjects: 27 with mild TBI and 19 controls. The time of initial neuroimaging was 48 (+22 S.D.) hours after injury (time 1). At follow up (8.7, + 1.2 S.D., days after injury, time 2), 18 of mTBI subjects (64%) reported moderate to complete cognitive recovery, 8 of whom fully recovered between initial and follow-up imaging. fMRI changes from time 1 to time 2 showed an increase in posterior cingulate activation in the mTBI subjects compared to controls. Increases in activation were greater in those mTBI subjects without cognitive recovery. As workload increased in mTBI subjects, activation increased in cortical regions in the right hemisphere. In summary, we found neuroimaging evidence for working memory deficits during the first week following mild traumatic brain injury. Subjects with persistent cognitive symptoms after mTBI had increased requirement for posterior cingulate activation to complete memory tasks at 1 week following a brain injury. These results provide insight into functional activation patterns during initial recovery from mTBI and expose the regional activation networks that may be involved in working memory deficits.
PMCID: PMC4427352  PMID: 25962067
23.  Gender Differences in Alcohol Treatment: An Analysis of Outcome from the COMBINE Study 
Relatively few studies have examined gender differences in the effectiveness of specific behavioral or pharmacologic treatment of alcohol dependence. The aim of this study is to assess whether there were gender differences in treatment outcomes for specific behavioral and medication treatments singly or in combination by conducting a secondary analysis of public access data from the national, multi-site NIAAA-sponsored COMBINE study.
The COMBINE study investigated alcohol treatment among eight groups of patients (378 women, 848 men) who received Medical Management with 16 weeks of placebo, naltrexone (100mg/day), acamprosate (3 grams/day), or their combination with or without a specialist-delivered Combined Behavioral Intervention. We examined efficacy measures separately for men and women, followed by an overall analysis that included gender and its interaction with treatment condition in the analyses. These analyses were done to confirm whether the findings reported in the parent trial were also relevant to women, and to more closely examine secondary outcome variables that were not analyzed previously for gender effects.
Compared to men, women reported a later age of onset of alcohol dependence by approximately 3 years, were significantly less likely to have had previous alcohol treatment; and drank fewer drinks per drinking day. Otherwise, there were no baseline gender differences in drinking measures. Outcome analyses of two primary (percent days abstinent and time to first heavy drinking day) and two secondary (good clinical response and percent heavy drinking days) drinking measures yielded the same overall pattern in each gender as that observed in the parent COMBINE study report. That is, only the naltrexone by behavioral intervention interaction reached or approached significance in women as well as in men. There was a naltrexone main effect that was significant in both men and women in reduction in alcohol craving scores with naltrexone-treated subjects reporting lower craving than placebo- treated subjects,
This gender-focused analysis found that alcohol-dependent women responded to naltrexone with COMBINE’s Medical Management, similar to the alcohol-dependent men, on a wide range of outcome measures. These results suggest that clinicians should feel comfortable prescribing naltrexone for alcohol dependence in both men and women. In this study, it is also notable that fewer women than men reported receiving any alcohol treatment prior to entry into the COMBINE study. Of note, women tend to go to primary health care more frequently than to specialty substance abuse programs for treatment, and so the benefit we confirm for women of the naltrexone and medical management combination has practical implications for treating alcohol-dependent women.
PMCID: PMC3048309  PMID: 20645934
24.  Managed Care and Gender Disparities in Problematic Health Care Experiences 
Health Services Research  2005;40(5 Pt 1):1489-1513.
To determine whether gender differences in reports of problematic health care experiences are associated with characteristics of managed care.
Data Sources
The 2002 Yale Consumer Experiences Survey (N=5,000), a nationally representative sample of persons over 18 years of age with private health insurance, Interstudy Competitive Edge HMO Industry Report 2001, Area Resource File 2002, and the American Hospital Association Annual Survey of Hospitals 2002.
Study Design
Independent and interactive effects of gender and managed care on reports of problematic health care experiences were modeled using weighted multivariate logistic regression.
Principal Findings
Women were significantly more likely to report problems with their health care compared with men, even after controlling for gendered differences in expectations about medical care. Gender disparities in problem reporting were larger in plans that used certain managed care techniques, but smaller in plans using other methods. Some health plan managed care practices, including closed networks of providers and gatekeepers to specialty care, were associated with greater problem reporting among women, while others, such as requirements for primary care providers, were associated with greater problem reporting among men. Markets with higher HMO competition and penetration were associated with greater problem reporting among women, but reduced problem reporting among men. Women reported more problems in states that had enacted regulations governing access to OB/GYNs, while men reported more problems in states with regulations allowing specialists to act as primary care providers in health plans.
There are nontrivial gender disparities in reports of problematic health care experiences. The differential consequences of managed care at both the plan and market levels explain a portion of these gender disparities in problem reporting.
PMCID: PMC1361205  PMID: 16174144
Managed care; women; gender disparities; state regulation; competition
25.  Associations between Intimate Partner Violence and Termination of Pregnancy: A Systematic Review and Meta-Analysis 
PLoS Medicine  2014;11(1):e1001581.
Lucy Chappell and colleagues conduct a systematic review and meta analysis to investigate a possible association between intimate partner violence and termination of pregnancy.
Please see later in the article for the Editors' Summary
Intimate partner violence (IPV) and termination of pregnancy (TOP) are global health concerns, but their interaction is undetermined. The aim of this study was to determine whether there is an association between IPV and TOP.
Methods and Findings
A systematic review based on a search of Medline, Embase, PsycINFO, and Ovid Maternity and Infant Care from each database's inception to 21 September 2013 for peer-reviewed articles of any design and language found 74 studies regarding women who had undergone TOP and had experienced at least one domain (physical, sexual, or emotional) of IPV. Prevalence of IPV and association between IPV and TOP were meta-analysed. Sample sizes ranged from eight to 33,385 participants. Worldwide, rates of IPV in the preceding year in women undergoing TOP ranged from 2.5% to 30%. Lifetime prevalence by meta-analysis was shown to be 24.9% (95% CI 19.9% to 30.6%); heterogeneity was high (I2>90%), and variation was not explained by study design, quality, or size, or country gross national income per capita. IPV, including history of rape, sexual assault, contraceptive sabotage, and coerced decision-making, was associated with TOP, and with repeat TOPs. By meta-analysis, partner not knowing about the TOP was shown to be significantly associated with IPV (pooled odds ratio 2.97, 95% CI 2.39 to 3.69). Women in violent relationships were more likely to have concealed the TOP from their partner than those who were not. Demographic factors including age, ethnicity, education, marital status, income, employment, and drug and alcohol use showed no strong or consistent mediating effect. Few long-term outcomes were studied. Women welcomed the opportunity to disclose IPV and be offered help. Limitations include study heterogeneity, potential underreporting of both IPV and TOP in primary data sources, and inherent difficulties in validation.
IPV is associated with TOP. Novel public health approaches are required to prevent IPV. TOP services provide an opportune health-based setting to design and test interventions.
Please see later in the article for the Editors' Summary
Editors' Summary
Intimate partner violence (sometimes referred to as domestic violence) is one of the commonest forms of violence against women and is a global health problem. The World Health Organization defines intimate partner violence as any act of physical, psychological, or sexual aggression or any controlling behavior (for example, restriction of access to assistance) perpetrated by the woman's current or past intimate partner. Although men also experience it, intimate partner violence is overwhelmingly experienced by women, particularly when repeated or severe. Studies indicate that the prevalence (the percentage of a population affected by a condition) of intimate partner violence varies widely within and between countries: the prevalence of intimate partner violence among women ranges from 15% in Japan to 71% in Ethiopia, and the lifetime prevalence of rape (forced sex) within intimate relationships ranges from 5.9% to 42% across the world, for example. Overall, a third of women experience intimate partner violence at some time during their lifetimes. The health consequences of such violence include physical injury, depression, suicidal behavior, and gastrointestinal disorders.
Why Was This Study Done?
Intimate partner violence can also lead to gynecological disorders (conditions affecting the female reproductive organs), unwanted pregnancy, premature labour and birth, and sexually transmitted infections. Because violence may begin or intensify during pregnancy, some countries recommend routine questioning about intimate partner violence during antenatal care. However, women seeking termination of pregnancy (induced abortion) are not routinely asked about intimate partner violence. Every year, many women worldwide terminate a pregnancy. Nearly half of these terminations are unsafe, and complications arising from unsafe abortions are responsible for more than 10% of maternal deaths (deaths from pregnancy or childbirth-related complications). It is important to know whether intimate partner violence and termination of pregnancy are associated in order to develop effective strategies to deal with both these global health concerns. Here, the researchers conducted a systematic review and meta-analysis to investigate the associations between intimate partner violence and termination or pregnancy. A systematic review identifies all the research on a given topic using predefined criteria; meta-analysis combines the results of several studies.
What Did the Researchers Do and Find?
The researchers identified 74 studies that provided information about experiences of intimate partner violence among women who had had a termination of pregnancy. Data in these studies indicated that, worldwide, intimate partner violence rates among women undergoing termination ranged from 2.5% to 30% in the preceding year and from 14% to 40% over their lifetime. In the meta-analysis, the lifetime prevalence of intimate partner violence was 24.9% among termination-seeking populations. The identified studies provided evidence that intimate partner violence was associated with termination and with repeat termination. In one study, for example, women presenting for a third termination were more than two and a half times more likely to have a history of physical or sexual violence than women presenting for their first termination. Moreover, according to the meta-analysis, women in violent relationships were three times as likely to conceal a termination from their partner as women in non-violent relationships. Finally, the studies indicated that women undergoing terminations of pregnancy welcomed the opportunity to disclose their experiences of intimate partner violence and to be offered help.
What Do These Findings Mean?
These findings indicate that intimate partner violence is associated with termination of pregnancy and that a woman's partner not knowing about the termination is a risk factor for intimate partner violence among women seeking termination. Overall, the researchers' findings support the concept that violence can lead to pregnancy and to subsequent termination of pregnancy, and that there may be a repetitive cycle of abuse and pregnancy. The accuracy of these findings is limited by heterogeneity (variability) among the included studies, by the likelihood of underreporting of both intimate partner violence and termination in the included studies, and by lack of validation of reports of violence through, for example, police reports. Nevertheless, health-care professionals should consider the possibility that women seeking termination of pregnancy may be experiencing intimate partner violence. In trying to prevent repeat terminations, health-care professionals should be aware that while focusing on preventing conception may reduce the chances of a woman becoming pregnant, she may still be vulnerable to abuse. Finally, given the clear associations between intimate partner violence and termination of pregnancy, the researchers suggest that termination services represent an appropriate setting in which to test interventions designed to reduce intimate partner violence.
Additional Information
Please access these websites via the online version of this summary at
The World Health organization provides detailed information about intimate partner violence and about termination of pregnancy (some information available in several languages)
MedlinePlus provides links to other resources about intimate partner violence and about termination of pregnancy (in English and Spanish)
The World Bank has a webpage that discusses the role of the health sector in preventing gender-based violence and a webpage with links to other resources about gender-based violence
The Gender and Health Research Unit of the South African Medical Research Council provides links to further resources about intimate partner violence (research briefs/policy briefs/fact sheets/research reports)
DIVERHSE (Domestic & Interpersonal Violence: Effecting Responses in the Health Sector in Europe) is a European forum for health professionals, nongovernmental organizations, policy-makers, and academics to share their expertise and good practice in developing and evaluating interventions to address violence against women and children in a variety of health-care settings
London School of Hygiene & Tropical Medicine's Gender Violence and Health Centre also has a number of research resources
The UK National Health Service Choices website provides personal stories of intimate partner violence during pregnancy
The March of Dimes provides information on identifying intimate partner violence during pregnancy and making a safety plan
PMCID: PMC3883805  PMID: 24409101

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