Related Articles

Objective

To estimate the prevalence of medical debt among traumatic brain injury (TBI) and spinal cord injury (SCI) patients who discharged their debts through bankruptcy.

Design

A cross-sectional comparison of bankruptcy filings of injured versus randomly selected bankruptcy petitioners.

Setting

Patients hospitalized with SCI or TBI (1996–2002) and personal bankruptcy petitioners (2001–2004) in western Washington State.

Participants

Subjects (N=186) who filed for bankruptcy, comprised of 93 patients with previous SCI or TBI and 93 randomly selected bankruptcy petitioners.

Interventions

Not applicable.

Main Outcome Measures

Medical and nonmedical debt, assets, income, expenses, and employment recorded in the bankruptcy petition.

Results

Five percent of randomly selected petitioners and 26% of petitioners with TBI or SCI had substantial medical debt (debt that accounted for more than 20% of all unsecured debts). SCI and TBI petitioners had fewer assets and were more likely to be receiving government income assistance at the time of bankruptcy than controls. SCI and TBI patients with a higher blood alcohol content at injury were more likely to have substantial medical debts (odds ratio=2.70; 95% confidence interval, 1.04–7.00).

Conclusions

Medical debt plays an important role in some bankruptcies after TBI or SCI. We discuss policy options for reducing financial distress after serious injury.

Background

The preoperative Heterotopic Ossification (HO) extent is usually one of the main used criteria to predict the recurrence before excision. Brooker et al built a radiologic scale to assess this pre operative extent around the hip. The aim of this study is to investigate the relationship between the recurrence risk after hip HO excision in Traumatic Brain Injury (TBI) and Spinal Cord Injury (SCI) patients and the preoperative extent of HO.

Methodology/Principal Findings

A case control study including TBI or SCI patients following surgery for troublesome hip HO with (case, n = 19) or without (control, n = 76) recurrence. Matching criteria were: sex, pathology (SCI or TBI) and age at the time of surgery (+/−4.5 years). For each etiology (TBI and SCI), the residual cognitive and functional status (Garland classification), the preoperative extent (Brooker status), the modified radiological and functional status (GCG-BD classification), HO localization, side, mean age at the CNS damage, mean delay for the first HO surgery, and for the case series, the mean operative delay for recurrence after the first surgical intervention were noted.

Conclusions/Significance

The median delay for first HO surgery was 38.6 months (range 4.5 to 414.5;) for the case subgroup and 17.6 months (range 5.7 to 339.6) for the control group. No significant link was found between recurrence and operative delay (p = 0.51); the location around the joint (0.07); the Brooker (p = 0.52) or GCG-BD status (p = 0.79). Including all the matching factors, no significant relationship was found between the recurrence HO risk and the preoperative extent of troublesome hip HO using Brooker status (OR = 1.56(95% CI: 0.47–5.19)) or GCG-BD status (OR class 3 versus 2 = 0.67(95% CI: 0.11–4.24) and OR class 4 versus 2 = 0.79(95%CI: 0.09–6.91)). Until the pathophysiology of HO development is understood, it will be difficult to create tools which can predict HO recurrence.

Abstract:

Background:

To evaluate demographic profile of traumatic and non-traumatic spinal cord injured (SCI) patients.

Methods:

Mobile rehabilitation teams gathered data in 20 out of 30 provinces in Iran. Of 8104 traumatic and non-traumatic SCI patients under coverage of the State Welfare Organization of Iran registered in the database, 7273 were included in the analysis.

The aggregate data on SCIs, including age, gender, place of residence, education level, marital status, etiology of injury, age at the time of injury, time passed since injury, level of injury, type of cord injury, having caregiver, and occupation were recorded.

Results:

Of 7273 patients, 5175 (71.1%) were male. At the time of the study, 46% were in the age group 20-40 years old, 34% were more than 40, and 20% were less than 20 years old. The residential place of 26% was in villages. 23.9% were illiterate, 6.9% had high school diploma or higher.

The distribution of cervical, thoracic, and lumbar levels of injury was 17.7, 24.4, and 57.9%, respectively. Overall, there were 49% married and 45.8% never married, while 1.4% patients were single because their partners had left them, 1.7% of partners had died, 1.9% had divorced, and 0.3% had remarried. At the time of the presentation of patients, 33% were 21-30 years-old, 17% were 31-40, and 16% were less than 20 years. About the type of cord injury, the paraplegia, paraparesia, quadriplegia, quadriparesia, and hemiparesia were present in 72.1, 12.5, 10.2, 4.0, and 1.1% of patients, respectively. Unemployment was reported in 55.6% of patients. However, 17% were unable to work, 7.1% had a job, and 3.4% were retired. Caregiver was not provided for 7.5% of them. The most prevalent causes of the injury were: trauma (57.4%), congenital (14.4%), tumors (4.4%), spinal degenerative disorder such as canal stenosis (2.2%), genetic (2.0%), infection (1.9%), scoliosis (1.1%), and miscellaneous (10.6%).

Conclusions:

These data will provide the information to guide future studies on SCI patients for better prevention and management of SCI patients.

Keywords:

Demography, Traumatic, Non-traumatic, Spinal cord injury, Etiology

Background

Acquired Brain Injury (ABI) from traumatic and non traumatic causes is a leading cause of disability worldwide yet there is limited research summarizing the health system economic burden associated with ABI. The objective of this study was to determine the direct cost of publicly funded health care services from the initial hospitalization to three years post-injury for individuals with traumatic (TBI) and non-traumatic brain injury (nTBI) in Ontario Canada.

Methods

A population-based cohort of patients discharged from acute hospital with an ABI code in any diagnosis position in 2004 through 2007 in Ontario was identified from administrative data. Publicly funded health care utilization was obtained from several Ontario administrative healthcare databases. Patients were stratified according to traumatic and non-traumatic causes of brain injury and whether or not they were discharged to an inpatient rehabilitation center. Health system costs were calculated across a continuum of institutional and community settings for up to three years after initial discharge. The continuum of settings included acute care emergency departments inpatient rehabilitation (IR) complex continuing care home care services and physician visits. All costs were calculated retrospectively assuming the government payer’s perspective.

Results

Direct medical costs in an ABI population are substantial with mean cost in the first year post-injury per TBI and nTBI patient being $32132 and $38018 respectively. Among both TBI and nTBI patients those discharged to IR had significantly higher treatment costs than those not discharged to IR across all institutional and community settings. This tendency remained during the entire three-year follow-up period. Annual medical costs of patients hospitalized with a brain injury in Ontario in the first follow-up year were approximately $120.7 million for TBI and $368.7 million for nTBI. Acute care cost accounted for 46-65% of the total treatment cost in the first year overwhelming all other cost components.

Conclusions

The main finding of this study is that direct medical costs in ABI population are substantial and vary considerably by the injury cause. Although most expenses occur in the first follow-up year ABI patients continue to use variety of medical services in the second and third year with emphasis shifting over time from acute care and inpatient rehabilitation towards homecare physician services and long-term institutional care. More research is needed to capture economic costs for ABI patients not admitted to acute care.

Background

Alpine skiing and snowboarding are popular winter activities worldwide, enjoyed by participants of all ages and skill levels. There is some evidence that the incidence of traumatic brain injury (TBI) and spinal cord injury (SCI) in these activities may be increasing. These injuries can cause death or severe debilitation, both physically and emotionally, and also result in enormous financial burden to society. Indeed, TBI is the leading cause of death and catastrophic injury in the skiing and snowboarding population. Furthermore, there are severe limitations to therapeutic interventions to restore neurological function after TBI and SCI, and thus the emphasis must be on prevention.

Objectives

(1) To examine the worldwide epidemiology of TBI and SCI in skiing and snowboarding; (2) to describe and examine the effectiveness of prevention strategies to reduce the incidence of TBI and SCI in skiing and snowboarding.

Search strategy

Searches were performed on a variety of databases to identify articles relevant to catastrophic central nervous system injury in skiing and snowboarding. The databases included PubMed, Medline, EMBASE, CDSR, ACP Journal Club, DARE, CCTR, SportDiscus, CINAHL, and Advanced Google searches.

Selection criteria and data collection

After initial prescreening, articles included in the review required epidemiological data on SCI, TBI, or both. Articles had to be directly associated with the topic of skiing and/or snowboarding and published between January 1990 and December 2004.

Results

24 relevant articles, from 10 different countries, were identified. They indicate that the incidence of TBI and SCI in skiing and snowboarding is increasing. The increases coincide with the development and acceptance of acrobatic and high‐speed activities on the mountains. There is evidence that helmets reduce the risk of head injury by 22–60%. Head injuries are the most common cause of death among skiers and snowboarders, and young male snowboarders are especially at risk of death from head injury.

Conclusions

There should be enhanced promotion of injury prevention that includes the use of helmets and emphasizes the skier's and snowboarder's responsibility code.

Abstract

A standardized measure of neurological dysfunction specifically designed for TBI currently does not exist and the lack of assessment of this domain represents a substantial gap. To address this, the Neurological Outcome Scale for Traumatic Brain Injury (NOS-TBI) was developed for TBI outcomes research through the addition to and modification of items specifically relevant to patients with TBI, based on the National Institutes of Health Stroke Scale. In a sample of 50 participants (mean age = 33.3 years, SD = 12.9) ≤18 months (mean = 3.1, SD = 3.2) following moderate (n = 8) to severe (n = 42) TBI, internal consistency of the NOS-TBI was high (Cronbach's alpha = 0.942). Test-retest reliability also was high (ρ = 0.97, p < 0.0001), and individual item kappas between independent raters were excellent, ranging from 0.83 to 1.0. Overall inter-rater agreement between independent raters (Kendall's coefficient of concordance) for the NOS-TBI total score was excellent (W = 0.995). Convergent validity was demonstrated through significant Spearman rank-order correlations between the NOS-TBI and the concurrently administered Disability Rating Scale (ρ = 0.75, p < 0.0001), Rancho Los Amigos Scale (ρ = −0.60, p < 0.0001), Supervision Rating Scale (ρ = 0.59, p < 0.0001), and the FIM™ (ρ = −0.68, p < 0.0001). These results suggest that the NOS-TBI is a reliable and valid measure of neurological functioning in patients with moderate to severe TBI.

Objective

Traumatic brain injury (TBI) is a risk associated with military duty, and residual effects from TBI may adversely affect a service member's ability to complete duties. It is, therefore, important to identify factors associated with a change in job status following TBI in an active military population. On the basis of previous research, we predicted that apolipoprotein E (APOE) genotype may be 1 factor.

Design

Cohort study of military personnel who sustained a mild to moderate TBI.

Setting

Military medical clinics.

Patients or Other Participants

Fifty-two military participants were recruited through the Defense and Veterans Brain Injury Center, affiliated with Naval Medical Center San Diego and the Defense and Veterans Brain Injury Center Concussion Clinic located at the First Marine Division at Camp Pendleton.

Intervention(s)

A multivariate statistical classification approach called optimal data analysis allowed for consideration of APOE genotype alongside cognitive, emotional, psychosocial, and physical functioning.

Main Outcome Measure(s)

APOE genotype, neuropsychological, psychosocial, and clinical outcomes.

Results

We identified a model of factors that was associated with a change in job status among military personnel who experienced a mild or moderate TBI.

Conclusions

Factors associated with a change in job status are different when APOE genotype is considered. We conclude that APOE genotype may be an important genetic factor in recovery from mild to moderate head injury.

Objective

To examine the applicability of marital resource (marriage has substantial benefits for well being over not being married) or marital crisis models (marital dissolution leads to poorer well being) to the spinal cord injury (SCI) population by studying the effects of gender, marital status and marital transitions on well-being.

Design

Prospective cohort from the SCI Model Systems National Database.

Setting

Community.

Participants

4,864 men and 1,277 women who sustained traumatic SCI and completed a minimum of one follow-up interview beginning at one year through 15 years post-injury.

Interventions

None.

Main outcomes measures

Life satisfaction, depressive symptomatology, and self-perceived health status using linear mixed models for longitudinal data.

Results

In general, well being improved over time since injury. Hypothesis testing supported the marital crisis model as marital loss through being or becoming separated or divorced and being or becoming widowed had the most consistent and negative impact across well-being outcomes, while being or becoming married only had an advantage for lower depression symptomatology over time. However, marital dissolution or loss did not have a uniformly adverse impact on well-being outcomes and this effect was often moderated by gender such that widows had higher depressive symptomatology and poorer self-perceived health than widowers, but separated or divorced women had higher life satisfaction and self-perceived health than men. Irrespective of gender, being separated or divorced vs. being single was associated with higher depression over time.

Conclusions

The results support the marital crisis model and that women and men can experience marital dissolution differently. Nor does all marital loss result in compromised well-being or marriage enhance well-being, highlighting complex dynamics worthy of further investigation in this population.

Abstract

Headache is one of the most common persisting symptoms after traumatic brain injury (TBI). Yet there is a paucity of prospective longitudinal studies of the incidence and prevalence of headache in a sample with a range of injury severity. We sought to describe the natural history of headache in the first year after TBI, and to determine the roles of prior history of headache, sex, and severity of TBI as risk factors for post-traumatic headache. A cohort of 452 acute, consecutive patients admitted to inpatient rehabilitation services with TBI were enrolled during their inpatient rehabilitation from February 2008 to June 2009. Subjects were enrolled across 7 acute rehabilitation centers designated as TBI Model Systems centers. They were prospectively assessed by structured interviews prior to inpatient rehabilitation discharge, and at 3, 6, and 12 months after injury. Results of this natural history study suggest that 71% of participants reported headache during the first year after injury. The prevalence of headache remained high over the first year, with more than 41% of participants reporting headache at 3, 6, and 12 months post-injury. Persons with a pre-injury history of headache (p<0.001) and females (p<0.01) were significantly more likely to report headache. The incidence of headache had no relation to TBI severity (p=0.67). Overall, headache is common in the first year after TBI, independent of the severity of injury range examined in this study. Use of the International Classification of Headache Disorders criteria requiring onset of headache within 1 week of injury underestimates rates of post-traumatic headache. Better understanding of the natural history of headache including timing, type, and risk factors should aid in the design of treatment studies to prevent or reduce the chronicity of headache and its disruptive effects on quality of life.

Objectives

To describe patterns of use for mannitol and hypertonic saline in children with traumatic brain injury (TBI), to evaluate any potential associations between hypertonic saline and mannitol use and patient demographic, injury, and treatment hospital characteristics, and to determine if the 2003 guidelines for severe pediatric TBI impacted clinical practice regarding osmolar therapy.

Design

Retrospective cohort study

Setting

Pediatric Health Information System (PHIS) database, January, 2001 to December, 2008

Patients

Children (age < 18 years) with TBI and head/neck Abbreviated Injury Scale (AIS) score ≥ 3 who received mechanical ventilation and intensive care

Interventions

None

Measurements and Main Results

The primary outcome was hospital billing for parenteral hypertonic saline and mannitol use, by day of service. Overall, 33% (2,069 of 6,238) of the patients received hypertonic saline and 40% (2,500 of 6,238) received mannitol. Of the 1,854 patients who received hypertonic saline or mannitol for ≥ 2 days in the first week of therapy, 29% did not have ICP monitoring. After adjustment for hospital-level variation, primary insurance payer, and overall injury severity, use of both drugs was independently associated with older patient age, intracranial hemorrhage (other than epidural), skull fracture, and higher head/neck injury severity. Hypertonic saline use increased and mannitol use decreased with publication of the 2003 guidelines, and these trends continued through 2008.

Conclusions

Hypertonic saline and mannitol are used less in infants than in older children. The patient-level and hospital-level variation in osmolar therapy use and the substantial amount of sustained osmolar therapy without ICP monitoring suggest opportunities to improve the quality of pediatric TBI care. With limited high-quality evidence available, published expert guidelines appear to significantly impact clinical practice in this area.

Abstract:

Background:

There is no clear evidence that early decompression following spinal cord injury (SCI) improves neurologic outcome. In this primary report for prospective, randomized clinical trial, 35 selected spinal cord injured patients with traumatic thoracolumbar spinal cord injury were randomly assigned to early surgery (before 24 hours); and late surgery (24–72 hours).

Methods:

Seventeen patients were assigned to the early and 18 to the late surgery. Twenty-five patients (71.4%) were male. Mean age of patients was 34 ± 12 years old. The most common levels of SCI were L1, T12, and T11 in 34%, 29%, and 11%, respectively. Sixteen (62.5%) had complete SCI (American Spinal Injury Association Impaired Scale (AIS) A. Number of patients with AIS B, C, D and E were 6, 5, 4, and 4, respectively. Follow-up of patients showed AIS A, B, C, D, and E in 7, 12, 4, 5, and 6 patients, respectively.

One patient (3%) was deteriorated who was from the early surgery group. No change in neurologic deficit was seen in 12 patients (34%). Eighteen patients (52%) improved one AIS grade, 8 were early and 10 late surgery. Three patients (9%) improved two AIS grades all were early surgery. Not available follow-up data for one patient (3%).

Results:

Only 3/7 patients with AIS A in early surgery had one AIS grade improvement. In late surgery, 6/9 patients with AIS A had just one AIS grade improvement. Mean duration of hospitalization for all SCI patients were 11 ± 10 days, which was 8 ± 8 days for early and 14±12 days for late surgery.

Conclusions:

Complications were two deaths, one in early surgery because of pulmonary emboli. Second death was in late surgery with unknown etiology. Two cases had deep vein thrombosis in early surgery. In late surgery, three cases had cerebrospinal fluid leak, meningitis and wound infection. Number of patients was not enough for comparing two surgery groups. However, both early and late surgery groups had some improvement in almost half of SCI patients.

Keywords:

Randomized controlled trial, Traumatic spinal cord injury, Thoracolumbar, Surgical decompression, Time

In 1974, work began on the first national survey of head and spinal cord injuries in the United States. The survey was a project of the National Institute of Neurological and Communicative Disorders and Stroke of the Public Health Service. This article presents highlights of the survey, particularly the findings about head injuries (that is, brain injuries). The survey population consisted of people admitted to U.S. hospitals as inpatients between January 1, 1970, and December 31, 1974. To be medically eligible, patients must have experienced physical injury (except birth trauma) caused by an external, mechanical force. Probability sampling was used in a three-stage plan to select appropriate hospital records. Findings of the head and spinal cord injury survey follow: Of all age groups, 15- to 24-year-olds had the highest rate of head injuries. Males had a rate of head injuries more than twice that of females. Head injuries occurred most often on Fridays, Saturdays, and Sundays. The chief cause of head injuries was motor vehicle accidents.

Polyethylene glycol (PEG; 2000 MW, 30% by volume) has been shown to mechanically repair damaged cellular membranes and reduce secondary axotomy after traumatic brain and spinal cord injury (TBI and SCI respectively). This repair is achieved following spontaneous reassembly of cell membranes made possible by the action of targeted hydrophilic polymers which first seal the compromised portion of the plasmalemma, and secondarily, allow the lipidic core of the compromised membranes to resolve into each other. Here we compared PEG-treated to untreated rats using a computer-managed open-field behavioral test subsequent to a standardized brain injury. Animals were evaluated after a 2-, 4-, and 6-hour delay in treatment after TBI. Treated animals receive a single subcutaneous injection of PEG. When treated within 2 hours of the injury, injured PEG-treated rats showed statistically significant improvement in their exploratory behavior recorded in the activity box when compared to untreated but brain-injured controls. A delay of 4 hours reduced this level of achievement, but a statistically significant improvement due to PEG injection was still clearly evident in most outcome measures compared at the various evaluation times. A further delay of 2 more hours, however, eradicated the beneficial effects of PEG injection as revealed using this behavioral assessment. Thus, there appears to be a critical window of time in which PEG administration after TBI can provide neuroprotection resulting in an enhanced functional recovery. As is often seen in clinically applied acute treatments for trauma, the earlier the intervention can be applied, the better the outcome.

Objectives—Little has been published before on the epidemiology and prevention of work related spinal cord injury (SCI). This study is the first national population based epidemiological analysis of this type of injury. It presents that largest case series ever reported.

Setting—The study utilises information from the Australian Spinal Cord Injury Register, which has full coverage of the population.

Methods—All newly incident cases of SCI from 1986 to 1997 were considered.

Results—Work related SCI accounted for about 13% of all traumatic cases of SCI over the period 1986–97. The labour force based incidence rate in Australia averaged four cases per million of population per annum over the period. The rate was highest among those aged 25–34 years (4.9/million) and among farmers (17.0/million). Nearly half of the cases studied received their injury due to a fall. Motor vehicle crashes were also common and vehicle rollover was the predominant crash type. A high proportion of cases did not receive any compensation for their SCI.

Conclusions—Although rare, SCI is one of the most severe and debilitating injuries that can be suffered in the workplace. As there is no cure for SCI, and the level of impairment does not improve substantially for the vast majority of cases even after rehabilitation, it is arguable that primary prevention should receive substantially greater emphasis.

Background:

Mechanical insufflation-exsufflation (MIE) is an option for secretion mobilization in outpatients with spinal cord injury (SCI) who lack an effective cough and are at high risk for developing pneumonia.

Objective:

To describe characteristics of persons with SCI who received MIE devices for outpatient use and compare respiratory hospitalizations before and after MIE prescription.

Design:

Retrospective cohort study of all persons who were prescribed MIE devices for outpatient use during 2000 to 2006 by a Veterans Affairs SCI service.

Results:

We identified 40 patients with tetraplegia (4.5% of population followed by the SCI service) who were prescribed MIE devices. Of these, 30 (75%) had neurologic levels of C5 or rostral, and 33 (83%) had motor-complete injuries. For chronically injured patients who were prescribed MIE for home use, there was a nonsignificant reduction in respiratory hospitalization rates by 34% (0.314/y before MIE vs 0.208/y after MIE; P  =  0.21). A posthoc subgroup analysis showed a significant decline in respiratory hospitalizations for patients with significant tobacco smoking histories.

Conclusions:

Mechanical insufflation-exsufflation was typically prescribed for people with motor-complete tetraplegia. Outpatient MIE usage may reduce respiratory hospitalizations in smokers with SCI. Further research of this alternative, noninvasive method is warranted in the outpatient SCI population.

Background

To compare the treatment of heterotopic ossification (HO) within traumatic brain and spinal cord injured populations.

Methods

MEDLINE/Pubmed, CINAHL, EMBASE, and PsycINFO databases were searched for articles addressing treatment of HO post-injury. Articles were constrained to: English language and human subjects. Studies were included if: n≥50% of the subjects had a SCI or TBI, n≥3 SCI or TBI subjects, and study subjects participated in a treatment or intervention. Study quality, for randomized control trials (RCTs), were assessed using the PEDro assessment scale, while non-RCTs was assessed using the Downs and Black evaluation tool. A modified Sackett scale was used to apply levels of evidence for each intervention.

Results

In total 26 studies (NTBI=12; NSCI=14) met inclusion criteria. The majority of studies (10/12) conducted in the TBI population were surgical interventions. Studies conducted with the SCI population investigated diverse pharmacological treatments including: bisphosphonates, non-steroidal anti-inflammatory drugs (NSAIDs) and Warfarin. Non-pharmacological studies investigated the benefits of pulse low-intensity electromagnetic field therapy, surgical excision, and radiotherapy in the treatment of HO.

Conclusions

Within the SCI literature, NSAIDs showed the greatest efficacy in the prevention of HO when administered early after a SCI, and biphosphonates were found to be the most effective treatment strategy. In the TBI population, surgical excision was the most effective treatment.

Background

Evidence mapping describes the quantity, design and characteristics of research in broad topic areas, in contrast to systematic reviews, which usually address narrowly-focused research questions. The breadth of evidence mapping helps to identify evidence gaps, and may guide future research efforts. The Global Evidence Mapping (GEM) Initiative was established in 2007 to create evidence maps providing an overview of existing research in Traumatic Brain Injury (TBI) and Spinal Cord Injury (SCI).

Methods

The GEM evidence mapping method involved three core tasks:

1. Setting the boundaries and context of the map: Definitions for the fields of TBI and SCI were clarified, the prehospital, acute inhospital and rehabilitation phases of care were delineated and relevant stakeholders (patients, carers, clinicians, researchers and policymakers) who could contribute to the mapping were identified. Researchable clinical questions were developed through consultation with key stakeholders and a broad literature search.

2. Searching for and selection of relevant studies: Evidence search and selection involved development of specific search strategies, development of inclusion and exclusion criteria, searching of relevant databases and independent screening and selection by two researchers.

3. Reporting on yield and study characteristics: Data extraction was performed at two levels - 'interventions and study design' and 'detailed study characteristics'. The evidence map and commentary reflected the depth of data extraction.

Results

One hundred and twenty-nine researchable clinical questions in TBI and SCI were identified. These questions were then prioritised into high (n = 60) and low (n = 69) importance by the stakeholders involved in question development. Since 2007, 58 263 abstracts have been screened, 3 731 full text articles have been reviewed and 1 644 relevant neurotrauma publications have been mapped, covering fifty-three high priority questions.

Conclusions

GEM Initiative evidence maps have a broad range of potential end-users including funding agencies, researchers and clinicians. Evidence mapping is at least as resource-intensive as systematic reviewing. The GEM Initiative has made advancements in evidence mapping, most notably in the area of question development and prioritisation. Evidence mapping complements other review methods for describing existing research, informing future research efforts, and addressing evidence gaps.

Infants and children less than 4 years old suffer chronic cognitive deficits following mild, moderate or severe diffuse traumatic brain injury (TBI). It has been suggested that the underlying neuropathologic basis for behavioral deficits following severe TBI is acute brain swelling, subarachnoid hemorrhage and axonal injury. To better understand mechanisms of cognitive dysfunction in mild-moderate TBI, a closed head injury model of midline TBI in the immature rat was developed. Following an impact over the midline suture of the intact skull, 17-day-old rats exhibited short apnea times (3–15 seconds), did not require ventilatory support and suffered no mortality, suggestive of mild TBI. Compared to un-injured rats, brain-injured rats exhibited significant learning deficits over the first week post-injury (P<0.0005), and, significant learning (P<0.005) and memory deficits (P<0.05) in the third post-injury week. Between 6 and 72h, blood-brain barrier breakdown, extensive traumatic axonal injury in the subcortical white matter and thalamus, and focal areas of neurodegeneration in the cortex and hippocampus were observed in both hemispheres of the injured brain. At 8 to 18 days post-injury, reactive astrocytosis in the cortex, axonal degeneration in the subcortical white matter tracts, and degeneration of neuronal cell bodies and processes in the thalamus of both hemispheres were observed; however, cortical volumes were not different between un-injured and injured rat brains. These data suggest that diffuse TBI in the immature rat can lead to ongoing degeneration of both cell soma and axonal compartments of neurons, which may contribute, in part, to the observed sustained cognitive deficits.

Objective

To evaluate the association of health status, secondary health conditions, hospitalizations, and risk of mortality and life expectancy (LE) after spinal cord injury (SCI).

Design

Prospective cohort study.

Setting

Preliminary data were collected from a specialty hospital in the Southeastern United States, with mortality follow-up and data analysis conducted at a medical university.

Participants

A total of 1361 adults with traumatic SCI, all at least 1 year post-injury at the time of assessment, were enrolled in the study. There were 325 deaths. After elimination of those with missing data on key variables, there were 267 deaths and 12,032 person-years.

Interventions

None

Main Outcome Measures

Mortality status was determined by routine follow-up using the National Death Index through December 31, 2008. A logistic regression model was developed to estimate the probability of dying in any given year using person years.

Results

A history of chronic pressure ulcers, amputations, a depressive disorder, symptoms of infections, and being hospitalized within the past year were all predictive of mortality. LE estimates were generated using the example of a male with non-cervical, non-ambulatory SCI. Using 3 age examples (20, 40, 60), the greatest estimated lost LE was associated with chronic pressure ulcers (50.3%), followed by amputations (35.4%), 1 or more recent hospitalizations (18.5%), and the diagnosis of probable major depression (18%). Symptoms of infections was associated with a 6.7% reduction in LE for a 1 standard deviation increase in infectious symptoms.

Conclusion

Several secondary health conditions represent risk factors for mortality and diminish LE after SCI. The presence of 1 or more of these factors should be taken as an indicator of the need for intervention.

Objective

To examine the importance of cardiorespiratory conditioning after traumatic brain injury (TBI) and provide recommendations for patients recovering from TBI.

Method

Review of literature assessing the effectiveness of endurance training programs.

Main outcomes and results

A sedentary lifestyle and lack of endurance are common characteristics of individuals with TBI who have a reduction in peak aerobic capacity of 25-30% compared to healthy sedentary persons. Increased physical activity and exercise training improves cardiorespiratory fitness in many populations with physical and cognitive impairments. Therefore, increasing the endurance and cardiorespiratory fitness of persons with TBI would seem to have important health implications. However, review of the TBI literature reveals that there have been few well-designed, well-controlled studies of physiologic and psychological adaptations of fitness training. Also lacking are long-term follow-up studies of persons with TBI.

Conclusions

Assessing endurance capacity and cardiorespiratory fitness early in the TBI rehabilitation process merits consideration as a standard of care by professional rehabilitation societies. Also, providing effective, safe and accessible training modalities would seem to be an important consideration for persons with TBI, given the mobility impairments many possess. Long-term follow-up studies are needed to assess the effectiveness of cardiorespiratory training programs on overall morbidity and mortality.

Background

In addition to cognitive dysfunction, locomotor deficits are prevalent in traumatic brain injured (TBI) patients; however, it is unclear how a concussive injury can affect spinal cord centers. Moreover, there are no current efficient treatments that can counteract the broad pathology associated with TBI.

Objective

The authors have investigated potential molecular basis for the disruptive effects of TBI on spinal cord and hippocampus and the neuroprotection of a curcumin derivative to reduce the effects of experimental TBI.

Methods

The authors performed fluid percussion injury (FPI) and then rats were exposed to dietary supplementation of the curcumin derivative (CNB-001; 500 ppm). The curry spice curcumin has protective capacity in animal models of neurodegenerative diseases, and the curcumin derivative has enhanced brain absorption and biological activity.

Results

The results show that FPI in rats, in addition to reducing learning ability, reduced locomotor performance. Behavioral deficits were accompanied by reductions in molecular systems important for synaptic plasticity underlying behavioral plasticity in the brain and spinal cord. The post-TBI dietary supplementation of the curcumin derivative normalized levels of BDNF, and its downstream effectors on synaptic plasticity (CREB, synapsin I) and neuronal signaling (CaMKII), as well as levels of oxidative stress–related molecules (SOD, Sir2).

Conclusions

These studies define a mechanism by which TBI can compromise centers related to cognitive processing and locomotion. The findings also show the influence of the curcumin derivative on synaptic plasticity events in the brain and spinal cord and emphasize the therapeutic potential of this noninvasive dietary intervention for TBI.

Background

Natural disasters result in significant numbers of disabling impairments. Paradoxically, however, the traditional health system response to natural disasters largely neglects health-related rehabilitation as a strategic intervention.

Objectives

To examine the role of health-related rehabilitation in natural disaster relief along three lines of inquiry: (1) epidemiology of injury and disability, (2) impact on health and rehabilitation systems, and (3) the assessment and measurement of disability.

Design

Qualitative literature review and secondary data analysis.

Results

Absolute numbers of injuries as well as injury to death ratios in natural disasters have increased significantly over the last 40 years. Major impairments requiring health-related rehabilitation include amputations, traumatic brain injuries, spinal cord injuries (SCI), and long bone fractures. Studies show that persons with pre-existing disabilities are more likely to die in a natural disaster. Lack of health-related rehabilitation in natural disaster relief may result in additional burdening of the health system capacity, exacerbating baseline weak rehabilitation and health system infrastructure. Little scientific evidence on the effectiveness of health-related rehabilitation interventions following natural disaster exists, however. Although systematic assessment and measurement of disability after a natural disaster is currently lacking, new approaches have been suggested.

Conclusion

Health-related rehabilitation potentially results in decreased morbidity due to disabling injuries sustained during a natural disaster and is, therefore, an essential component of the medical response by the host and international communities. Significant systematic challenges to effective delivery of rehabilitation interventions during disaster include a lack of trained responders as well as a lack of medical recordkeeping, data collection, and established outcome measures. Additional development of health-related rehabilitation following natural disaster is urgently required.

Objective: To describe the emergency department (ED) management of isolated mild traumatic brain injury (TBI) in the USA and to examine variation in care across age and insurance types.

Methods: A secondary analysis of ED visits for isolated mild TBI in the National Hospital Ambulatory Medical Care Survey 1998–2000 was performed. Mild TBI was defined by International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9) codes for skull fracture, concussion, intracranial injury (unspecified), and head injury (unspecified). Available ED care variables were analysed by patient age and insurance categories using multivariate logistic regression.

Results: The incidence of isolated mild TBI cases attending ED was 153 296 per year, or 56.4/100 000 people. Of the patients with isolated mild TBI, 44.3% underwent computed tomography, 23.9% underwent other non-extremity, non-chest x rays, 17.1% received wound care and 14.1% received intravenous fluids. However, only 43.8% had an assessment of pain. Of those with documented pain, only 45.5% received analgesics in the ED. Nearly 38% were discharged without recommendations for specific follow up. Several aspects of ED care varied by age but not by insurance type.

Conclusion: Substantial ED resources are devoted to the care of isolated mild TBI. The present study identified deficiencies in and variation around several important aspects of ED care. The development of guidelines specific for mild TBI could reduce variation and improve emergency care for this injury.

Context

Uncertainties exist about the rates, predictors and outcomes of major depressive disorder (MDD) among people with traumatic brain injury (TBI).

Objectives

To describe MDD related rates, predictors, outcomes and treatment during the first year after TBI

Design

Cohort from 6/2001–3/2005 followed by structured telephone interviews at months 1–6, 8, 10, and 12 (data collection ending 2/2006).

Setting

Harborview Medical Center, a Level I trauma center in Seattle, WA

Participants

559 consecutively hospitalized adults with complicated mild to severe TBI

Main Outcome Measures

The Patient Health Questionnaire (PHQ) depression and anxiety modules were administered at each assessment and the European Quality of Life measure (EQ-5D) was given at 12 months.

Results

53% met criteria for MDD at least once in the follow-up period. Point prevalences ranged between 31% at one month and 21% at six months. In a multivariate model, increased risk of MDD after TBI was associated with MDD at the time of injury (risk ratio [RR], 1.62; 95% confidence interval [CI], 1.37–1.91), history of MDD prior to injury (but not at the time of injury) (RR, 1.54; 95% CI, 1.31–1.82), age (RR, 0.61; 95% CI, 0.44–0.83 for 60+ years vs. 18–29 years) and lifetime alcohol dependence (RR, 1.34; 95% CI, 1.14–1.57). Those with MDD were more likely to report co-morbid anxiety disorders after TBI than those without MDD (60% versus 7%; RR, 8.77; 95% CI, 5.56–13.83). Only 44% of those with MDD received antidepressants or counseling. After adjusting for predictors of MDD, persons with MDD reported lower quality of life at one year, compared to the nondepressed group.

Conclusions

Among a cohort of patients hospitalized for TBI, 53% met criteria for MDD during the first year after TBI. MDD was associated with prior history of MDD and was an independent predictor of poorer health-related quality of life.

Context:

Mild traumatic brain injury (mTBI) represents a major health problem in civilian populations as well as among the military service members due to (1) lack of effective treatments, and (2) our incomplete understanding about the progression of secondary cell injury cascades resulting in neuronal cell death due to deficient cellular energy metabolism and damaged mitochondria.

Aims:

The aim of this study was to identify and delineate the mitochondrial targeted genes responsible for altered brain energy metabolism in the injured brain.

Settings and Design:

Rats were either grouped into naïve controls or received lateral fluid percussion brain injury (2–2.5 atm) and followed up for 7 days.

Materials and Methods:

Rats were either grouped into naïve controls or received lateral fluid percussion brain injury (2–2.5 atm) and followed for 7 days. The severity of brain injury was evaluated by the neurological severity scale—revised (NSS-R) at 3 and 5 days post TBI and immunohistochemical analyses at 7 days post TBI. The expression profiles of mitochondrial-targeted genes across the hippocampus from TBI and naïe rats were also examined by oligo-DNA microarrays.

Results:

NSS-R scores of TBI rats (5.4 ± 0.5) in comparison to naïe rats (3.9 ± 0.5) and H and E staining of brain sections suggested a mild brain injury. Bioinformatics and systems biology analyses showed 31 dysregulated genes, 10 affected canonical molecular pathways including a number of genes involved in mitochondrial enzymes for oxidative phosphorylation, mitogen-activated protein Kinase (MAP), peroxisome proliferator-activated protein (PPAP), apoptosis signaling, and genes responsible for long-term potentiation of Alzheimer's and Parkinson's diseases.

Conclusions:

Our results suggest that dysregulated mitochondrial-focused genes in injured brains may have a clinical utility for the development of future therapeutic strategies aimed at the treatment of TBI.