Implementation of low-intensity thrombolysis monitoring care in routine practice: process evaluation of the Optimal Post rtPA-IV Monitoring in Acute Ischemic Stroke (OPTIMISTmain) study in the United States.

INTRODUCTION: The ongoing OPTIMISTmain study, an international, multicenter, stepped-wedge cluster randomized trial, aims to determine effectiveness and safety of low-intensity versus standard monitoring in thrombolysis-treated patients with mild-to-moderate acute ischemic stroke (AIS). An embedded process evaluation explored integration and impact of the intervention on care processes at participating US sites. METHODS: A mixed-methods approach with quantitative and qualitative data were collected between September 2021 and November 2022. Implementer surveys were undertaken at pre- and post-intervention phases to understand the perceptions of low-intensity monitoring strategy. A sample of stroke care nurses were invited to participate in semi-structured interviews at an early stage of post-intervention. Qualitative data were analyzed deductively using the normalization process theory; quantitative data were tabulated. RESULTS: Interviews with 21 nurses at 8 hospitals have shown low-intensity monitoring was well accepted, as there were less time constraints and reduced workload for each patient. There were initial safety concerns over missing deteriorating patients and difficulties in changing established routines. Proper training, education, and communication, and changing the habits and culture of care, were key elements to successfully adopting the new monitoring care into routine practice. Similar results were found in the post-intervention survey (42 nurses from 13 hospitals). Nurses reported time being freed up to provide patient education (56%), daily living care (50%), early mobilization (26%), mood/cognition assessment (44%), and other aspects (i.e. communication, family support). CONCLUSIONS: Low-intensity monitoring for patients with mild-to-moderate acute ischemic stroke, facilitated by appropriate education and organizational support, appears feasible and acceptable at US hospitals.

The main Optimal Post rTpa-Iv Monitoring in Ischemic Stroke Trial (OPTIMISTmain): protocol for a pragmatic, stepped wedge, cluster randomized controlled trial.

Introduction Careful monitoring of patients who receive intravenous thrombolysis (IVT) for acute ischemic stroke (AIS) is resource-intensive, and potentially less relevant in those with mild degrees of neurological impairment who are at low-risk of symptomatic intracerebral hemorrhage (sICH) and other complications. \ Methods OPTIMISTmain is an international, multicenter, prospective, stepped wedge, cluster randomized, blinded outcome assessed trial aims to determine whether a less-intensity monitoring protocol is at least as effective, safe and efficient as standard post-IVT monitoring in patients with mild deficits post-AIS. Clinically-stable adult patients with mild AIS (defined by a NIHSS <10) who do not require intensive care within 2 hours post-IVT are recruited at hospitals in Australia, Chile, China, Malaysia, Mexico, UK, US and Vietnam. An average of 15 patients recruited per period (overall 60 patient participants) at 120 sites for a total of 7200 IVT-treated AIS patients will provide 90% power (one-sided α 0.025). The initiation of eligible hospitals is based on a rolling process whenever ready, stratified by country. Hospitals are randomly allocated using permuted blocks into 3 sequences of implementation, stratified by country and the projected number of patients to be recruited over 12 months. These sequences have four periods that dictate the order in which they are to switch from control (usual care) to intervention (implementation of low intensity monitoring protocol) to different clusters of patients in a stepped manner. Compared to standard monitoring, the low-intensity monitoring protocol includes assessments of neurological and vital signs every 15 minutes for 2 hours, 2 hourly (versus every 30 minutes) for 8 hours, and 4 hourly (versus every 1 hour) until 24 hours, post-IVT. The primary outcome measure is functional recovery, defined by the modified Rankin scale (mRS) at 90 days, a seven-point ordinal scale (0 [no residual symptom] to 6 [death]). Secondary outcomes include death or dependency, length of hospital stay, and health-related quality of life, sICH and serious adverse events. Conclusion OPTIMISTmain will provide Level I evidence for the safety and effectiveness of a low-intensity post-IVT monitoring protocol in patients with mild severity of AIS.

Return to School After Traumatic Brain Injury: Description of Implementation Settings.

OBJECTIVE: Children who experience traumatic brain injury (TBI) of any severity may need accommodations when they return to school-the setting that manages academic achievement and learning. However, variations exist in current return to school (RTS) programs that address a child's transition to school following TBI. This article describes some of these return to school (RTS) programs and how they vary by setting. DESIGN: This article provides insights from a modified evaluability assessment that examined RTS programs and their readiness for rigorous evaluation. A secondary analysis was conducted to better describe the types and location of programs examined. RESULTS: Differences exist in program structure, access, and how care for children is monitored over time. RTS programs that serve children following TBI are located in healthcare settings, schools, and state agencies and vary in models of care due to their location and organizational structure. CONCLUSIONS: Children who experience TBI benefit from a healthcare assessment and follow-up upon RTS that includes parental involvement. Models of care for this process vary based on program location and organizational structure. Further research and program evaluation are needed to better understand effectiveness and how to optimally monitor and care for children returning to school after a concussion or TBI.

Gerontological nursing competencies: A crosswalk with the 4Ms framework of the age-friendly initiative.

The Age-friendly Health Systems Initiative is a current multidisciplinary movement driving quality improvement across all health care settings. The 4Ms framework (What Matters, Medication, Mobility, and Mentation) provides a common evidence-based language and system of care that can be utilized by all health care providers. Faculty of one nursing program were interested in knowing whether the principles and language of the 4Ms framework align well with the current competencies used to guide undergraduate and beginning level practice for nurses. To answer this question, a crosswalk of curricular and competency guidelines for gerontological nursing was completed to identify how well the competencies aligned with the key concepts of the evidence-based 4Ms framework. Key findings of this crosswalk are being shared with educators for the purpose of describing a systematic way to ensure that the 4Ms are integrated into gerontological curricula and course design. The steps taken to complete the crosswalk are described to guide educators across all disciplines interested in creating curricula that will adequately prepare students to be collaborative partners and leaders in Age-friendly Health Systems.

Sustainability of Intravenous Alteplase Administration via Telephone-Based Consult: Data from a US Health System.

OBJECTIVES: Telephone-based consults using remote imaging review and standardization of evaluation but without visualizing the patient are an alternative to video-telestroke consults but are less well-studied. We aim to demonstrate the safety and efficacy of telephone-based acute consults in which IV tPA was administered over nearly a decade within one health system. MATERIALS AND METHODS: Clinical characteristics and outcomes were compared between a community hospital (spoke; uses telephone-based consults) and the academic comprehensive stroke center (hub; uses oversight of on-site neurology trainees) from 2008-2017. In both institutions acute therapy decisions are made by the same stroke neurologists. RESULTS: 2518 acute ischemic stroke consults were evaluated at hub and 2049 at spoke. Of these, 191 patients received IV tPA at hub and 184 at spoke. Patients at hub were younger (median (IQR): 61 (51-74) vs 69 (56-81) years, p = 0.0021) but admission National Institutes of Health Stroke Scale (NIHSS) was similar. There were no differences between door-to-needle times (69 (56-101) vs 69 (51-92) minutes, p = 0.13), last known well-to-tPA times (157 (113-202) vs 144 (110-175) minutes, p = 0.053), and rates of overall intracranial hemorrhage (ICH) after tPA (n = 23 (13.5%) vs 31 (17.0%), p = 0.35). In multivariable analyses, hospital was not an independent predictor of ICH after tPA. CONCLUSIONS: In a large dataset over nearly a decade, assessment for IV tPA administration using telephone assessment along with imaging review and emergency department standardization resulted in similar safety and outcomes as in the presence of on-site stroke/neurology expertise. Future studies are needed to confirm these findings.

Accidental Fall Death in McLean County: Examining Variables in Community-Dwelling Older Adults.

Fall risk assessment is a complex phenomenon involving several risk factors, including an individual's balance and mobility status, chronic health conditions, visual impairment, hearing deficits, environmental hazards (e.g., loose rugs, clutter), and being homebound or semi-homebound. Comprehensive fall risk assessment is the cornerstone of fall prevention in older adults throughout the community. The current study was based on secondary data and sought to examine variables associated with death due to accidental fall in a rural, midwestern county in Illinois, and to heighten awareness for consistent screening and risk assessment in older adults residing in the community. Results illustrated that among community-dwelling older adults with accidental falls, blunt injury or subdural hematoma had significantly fewer days until death than a fracture. [Journal of Gerontological Nursing, 48(6), 26-32.].

Care of the Patient With Acute Ischemic Stroke (Endovascular/Intensive Care Unit-Postinterventional Therapy): Update to 2009 Comprehensive Nursing Care Scientific Statement: A Scientific Statement From the American Heart Association.

Ischemic stroke remains the fifth leading cause of death in the United States. Nurses play a pivotal role in the care of patients throughout the continuum. With the advances in stroke care, including mechanical thrombectomy, the American Heart Association/American Stroke Association charged the writing panel to complement the 2009 clinical practice guideline, "Comprehensive Overview of Nursing and Interdisciplinary Care of the Acute Ischemic Stroke Patient," with current evidence-based nursing care. This update is 1 of a 3-part series focusing on emergency medical services/emergency care, endovascular/intensive care unit care, and postacute care. The aim of this scientific statement is to review and present current evidence, complications, best practices, and clinical practice strategies to provide current comprehensive scientific information for nursing care in the neuroendovascular area and intensive care unit in conjunction with medical treatments, including intravenous thrombolysis and mechanical thrombectomy.

Exploring the Collateral Damage of the COVID-19 Pandemic on Stroke Care: A Statewide Analysis.

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Hemoglobin concentration does not impact 3-month outcome following acute ischemic stroke.

BACKGROUND: There is uncertainty regarding the effect of anemia and red blood cell transfusion on functional outcome following acute ischemic stroke. We studied the relationship of hemoglobin parameters and red cell transfusion with post stroke functional outcome after adjustment for neurological severity and medical comorbidities. METHODS: Retrospective cohort study of 536 patients discharged with a diagnosis of ischemic stroke from a tertiary care hospital between January 2012 and April 2015. Hemoglobin level at hospital admission, lowest recorded value during hospitalization (nadir), delta hemoglobin (admission minus nadir), red cell transfusion during hospitalization were noted. Charlson Comorbidity Index (CCI) was computed as a summary measure of medical comorbidities. A multivariable logistic regression model was used to determine risk-adjusted odds of unfavorable outcome, defined as a modified Rankin Score of > 2. RESULTS: Anemia was present on hospital admission in 31% of patients. Forty five percent of patients had unfavorable outcome. In the univariable analysis increasing age, admission National Institutes of Health Stroke Scale (NIHSS), CCI, nadir hemoglobin, delta hemoglobin and blood transfusion were associated with unfavorable outcome. In the multivariable model, only increasing age, CCI and NIHSS remained associated with unfavorable outcome. No quadratic association was found on repeating the model to identify a possible U-shaped relationship of hemoglobin with outcome. CONCLUSIONS: Our findings contradict prior observational studies and highlight an area of clinical equipoise regarding the optimal management of anemia in patients hospitalized for ischemic stroke. This uncertainty could be addressed with appropriately designed clinical trials.

Evaluation of Huddles: A Multisite Study.

Regular, interdisciplinary group meetings, "huddles," may be useful in improving communication among disciplines, resolving problems, and sharing information. Daily use of huddles may contribute to the development of a highly reliable health care organization. The purpose of this study was to describe safety huddles in relation to (1) problem type, (2) timeliness of resolution, (3) attendance of representatives from each discipline, (4) amount of information sharing, and (5) attendees' satisfaction with the process. Overall, results demonstrated that the primary function of huddles was the exchange of information that posed or had the potential to pose safety risks to patients. Across seven hospitals, the range of information sharing during huddles was 61.0% to 95.6%. Regarding satisfaction with the huddle process, staff reported that huddles were useful in improving awareness of safety concerns and also improved communication between disciplines. Huddles provide a structured format in which staff can positively impact safety concerns, form a greater sense of medical community, increase sharing of information between disciplines, quickly resolve discipline-based problems, and increase awareness of safety concerns. Given the results of this study, it is recommended that health care administrators and managers develop a huddle process.

Stroke Knowledge in African Americans: A Narrative Review.

OBJECTIVE: The purpose of this review is to evaluate the state of knowledge in regard to stroke literacy in African Americans. This topic is important for assessing the specific gaps in stroke knowledge for this population, as well as to evaluate the methodology that has been used to assess stroke literacy. METHODS: This narrative review includes studies that evaluated and reported stroke knowledge in African Americans and were published between January 2000 and October 2015. RESULTS: Our review revealed that disparities may exist in recognition of headache and visual symptoms, knowledge of the organ in which stroke occurs, and identification of tobacco use as a risk factor. Stress may be perceived as a more important risk factor among African Americans than among White Americans. The literature does not suggest disparities in knowledge of the appropriate action to take for stroke. CONCLUSIONS: Racial disparities may exist for specific domains of stroke knowledge. Future studies should explore specific gaps in knowledge to be addressed in stroke prevention interventions for African Americans. Standardization of methods is needed to aid comparisons across populations. The relationship between stroke knowledge and clinical outcomes also needs to be evaluated.

Potential negative ecological effects of corridors.

Despite many studies showing that landscape corridors increase dispersal and species richness for disparate taxa, concerns persist that corridors can have unintended negative effects. In particular, some of the same mechanisms that underlie positive effects of corridors on species of conservation interest may also increase the spread and impact of antagonistic species (e.g., predators and pathogens), foster negative effects of edges, increase invasion by exotic species, increase the spread of unwanted disturbances such as fire, or increase population synchrony and thus reduce persistence. We conducted a literature review and meta-analysis to evaluate the prevalence of each of these negative effects. We found no evidence that corridors increase unwanted disturbance or non-native species invasion; however, these have not been well-studied concerns (1 and 6 studies, respectively). Other effects of corridors were more often studied and yielded inconsistent results; mean effect sizes were indistinguishable from zero. The effect of edges on abundances of target species was as likely to be positive as negative. Corridors were as likely to have no effect on antagonists or population synchrony as they were to increase those negative effects. We found 3 deficiencies in the literature. First, despite studies on how corridors affect predators, there are few studies of related consequences for prey population size and persistence. Second, properly designed studies of negative corridor effects are needed in natural corridors at scales larger than those achievable in experimental systems. Third, studies are needed to test more targeted hypotheses about when corridor-mediated effects on invasive species or disturbance may be negative for species of management concern. Overall, we found no overarching support for concerns that construction and maintenance of habitat corridors may result in unintended negative consequences. Negative edge effects may be mitigated by widening corridors or softening edges between corridors and the matrix. Other negative effects are relatively small and manageable compared with the large positive effects of facilitating dispersal and increasing diversity of native species.

The Baptist Health High Risk Falls Assessment: a methodological study.

OBJECTIVE: The purpose of this study was to evaluate the psychometric properties of the Baptist Health High Risk Falls Assessment (BHHRFA). BACKGROUND: The cost of falls and the potential for increased patient morbidity and mortality necessitate the development of a psychometrically sound assessment. METHODS: Based on pilot data, a multisite study was conducted. Assessments were collected on 21 medical-surgical units, 1 rehabilitation unit, 1 psychiatric unit, and 3 critical care units (N = 241599). Sensitivity, specificity, and diagnostic odds ratios (DORs) were calculated. Clinical usefulness in terms of assessment performance time was addressed. RESULTS: Psychometric properties were within a desirable range for each site, critical care patients, and all participants (sensitivity, 0.64-1.00; specificity, 0.50-0.70; and DOR, 4.73-7.0). Although sensitivity at 1 site was high (0.84), specificity was low (0.37). CONCLUSIONS: Results suggest that the BHHRFA is clinically useful for adult inpatients across acute care settings.

Self-Triage Use, Subsequent Healthcare Utilization, and Diagnoses: A Retrospective Study of Process and Clinical Outcomes Following Self-Triage and Self-Scheduling for Ear or Hearing Symptoms.

Background: Self-triage is becoming more widespread, but little is known about the people who are using online self-triage tools and their outcomes. For self-triage researchers, there are significant barriers to capturing subsequent healthcare outcomes. Our integrated healthcare system was able to capture subsequent healthcare utilization of individuals who used self-triage integrated with self-scheduling of provider visits. Methods: We retrospectively examined healthcare utilization and diagnoses after patients had used self-triage and self-scheduling for ear or hearing symptoms. Outcomes and counts of office visits, telemedicine interactions, emergency department visits, and hospitalizations were captured. Diagnosis codes associated with subsequent provider visits were dichotomously categorized as being associated with ear or hearing concerns or not. Nonvisit care encounters of patient-initiated messages, nurse triage calls, and clinical communications were also captured. Results: For 2168 self-triage uses, we were able to capture subsequent healthcare encounters within 7 days of the self-triage for 80.5% (1745/2168). In subsequent 1092 office visits with diagnoses, 83.1% (891/1092) of the uses were associated with relevant ear, nose and throat diagnoses. Only 0.24% (4/1662) of patients with captured outcomes were associated with a hospitalization within 7 days. Self-triage resulted in a self-scheduled office visit in 7.2% (126/1745). Office visits resulting from a self-scheduled visit had significantly fewer combined non-visit care encounters per office visit (fewer combined nurse triage calls, patient messages, and clinical communication messages) than office visits that were not self-scheduled (-0.51; 95% CI, -0.72 to -0.29; P < .0001). Conclusion: In an appropriate healthcare setting, self-triage outcomes can be captured in a high percentage of uses to examine for safety, patient adherence to recommendations, and efficiency of self-triage. With the ear or hearing self-triage, most uses had subsequent visit diagnoses relevant to ear or hearing, so most patients appeared to be selecting the appropriate self-triage pathway for their symptoms.

A large public dataset of annotated clinical MRIs and metadata of patients with acute stroke.

To extract meaningful and reproducible models of brain function from stroke images, for both clinical and research proposes, is a daunting task severely hindered by the great variability of lesion frequency and patterns. Large datasets are therefore imperative, as well as fully automated image post-processing tools to analyze them. The development of such tools, particularly with artificial intelligence, is highly dependent on the availability of large datasets to model training and testing. We present a public dataset of 2,888 multimodal clinical MRIs of patients with acute and early subacute stroke, with manual lesion segmentation, and metadata. The dataset provides high quality, large scale, human-supervised knowledge to feed artificial intelligence models and enable further development of tools to automate several tasks that currently rely on human labor, such as lesion segmentation, labeling, calculation of disease-relevant scores, and lesion-based studies relating function to frequency lesion maps.

Factors impacting educational outcomes for students with traumatic brain injury in BrainSTEPS.

Purpose: To describe child pre-injury and injury factors impacting post-injury educational outcomes for students with traumatic brain injury (TBI) participating in a state-wide, school-based, school re-entry consultation program, BrainSTEPS in Pennsylvania.Method: Retrospective analysis of a BrainSTEPS annual follow-up survey.Result: A total of 296 parent surveys were completed. Analysis revealed a significant difference between levels of severity of TBI and current educational placement (p < 0.001), receipt of current therapy (p < 0.05) and need for additional consult (p < 0.05). Severity of TBI was not related to other examined educational outcome variables (i.e. school performance, current symptoms). History of TBI, symptoms and treatment were not found to be associated with educational outcomes.Conclusion: These results both support findings from previous studies, and extend previous work by highlighting ongoing needs, including continued, individualised support, of children who sustain a moderate-severe TBI during childhood, and are currently in the chronic stages of injury, with consideration of pre- and post- injury factors. Programs such as BrainSTEPS provide identification of educational needs and provide needed services and supports for children with TBI. Sensitive, validated measures are needed to further understand the role of pre-injury and injury factors on educational outcomes, particularly in programs like BrainSTEPS.

Assessing the Relationship between LAMS and CT Perfusion Parameters in Acute Ischemic Stroke Secondary to Large Vessel Occlusion.

BACKGROUND: The Los Angeles Motor Scale (LAMS) is a rapid pre-hospital scale used to predict stroke severity which has also been shown to accurately predict large vessel occlusions (LVOs). However, to date there is no study exploring whether LAMS correlates with the computed tomography perfusion (CTP) parameters in LVOs. METHODS: Patients with LVO between September 2019 and October 2021 were retrospectively reviewed and included if the CTP data and admission neurologic exams were available. The LAMS was documented based on emergency personnel exams or scored retrospectively using an admission neurologic exam. The CTP data was processed by RAPID (IschemaView, Menlo Park, CA, USA) with an ischemic core volume (relative cerebral blood flow [rCBF] < 30%), time-to-maximum (Tmax) volume (Tmax > 6 s delay), hypoperfusion index (HI), and cerebral blood volume (CBV) index. Spearman's correlations were performed between the LAMS and CTP parameters. RESULTS: A total of 85 patients were included, of which there were 9 intracranial internal carotid artery (ICA), 53 proximal M1 branch middle cerebral artery M1, and 23 proximal M2 branch occlusions. Overall, 26 patients had LAMS 0-3, and 59 had LAMS 4-5. In total, LAMS positively correlated with CBF < 30% (Correlation Coefficient (CC): 0.32, p < 0.01), Tmax > 6 s (CC:0.23, p < 0.04), HI (CC:0.27, p < 0.01), and negatively correlated with the CBV index (CC:-0.24, p < 0.05). The relationships between LAMS and CBF were < 30% and the HI was more pronounced in M1 occlusions (CC:0.42, p < 0.01; 0.34, p < 0.01 respectively) and proximal M2 occlusions (CC:0.53, p < 0.01; 0.48, p < 0.03 respectively). The LAMS also correlated with a Tmax > 6 s in M1 occlusions (CC:0.42, p < 0.01), and negatively correlated with the CBV index in M2 occlusions (CC:-0.69, p < 0.01). There were no significant correlations between the LAMS and intracranial ICA occlusions. CONCLUSIONS: The results of our preliminary study indicate that the LAMS is positively correlated with the estimated ischemic core, perfusion deficit, and HI, and negatively correlated with the CBV index in patients with anterior circulation LVO, with stronger relationships in the M1 and M2 occlusions. This is the first study showing that the LAMS may be correlated with the collateral status and estimated ischemic core in patients with LVO.

Online Self-Triage of Ear or Hearing Concerns in a Patient Portal: Comparison of Subsequent Diagnoses and Hospitalizations to National Emergency Department and National Ambulatory Ear or Hearing Visits.

Background: Although online self-triage is easily accessible, little is known about the patients who use self-triage or their subsequent diagnoses. We compared ear/hearing self-triage subsequent diagnoses to ear/hearing visit diagnoses in emergency departments (ED) and ambulatory clinics across the United States. Methods: We compared International Classification of Diseases version 10 (ICD10) coded diagnoses following online self-triage for ear/hearing concerns with those from national ED and ambulatory clinic samples. We used data from the Centers for Disease Control (CDC) National Hospital Ambulatory Medical Care Survey (NHAMCS) and National Ambulatory Medical Care Survey (NAMCS) for comparison. Using matched ear/hearing diagnostic categories for those aged 1 and over, we compared self-triage diagnosis frequencies with national ED and ambulatory diagnosis frequencies. Results: Following ear/hearing self-triage, there were 1092 subsequent office visits with a primary diagnosis code. For five frequently diagnosed ear/hearing conditions (i.e., suppurative and nonsuppurative otitis media [OM], otalgia, otitis externa, and cerumen impaction), there was a strong correlation between diagnosis counts made following self-triage and estimated counts of national ED visit diagnoses (r = 0.94; CI 95% [0.37 to 0.99]; p = .016, adjusted r2 = 0.85). Seven diagnoses were available to compare with the national ambulatory sample; correlation was r = 0.79; CI 95% [0.08 to 0.97]; p = .037, adjusted r2 = 0.54. For ages 1 and over, estimated hospital admissions from the national ED visits for ear/hearing were 0.76%, CI 95% [0.28-2.1%]; estimated total national ear/hearing ED visits were 7.5 million (for 4 years, 2016 through 2019). Conclusion: The strong correlation of ear-related self-triage diagnoses with national ED diagnoses and the low hospitalization risk for these diagnoses suggests that there is an opportunity for self-triage of ear/hearing concerns to decrease ED visits for these symptoms.

Cognitive, social, and health functioning of children with TBI engaged in a formal support program.

BACKGROUND: Students with traumatic brain injury (TBI) often demonstrate difficulties that impact their successful return to school (RTS). OBJECTIVE: To explore injury severity, age at injury, and time since injury as predictors for performance on measures of cognitive, social and health functioning for students' participating in a formal RTS cohort at the time of their enrollment in the School Transition After Traumatic Brain Injury (STATBI) research project. METHODS: Outcome measures across cognitive, social, and health domains were analyzed for association with the explanatory variables of interest using quantile regressions and ordinary least squares regression, as appropriate. RESULTS: Students (N = 91) injured after age 13 showed significantly lower cognitive outcomes than students whose injury occurred earlier. Additionally, students more than one-year post-injury demonstrated poorer social outcome on one measure compared to students whose injury occurred more recently. Health outcomes showed no significant association to any predictors. CONCLUSION: The results of this analysis provide a baseline for a group of students with TBI as they enter a RTS research study. This data can now be paired with longitudinal measures and qualitative data collected simultaneously to gain a deeper understanding of how students with TBI present for RTS.