RESUMEN
OBJECTIVE: To examine the association between hearing impairment and cognitive function after traumatic brain injury (TBI). SETTING: A total of 18 level I trauma centers throughout the United States in the T ransforming R esearch a nd C linical K nowledge in TBI (TRACK-TBI) study. PARTICIPANTS: From February 2014 to June 2018, a total of 2697 participants with TBI were enrolled in TRACK-TBI. Key eligibility criteria included external force trauma to the head, presentation to a participating level I trauma center, and receipt of a clinically indicated head computed tomographic (CT) scan within 24 hours of injury. A total of 1267 participants were evaluated in the study, with 216 participants with hearing impairment and 1051 participants without hearing impairment. Those with missing or unknown hearing status or cognitive assessment were excluded from analysis. DESIGN: Prospective, observational cohort study. MAIN MEASURES: Hearing impairment at 2 weeks post-TBI was based on self-report. Participants who indicated worse hearing in one or both ears were defined as having hearing impairment, whereas those who denied worse hearing in either ear were defined as not having hearing impairment and served as the reference group. Cognitive outcomes at 6 months post-TBI included executive functioning and processing speed, as measured by the Trail Making Test (TMT) B/A and the Wechsler Adult Intelligence Scale, Fourth Edition, Processing Speed Index subscale (WAIS-IV PSI), respectively. RESULTS: TBI-related hearing impairment had a small but significantly greater TMT B/A ratio than without TBI-related hearing impairment: mean difference ( B ) = 0.25; 95% CI, 0.07 to 0.43; P = .005. No significant mean differences on WAIS-IV PSI scores were found between participants with and without TBI-related hearing impairment: B = 0.36; 95% CI, -2.07 to 2.60; P = .825. CONCLUSION: We conclude that TBI-related hearing impairment at 6 months postinjury was significantly associated with worse executive functioning but not cognitive processing speed.
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Lesiones Traumáticas del Encéfalo , Pérdida Auditiva , Adulto , Lesiones Traumáticas del Encéfalo/complicaciones , Lesiones Traumáticas del Encéfalo/diagnóstico , Cognición , Humanos , Pruebas Neuropsicológicas , Estudios Prospectivos , Estados Unidos/epidemiología , Escalas de WechslerRESUMEN
OBJECTIVE: To identify risk factors for suicidal ideation (SI) following mild traumatic brain injury (mTBI). SETTING: Eleven US level 1 trauma centers. PARTICIPANTS: A total of 1158 emergency department patients with mTBI (Glasgow Coma Scale score = 13-15) enrolled in the Transforming Research and Clinical Knowledge in Traumatic Brain Injury (TRACK-TBI) study. DESIGN: Prospective observational study; weights-adjusted multivariable logistic regression models (n's = 727-883) estimated associations of baseline factors and post-TBI symptoms with SI at 2 weeks and 3, 6, and 12 months postinjury. MAIN MEASURES: Patient Health Questionnaire, Rivermead Post-Concussion Symptoms Questionnaire. RESULTS: Preinjury psychiatric history predicted SI at all follow-ups (adjusted odds ratios [AORs] = 2.26-6.33, P values <.05) and history of prior TBI predicted SI at 2 weeks (AOR = 2.36, 95% confidence interval [CI] = 1.16-4.81, P = .018), 3 months (AOR = 2.62, 95% CI = 1.33-5.16, P = .005), and 6 months postinjury (AOR = 2.54, 95% CI = 1.19-5.42, P = .016). Adjusting for these baseline factors, post-TBI symptoms were strongly associated with SI at concurrent (AORs = 1.91-2.88 per standard deviation unit increase in Rivermead Post-Concussion Symptoms Questionnaire score; P values <.0005) and subsequent follow-up visits (AORs = 1.68-2.53; P values <.005). Most of the associations between post-TBI symptoms and SI were statistically explained by co-occurring depression. CONCLUSION: Screening for psychiatric and prior TBI history may help identify patients at risk for SI following mTBI. Awareness of the strong associations of post-TBI symptoms with SI may facilitate interventions to prevent suicide-related outcomes in patients with mTBI.
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Conmoción Encefálica , Lesiones Traumáticas del Encéfalo , Conmoción Encefálica/diagnóstico , Conmoción Encefálica/epidemiología , Lesiones Traumáticas del Encéfalo/diagnóstico , Lesiones Traumáticas del Encéfalo/epidemiología , Escala de Coma de Glasgow , Humanos , Factores de Riesgo , Ideación SuicidaRESUMEN
OBJECTIVES: The primary outcome of this study was to assess the efficacy and safety of preventive treatment with amitriptyline on headache frequency and severity after mild traumatic brain injury (mTBI). BACKGROUND: Despite the fact that headache is the most common and persistent physical symptom after TBI, there has been little research on the longitudinal course or pharmacologic treatment of this disorder. Of those who have headache after injury, about 60% continue to complain of headache at 3 months post injury, with higher levels of disability than those without headache. There have been no prospective, randomized, controlled trials of a pharmacologic agent for headache after TBI. Additionally, a brain-injured population may be more susceptible to side effects of medication. DESIGN: This is a single-center phase II trial of amitriptyline to prevent persistent headache after an mTBI. Medication dose was gradually increased from 10 to 50 mg daily. RESULTS: Fifty participants were enrolled and 33 who completed the 90-day assessment were included in the final analysis. In order to detect a possible cognitive impact of the study drug, 24 participants were randomly assigned to start amitriptyline immediately after study enrollment and 26 were assigned to start 30 days after enrollment. Forty-nine percent (18/37) of those assigned to take medication took none throughout the study period, with less compliance in younger participants with mean ages of 32.7 in those who did not take any medication, 33.4 who were less than 80% compliant, and 42.3 who were compliant (P = .013). Compliance in keeping a daily headache diary was low, with 29/50 participants (58%) meeting daily entry completion, and only 10 participants maintaining 100% diary completion. No differences were found between those who started medication immediately vs at day 30 in headache frequency or severity. CONCLUSIONS: While headache is the most common symptom following mTBI, current evidence does not support a specific treatment. No differences were noted in headache frequency compared to our prior study. However, the current sample had significantly lower headache severity (15% vs 36% with pain rating of 6 or above, P = .015) compared to our prior study. Our current study was not able to determine whether there is any benefit for the use of amitriptyline as a headache preventive because of difficulty with study recruitment and compliance. The challenges with recruitment and retention in the mTBI population were instructive, and future research in this area will need to identify strategies to improve recruitment, diary compliance, and medication adherence in this population.
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Amitriptilina/farmacología , Analgésicos no Narcóticos/farmacología , Conmoción Encefálica/complicaciones , Evaluación de Resultado en la Atención de Salud , Cefalea Postraumática/prevención & control , Adolescente , Adulto , Amitriptilina/administración & dosificación , Analgésicos no Narcóticos/administración & dosificación , Estudios de Factibilidad , Femenino , Escala de Coma de Glasgow , Humanos , Masculino , Persona de Mediana Edad , Cefalea Postraumática/etiología , Estudios Prospectivos , Índice de Severidad de la Enfermedad , Insuficiencia del Tratamiento , Adulto JovenRESUMEN
OBJECTIVE: To characterize employment stability and identify predictive factors of employment stability in working-age individuals after moderate-to-severe traumatic brain injury (TBI) that may be clinically addressed. DESIGN: Longitudinal observational study of an inception cohort from the Traumatic Brain Injury Model Systems National Database (TBIMS-NDB) using data at years 1, 2, and 5 post-TBI. SETTING: Inpatient rehabilitation centers with telephone follow-up. PARTICIPANTS: Individuals enrolled in the TBIMS-NDB since 2001, aged 18-59, with employment data at 2 or more follow-up interviews at years 1, 2, and 5 (N=5683). INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURE: Employment stability, categorized using post-TBI employment data as no paid employment (53.25%), stably (27.20%), delayed (10.24%), or unstably (9.31%) employed. RESULTS: Multinomial regression analyses identified predictive factors of employment stability, including younger age, white race, less severe injuries, preinjury employment, higher annual earnings, male sex, higher education, transportation independence postinjury, and no anxiety or depression at 1 year post-TBI. CONCLUSIONS: Employment stability serves as an important measure of productivity post-TBI. Psychosocial, clinical, environmental, and demographic factors predict employment stability post-TBI. Notable predictors include transportation independence as well as the presence of anxiety and depression at year 1 post-TBI as potentially modifiable intervention targets.
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Lesiones Traumáticas del Encéfalo/rehabilitación , Empleo/estadística & datos numéricos , Adolescente , Adulto , Factores de Edad , Femenino , Humanos , Estudios Longitudinales , Masculino , Persona de Mediana Edad , Análisis de Regresión , Centros de Rehabilitación , Factores de Tiempo , Adulto JovenRESUMEN
OBJECTIVE: To evaluate the relationship between satisfaction with life (SWL) and functional outcome after traumatic brain injury (TBI). SETTING AND PARTICIPANTS: The Transforming Research and Clinical Knowledge in Traumatic Brain Injury Pilot study (TRACK-TBI Pilot) enrolled patients at 3 US Level I trauma centers within 24 hours of TBI. DESIGN: Patients were grouped by outcome measure concordance (good-recovery/good-satisfaction, impaired-recovery/impaired-satisfaction) and discordance (good-recovery/impaired-satisfaction, impaired-recovery/good-satisfaction). Logistic regression was utilized to determine predictors of discordance. MAIN MEASURES: Functional outcome: Glasgow Outcome Scale-Extended (GOSE); SWL: Satisfaction with Life Scale (SWLS). RESULTS: Of the 586 enrolled subjects, 298 had completed both outcome measures at 6-month follow-up; the correlation between GOSE and SWLS was 0.380. Patients with impaired-recovery (GOSE < 7)/impaired-satisfaction (SWLS < 20) were more likely to have mild TBI (83% vs 62%, P = .012), baseline depression (42% vs 15%, P < .0001), and 6-month depression (59% vs 21%, P < .0001) when compared with patients with impaired-recovery/good-satisfaction. Patients with good-recovery/impaired-satisfaction were more likely to have baseline depression (31% vs 13%, P < .0001) and 6-month depression (33% vs 6%, P < .0001) compared with good-recovery/good-satisfaction. CONCLUSION: Correlation between SWL and functional outcome was not strong, and depression may modulate the association. Future research should account for functional, mental health, and patient-centered outcomes when assessing TBI recovery.
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Lesiones Traumáticas del Encéfalo/psicología , Satisfacción Personal , Adulto , Anciano , Lesiones Traumáticas del Encéfalo/terapia , Femenino , Escala de Consecuencias de Glasgow , Humanos , Masculino , Persona de Mediana Edad , Evaluación de Resultado en la Atención de Salud , Proyectos Piloto , Recuperación de la Función , Factores Socioeconómicos , Factores de TiempoRESUMEN
OBJECTIVES: Aging individuals with traumatic brain injury (TBI) experience multiple comorbidities that can affect recovery from injury. The objective of this study was to describe the most commonly co-occurring comorbid conditions among adults 50 years and older with TBI. SETTING: Level I Trauma centers. PARTICIPANTS: Adults 50 years and older with moderate/severe TBI enrolled in the TBI-Model Systems (TBI-MS) from 2007 to 2014 (n = 2134). DESIGN: A TBI-MS prospective cohort study. MAIN MEASURES: International Classification of Disease-9th Revision codes collapsed into 45 comorbidity categories. Comorbidity prevalence estimates and trend analyses were conducted by age strata (50-54, 55-64, 65-74, 75-84, ≥85 years). A dimension reduction method, Treelet Transform, classified clusters of comorbidities that tended to co-occur. RESULTS: The 3 most commonly occurring comorbid categories were hypertensive disease (52.6/100 persons), other diseases of the respiratory system (51.8/100 persons), and fluid component imbalances (43.7/100 persons). Treelet Transform classified 3 clusters of comorbid codes, broadly classified as (1) acute medical diseases/infections, (2) chronic conditions, and (3) substance abuse disorders. CONCLUSION: This study provides valuable insight into comorbid conditions that co-occur among adults 50 years and older with TBI and provides a foundation for future studies to explore how specific comorbidities affect TBI recovery.
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Lesiones Traumáticas del Encéfalo/complicaciones , Lesiones Traumáticas del Encéfalo/epidemiología , Factores de Edad , Anciano , Anciano de 80 o más Años , Lesiones Traumáticas del Encéfalo/psicología , Enfermedad Crónica , Análisis por Conglomerados , Estudios de Cohortes , Comorbilidad , Femenino , Humanos , Masculino , Persona de Mediana Edad , PrevalenciaRESUMEN
Traumatic brain injury (TBI) is a global public health problem that affects the long-term cognitive, physical, and psychological health of patients, while also having a major impact on family and caregivers. In stark contrast to the effective trials that have been conducted in other neurological diseases, nearly 30 studies of interventions employed during acute hospital care for TBI have failed to identify treatments that improve outcome. Many factors may confound the ability to detect true and meaningful treatment effects. One promising area for improving the precision of intervention studies is to optimize the validity of the outcome assessment battery by using well-designed tools and data collection strategies to reduce variability in the outcome data. The Transforming Research and Clinical Knowledge in TBI (TRACK-TBI) study, conducted at 18 sites across the United States, implemented a multidimensional outcome assessment battery with 22 measures aimed at characterizing TBI outcome up to 1 year postinjury. In parallel, through the TBI Endpoints Development (TED) Initiative, federal agencies and investigators have partnered to identify the most valid, reliable, and sensitive outcome assessments for TBI. Here, we present lessons learned from the TRACK-TBI and TED initiatives aimed at optimizing the validity of outcome assessment in TBI.
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Lesiones Traumáticas del Encéfalo/epidemiología , Lesiones Traumáticas del Encéfalo/terapia , Ensayos Clínicos como Asunto/organización & administración , Evaluación de Resultado en la Atención de Salud , Lesiones Traumáticas del Encéfalo/diagnóstico , Terapia Combinada , Femenino , Escala de Coma de Glasgow , Humanos , Incidencia , Puntaje de Gravedad del Traumatismo , Masculino , Evaluación de Necesidades , Evaluación de Programas y Proyectos de Salud , Medición de Riesgo , Resultado del Tratamiento , Estados UnidosRESUMEN
OBJECTIVE: Major depressive disorder (MDD) is common and associated with impaired functioning after traumatic brain injury (TBI). Few placebo-controlled antidepressant trials exist in this population. We evaluated the efficacy and tolerability of sertraline for MDD within 1 year of sustaining a TBI. SETTING: Level I trauma center. PARTICIPANTS: Adults with MDD within 1 year of hospitalization for complicated mild to severe TBI. DESIGN: Randomized, double-blind, placebo-controlled trial. MAIN MEASURES: Twelve-week treatment response on the 17-item Hamilton Depression Rating Scale. We also assessed symptom improvement and remission. RESULTS: We randomized 62 participants: 32% sustained a severe TBI, 68% had significant anxiety, 63% had a history of prior MDD, and 69% had a history of alcohol or drug dependence. Depression significantly improved from baseline to 12 weeks in both treatment groups (P < .001). There were no significant differences between the sertraline and placebo groups over 12 weeks on depression severity, response, or remission. The sertraline group had significant improvement on speed of information processing compared with the placebo group (P < .006). CONCLUSION: Sertraline monotherapy was not superior to placebo for MDD in people with post-acute complicated mild to severe TBI. Research is needed on the effectiveness of interventions that also address the significant psychosocial needs of this population.
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Antidepresivos/uso terapéutico , Lesiones Traumáticas del Encéfalo/complicaciones , Trastorno Depresivo Mayor/tratamiento farmacológico , Sertralina/uso terapéutico , Adulto , Lesiones Traumáticas del Encéfalo/diagnóstico , Lesiones Traumáticas del Encéfalo/psicología , Trastorno Depresivo Mayor/etiología , Trastorno Depresivo Mayor/fisiopatología , Relación Dosis-Respuesta a Droga , Método Doble Ciego , Esquema de Medicación , Femenino , Estudios de Seguimiento , Humanos , Masculino , Persona de Mediana Edad , Análisis Multivariante , Escalas de Valoración Psiquiátrica , Índice de Severidad de la Enfermedad , Factores de Tiempo , Resultado del TratamientoRESUMEN
OBJECTIVE: To assess the effects of amantadine on anger and aggression among individuals with a chronic traumatic brain injury (TBI). METHODS: A cohort of 118 persons with chronic TBI (>6 months postinjury) and moderate-severe aggression selected from a larger cohort of 168 participants enrolled in a parallel-group, randomized, double-blind, placebo-controlled trial of amantadine 100 mg twice daily (n = 82) versus placebo (n = 86) for treatment of irritability were studied. Anger and aggression were measured at treatment days 0, 28, and 60 using observer-rated and participant-rated State-Trait Anger Expression Inventory-2 (STAXI-2) and Neuropsychiatric Inventory-Agitation/Aggression domain (NPI-A) Most Problematic and Distress scores. RESULTS: Participant-rated day 60 NPI-A Most Problematic (adjusted P = .0118) and NPI-A Distress (adjusted P = .0118) were statistically significant between the 2 groups, but STAXI-2 differences were not significant after adjustment for multiple comparisons. Substantial improvements were noted in both amantadine and placebo groups (70% vs 56% improving at least 3 points on day 60 Observer NPI-A; P = .11). CONCLUSION: Amantadine 100 mg twice daily in this population with chronic TBI appears to be beneficial in decreasing aggression from the perspective of the individual with TBI. No beneficial impact on anger was found. TRIAL REGISTRATION: clinicaltrials.gov Identifier: NCT00779324; http://www.clinicaltrials.gov/ct2/show/NCT00779324?term=irritability&rank=6.
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Agresión/efectos de los fármacos , Amantadina/administración & dosificación , Lesiones Traumáticas del Encéfalo/complicaciones , Genio Irritable/efectos de los fármacos , Adulto , Agresión/psicología , Amantadina/efectos adversos , Lesiones Traumáticas del Encéfalo/diagnóstico , Lesiones Traumáticas del Encéfalo/psicología , Distribución de Chi-Cuadrado , Enfermedad Crónica , Relación Dosis-Respuesta a Droga , Método Doble Ciego , Esquema de Medicación , Femenino , Estudios de Seguimiento , Escala de Coma de Glasgow , Humanos , Puntaje de Gravedad del Traumatismo , Masculino , Persona de Mediana Edad , Medición de Riesgo , Estadísticas no Paramétricas , Resultado del TratamientoRESUMEN
OBJECTIVE: To investigate the clinical management and medical follow-up of patients with mild traumatic brain injury (mTBI) presenting to emergency departments (EDs). METHODS: Overall, 168 adult patients with mTBI from the prospective, multicentre Transforming Research and Clinical Knowledge in TBI (TRACK-TBI) Pilot study with Glasgow Coma Scale (GCS) 13-15, no polytrauma and alive at six months were included. Predictors for hospital admission, three-month follow-up referral and six-month functional disability (Glasgow Outcome Scale-Extended (GOSE) ≤ 6) were analysed using multivariable regression. RESULTS: Overall, 48% were admitted to hospital, 22% received three-month referral and 27% reported six-month functional disability. Intracranial pathology on ED head computed tomography (multivariable odds ratio (OR) = 81.08, 95% confidence interval (CI) [10.28-639.36]) and amnesia (>30-minutes: OR = 5.27 [1.75-15.87]; unknown duration: OR = 4.43 [1.26-15.62]) predicted hospital admission. Older age (per-year OR = 1.03 [1.01-1.05]) predicted three-month referral, while part-time/unemployment predicted lack of referral (OR = 0.17 [0.06-0.50]). GCS < 15 (OR = 2.46 [1.05-5.78]) and prior history of seizures (OR = 3.62 [1.21-10.89]) predicted six-month functional disability, while increased education (per-year OR = 0.86 [0.76-0.97]) was protective. CONCLUSIONS: Clinical factors modulate triage to admission, while demographic/socioeconomic elements modulate follow-up care acquisition; six-month functional disability associates with both clinical and demographic/socioeconomic variables. Improving triage to acute and outpatient care requires further investigation to optimize resource allocation and outcome after mTBI. ClinicalTrials.gov registration: NCT01565551.
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Lesiones Traumáticas del Encéfalo/terapia , Personas con Discapacidad/psicología , Administración Hospitalaria , Resultado del Tratamiento , Adulto , Evaluación de la Discapacidad , Personas con Discapacidad/rehabilitación , Servicio de Urgencia en Hospital , Femenino , Estudios de Seguimiento , Escala de Consecuencias de Glasgow , Humanos , Masculino , Persona de Mediana Edad , Análisis Multivariante , Valor Predictivo de las Pruebas , Adulto JovenRESUMEN
OBJECTIVE: To examine headache and depression over time in individuals who sustained mild traumatic brain injury (mTBI). Prevalence of headache and depression early after mTBI and at 1 year postinjury as well as the relationship between the two are evaluated. BACKGROUND: Headache is the most common physical symptom and depression is among the most common psychiatric diagnosis after traumatic brain injury regardless of severity. Headache and depression have been found to be two independent factors related to poor outcome after mTBI, yet there appears to be a paucity of research exploring the comorbidity of these two conditions after injury. METHOD/DESIGN: Longitudinal survey design over 1 year of 212 participants with mTBI who were admitted to a Level 1 trauma center for observation or other system injuries. Depression was based on a score ≥10 on the Patient Health Questionnaire-9. Headache was based on participant report of new or worse-than-preinjury headache since hospitalization (baseline) or within the previous 3 months at 1 year postinjury. RESULTS: The prevalence of headache and depression at baseline was 64% (135/212) and 15% (31/212), respectively. The prevalence of headache and depression at 1 year was 68% (127/187) and 27% (50/187), respectively. The co-occurrence of headache and depression increased from 11% (23/212) at baseline to 25% (46/187) at 1 year. At 1 year, the risk ratio of individuals who had headache to be depressed was 5.43 (95% CI 2.05-14.40) compared to those without headache (P < .001). The corresponding risk ratio at baseline was 1.64 (95% CI .77-3.49; P = .23). CONCLUSIONS: While prevalence of headache is consistently high over the first year after injury, rate of depression increased over the first year for those who were followed. Given the high rate of comorbidity, those with headache may develop depression over time. Evaluation for possible depression in those with headache after mTBI should be conducted to address both conditions over the year following injury.
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Conmoción Encefálica/complicaciones , Depresión/epidemiología , Depresión/etiología , Cefalea/epidemiología , Cefalea/etiología , Adulto , Anciano , Comorbilidad , Femenino , Humanos , Estudios Longitudinales , Masculino , Persona de Mediana Edad , Prevalencia , Escalas de Valoración Psiquiátrica , Índices de Gravedad del TraumaRESUMEN
OBJECTIVE: To develop, in partnership with families of children with traumatic brain injury, a postdischarge intervention that is effective, simple, and sustainable. DESIGN: Randomized Controlled Trial. SETTING: Seven Level 1 Pediatric Trauma Centers in Argentina. PATIENTS: Persons less than 19 years of age admitted to one of the study hospitals with a diagnosis of severe, moderate, or complicated mild traumatic brain injury and were discharged alive. INTERVENTIONS: Patients were randomly assigned to either the intervention or standard care group. A specially trained Community Resource Coordinator was assigned to each family in the intervention group. We hypothesized that children with severe, moderate, and complicated mild traumatic brain injury who received the intervention would have significantly better functional outcomes at 6 months post discharge than those who received standard care. We further hypothesized that there would be a direct correlation between patient outcome and measures of family function. MEASUREMENTS AND MAIN RESULTS: The primary outcome measure was a composite measured at 6 months post injury. There were 308 patients included in the study (61% men). Forty-four percent sustained a complicated mild traumatic brain injury, 18% moderate, and 38% severe. Sixty-five percent of the patients were 8 years old or younger, and over 70% were transported to the hospital without ambulance assistance. There was no significant difference between groups on the primary outcome measure. There was a statistically significant correlation between the primary outcome measure and the scores on the Family Impact Module of the Pediatric Quality of Life Inventory (ρ = 0.57; p < 0.0001). Children with better outcomes lived with families reporting better function at 6 months post injury. CONCLUSIONS: Although no significant effect of the intervention was demonstrated, this study represents the first conducted in Latin America that documents the complete course of treatment for pediatric patients with traumatic brain injury spanning hospital transport through hospital care and into the postdischarge setting.
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Lesiones Traumáticas del Encéfalo/rehabilitación , Adolescente , Argentina , Niño , Preescolar , Continuidad de la Atención al Paciente/organización & administración , Femenino , Estudios de Seguimiento , Indicadores de Salud , Humanos , Lactante , Recién Nacido , Masculino , Evaluación de Resultado en la Atención de Salud , Alta del Paciente , Calidad de Vida , Método Simple Ciego , Centros Traumatológicos/organización & administración , Resultado del Tratamiento , Adulto JovenRESUMEN
OBJECTIVES: Examine the effects of posttraumatic amnesia (PTA) duration on neuropsychological and global recovery from 1 to 6 months after complicated mild traumatic brain injury (cmTBI). PARTICIPANTS: A total of 330 persons with cmTBI defined as Glasgow Coma Scale score of 13 to 15 in emergency department, with well-defined abnormalities on neuroimaging. METHODS: Enrollment within 24 hours of injury with follow-up at 1, 3, and 6 months. MEASURES: Glasgow Outcome Scale-Extended, California Verbal Learning Test II, and Controlled Oral Word Association Test. Duration of PTA was retrospectively measured with structured interview at 30 days postinjury. RESULTS: Despite all having a Glasgow Coma Scale Score of 13 to 15, a quarter of the sample had a PTA duration of greater than 7 days; half had PTA duration of 1 of 7 days. Both cognitive performance and Extended Glasgow Outcome Scale outcomes were strongly associated with time since injury and PTA duration, with those with PTA duration of greater than 1 week showing residual moderate disability at 6-month assessment. CONCLUSIONS: Findings reinforce importance of careful measurement of duration of PTA to refine outcome prediction and allocation of resources to those with cmTBI. Future research would benefit from standardization in computed tomographic criteria and use of severity indices beyond Glasgow Coma Scale to characterize cmTBI.
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Amnesia/etiología , Conmoción Encefálica/psicología , Adolescente , Adulto , Conmoción Encefálica/complicaciones , Conmoción Encefálica/tratamiento farmacológico , Citidina Difosfato Colina/administración & dosificación , Citidina Difosfato Colina/uso terapéutico , Femenino , Escala de Coma de Glasgow , Escala de Consecuencias de Glasgow , Humanos , Masculino , Persona de Mediana Edad , Fármacos Neuroprotectores/administración & dosificación , Fármacos Neuroprotectores/uso terapéutico , Pruebas Neuropsicológicas , Adulto JovenRESUMEN
BACKGROUND: Intracranial-pressure monitoring is considered the standard of care for severe traumatic brain injury and is used frequently, but the efficacy of treatment based on monitoring in improving the outcome has not been rigorously assessed. METHODS: We conducted a multicenter, controlled trial in which 324 patients 13 years of age or older who had severe traumatic brain injury and were being treated in intensive care units (ICUs) in Bolivia or Ecuador were randomly assigned to one of two specific protocols: guidelines-based management in which a protocol for monitoring intraparenchymal intracranial pressure was used (pressure-monitoring group) or a protocol in which treatment was based on imaging and clinical examination (imaging-clinical examination group). The primary outcome was a composite of survival time, impaired consciousness, and functional status at 3 months and 6 months and neuropsychological status at 6 months; neuropsychological status was assessed by an examiner who was unaware of protocol assignment. This composite measure was based on performance across 21 measures of functional and cognitive status and calculated as a percentile (with 0 indicating the worst performance, and 100 the best performance). RESULTS: There was no significant between-group difference in the primary outcome, a composite measure based on percentile performance across 21 measures of functional and cognitive status (score, 56 in the pressure-monitoring group vs. 53 in the imaging-clinical examination group; P=0.49). Six-month mortality was 39% in the pressure-monitoring group and 41% in the imaging-clinical examination group (P=0.60). The median length of stay in the ICU was similar in the two groups (12 days in the pressure-monitoring group and 9 days in the imaging-clinical examination group; P=0.25), although the number of days of brain-specific treatments (e.g., administration of hyperosmolar fluids and the use of hyperventilation) in the ICU was higher in the imaging-clinical examination group than in the pressure-monitoring group (4.8 vs. 3.4, P=0.002). The distribution of serious adverse events was similar in the two groups. CONCLUSIONS: For patients with severe traumatic brain injury, care focused on maintaining monitored intracranial pressure at 20 mm Hg or less was not shown to be superior to care based on imaging and clinical examination. (Funded by the National Institutes of Health and others; ClinicalTrials.gov number, NCT01068522.).
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Lesiones Encefálicas/fisiopatología , Encéfalo/diagnóstico por imagen , Hipertensión Intracraneal/diagnóstico , Presión Intracraneal , Monitoreo Fisiológico , Examen Neurológico , Adulto , Encéfalo/fisiopatología , Lesiones Encefálicas/complicaciones , Lesiones Encefálicas/mortalidad , Femenino , Humanos , Hipertensión Intracraneal/etiología , Estimación de Kaplan-Meier , Tiempo de Internación , Masculino , Monitoreo Fisiológico/instrumentación , Monitoreo Fisiológico/métodos , Tasa de Supervivencia , Tomografía Computarizada por Rayos X , Resultado del Tratamiento , Adulto JovenRESUMEN
OBJECTIVE: To examine headache trajectories among persons with mild traumatic brain injury (MTBI) in the year after injury and the relation of headache trajectory to posttraumatic stress disorder (PTSD) at 1 year postinjury. DESIGN: Prospective, longitudinal study. SETTING: Participants were recruited through a university medical center and participated in follow-up assessments by telephone. PARTICIPANTS: Prospectively enrolled individuals (N=212) within 1 week of MTBI who were hospitalized for observation or other system injuries. Participants were assessed at baseline and 3, 6, and 12 months postinjury. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Participants rated average headache pain intensity using the 0 to 10 numerical rating scale at each assessment period. The PTSD Checklist-Civilian Version was completed at 12 months postinjury. RESULTS: Latent class growth analysis produced a 4-trajectory group model, with groups labeled resolved, worsening, improving, and chronic. Multivariate regression modeling revealed that younger age and premorbid headache correlated with membership in the worse trajectory groups (worsening and chronic; P<.001). Univariate regression revealed a significant association between PTSD and membership in the worse trajectory groups (P<.001). CONCLUSIONS: Headache is common in the year after MTBI, with younger people, persons who previously had headaches, and persons with PTSD more likely to report chronic or worsening headache. Further research is needed to examine whether PTSD symptoms exacerbate headaches or whether problematic headache symptoms exacerbate PTSD.
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Lesiones Encefálicas/epidemiología , Cefalea/epidemiología , Trastornos por Estrés Postraumático/epidemiología , Adolescente , Adulto , Factores de Edad , Anciano , Anciano de 80 o más Años , Femenino , Humanos , Estudios Longitudinales , Masculino , Persona de Mediana Edad , Dimensión del Dolor , Estudios Prospectivos , Centros Traumatológicos , Adulto JovenRESUMEN
BACKGROUND: Headache is one of the most common and persistent symptoms following traumatic brain injury (TBI). The current study examines the prevalence and characteristics of headache following mild TBI (mTBI). METHODS: We prospectively enrolled 212 subjects within one week of mTBI who were hospitalized for observation or other system injuries in a single level 1 US trauma center and followed by telephone at three, six, and 12 months after injury for evaluation of headache. Headaches were classified according to ICHD-2 criteria as migraine, probable migraine, tension-type, cervicogenic, or unclassifiable headache. RESULTS: Subjects were 76% male and 75% white, and 58% were injured in vehicle-related crashes. A follow-up rate of 90% (190/212) occurred at 12 months post-injury. Eighteen percent (38/212) of subjects reported having a problem with headaches pre-injury while 54% (114/210) of subjects reported new or worse headaches compared to pre-injury immediately after injury, 62% (126/203) at three months, 69% (139/201) at six months, and 58% (109/189) at one year. Cumulative incidence was 91% (172/189) over one year. Up to 49% of headaches met criteria for migraine and probable migraine, followed by tension-type headaches (up to 40%). Age (≤ 60) was found to be a risk factor, but no significant difference was found in persistence of new or worse headache compared to pre-injury between males and females. More than one-third of the subjects reported persistent headache across all three follow-up time periods. CONCLUSIONS: Headache after mTBI is very common and persistent across the first year after injury. Assertive, early treatment may be warranted to avoid chronicity and disability. Further research is needed to determine whether post-traumatic headache (PTH) responds to headache treatment used in the primary headache disorders and whether chronic PTH is preventable.
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Lesiones Encefálicas/epidemiología , Cefaleas Secundarias/epidemiología , Trastornos Migrañosos/epidemiología , Cefalea Postraumática/epidemiología , Cefalea de Tipo Tensional/epidemiología , Adolescente , Adulto , Lesiones Encefálicas/complicaciones , Femenino , Estudios de Seguimiento , Cefaleas Secundarias/etiología , Humanos , Incidencia , Estudios Longitudinales , Masculino , Persona de Mediana Edad , Trastornos Migrañosos/etiología , Cefalea Postraumática/etiología , Prevalencia , Estudios Prospectivos , Factores de Riesgo , Cefalea de Tipo Tensional/etiología , Índices de Gravedad del Trauma , Adulto JovenRESUMEN
OBJECTIVES: We examined rates of suicidal ideation (SI) after traumatic brain injury (TBI) and investigated whether demographic characteristics, preinjury psychiatric history, or injury-related factors predicted SI during the first year after injury. METHODS: We followed a cohort of 559 adult patients who were admitted to Harborview Medical Center in Seattle, Washington, with a complicated mild to severe TBI between June 2001 and March 2005. Participants completed structured telephone interviews during months 1 through 6, 8, 10, and 12 after injury. We assessed SI using item 9 of the Patient Health Questionnaire (PHQ-9). RESULTS: Twenty-five percent of the sample reported SI during 1 or more assessment points. The strongest predictor of SI was the first PHQ-8 score (i.e., PHQ-9 with item 9 excluded) after injury. Other significant multivariate predictors included a history of a prior suicide attempt, a history of bipolar disorder, and having less than a high school education. CONCLUSIONS: Rates of SI among individuals who have sustained a TBI exceed those found among the general population. Increased knowledge of risk factors for SI may assist health care providers in identifying patients who may be vulnerable to SI after TBI.
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Lesiones Encefálicas/psicología , Ideación Suicida , Adolescente , Adulto , Lesiones Encefálicas/epidemiología , Femenino , Estado de Salud , Humanos , Incidencia , Masculino , Salud Mental , Persona de Mediana Edad , Prevalencia , Factores Socioeconómicos , Trastornos Relacionados con Sustancias/epidemiología , Factores de Tiempo , Washingtón/epidemiología , Adulto JovenRESUMEN
Episodic memory is one of the most important cognitive domains that involves acquiring, storing and recalling new information. In this article, we describe a new measure developed for the NIH Toolbox, called the Picture Sequence Memory Test (PSMT) that is the first to examine episodic memory across the age range from 3 to 85. We describe the development of the measure and present validation data for ages 20 to 85. The PSMT involves presentation of sequences of pictured objects and activities in a fixed order on a computer screen and simultaneously verbally described, that the participant must remember and then reproduce over three learning trials. The results indicate good test-retest reliability and construct validity. Performance is strongly related to well-established "gold standard" measures of episodic memory and, as expected, much less well correlated with those of a measure of vocabulary. It shows clear decline with aging in parallel with a gold standard summary measure and relates to several other demographic factors and to self-reported general health status. The PSMT appears to be a reliable and valid test of episodic memory for adults, a finding similar to those found for the same measure with children.
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Envejecimiento , Memoria Episódica , National Institutes of Health (U.S.) , Pruebas Neuropsicológicas/normas , Adolescente , Adulto , Factores de Edad , Anciano , Anciano de 80 o más Años , Niño , Preescolar , Femenino , Humanos , Masculino , Persona de Mediana Edad , Estimulación Luminosa , Reproducibilidad de los Resultados , Estadística como Asunto , Estados Unidos , Aprendizaje Verbal , Adulto JovenRESUMEN
This study describes psychometric properties of the NIH Toolbox Cognition Battery (NIHTB-CB) Composite Scores in an adult sample. The NIHTB-CB was designed for use in epidemiologic studies and clinical trials for ages 3 to 85. A total of 268 self-described healthy adults were recruited at four university-based sites, using stratified sampling guidelines to target demographic variability for age (20-85 years), gender, education, and ethnicity. The NIHTB-CB contains seven computer-based instruments assessing five cognitive sub-domains: Language, Executive Function, Episodic Memory, Processing Speed, and Working Memory. Participants completed the NIHTB-CB, corresponding gold standard validation measures selected to tap the same cognitive abilities, and sociodemographic questionnaires. Three Composite Scores were derived for both the NIHTB-CB and gold standard batteries: "Crystallized Cognition Composite," "Fluid Cognition Composite," and "Total Cognition Composite" scores. NIHTB Composite Scores showed acceptable internal consistency (Cronbach's alphas=0.84 Crystallized, 0.83 Fluid, 0.77 Total), excellent test-retest reliability (r: 0.86-0.92), strong convergent (r: 0.78-0.90) and discriminant (r: 0.19-0.39) validities versus gold standard composites, and expected age effects (r=0.18 crystallized, r=-0.68 fluid, r=-0.26 total). Significant relationships with self-reported prior school difficulties and current health status, employment, and presence of a disability provided evidence of external validity. The NIH Toolbox Cognition Battery Composite Scores have excellent reliability and validity, suggesting they can be used effectively in epidemiologic and clinical studies.
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Cognición/fisiología , National Institutes of Health (U.S.)/normas , Pruebas Neuropsicológicas , Reproducibilidad de los Resultados , Adulto , Factores de Edad , Anciano , Anciano de 80 o más Años , Función Ejecutiva , Femenino , Humanos , Lenguaje , Masculino , Memoria Episódica , Memoria a Corto Plazo , Persona de Mediana Edad , Pruebas Neuropsicológicas/normas , Psicometría/métodos , Psicometría/normas , Tiempo de Reacción , Encuestas y Cuestionarios , Estados Unidos , Adulto JovenRESUMEN
This study introduces a special series on validity studies of the Cognition Battery (CB) from the U.S. National Institutes of Health Toolbox for the Assessment of Neurological and Behavioral Function (NIHTB) (Gershon, Wagster et al., 2013) in an adult sample. This first study in the series describes the sample, each of the seven instruments in the NIHTB-CB briefly, and the general approach to data analysis. Data are provided on test-retest reliability and practice effects, and raw scores (mean, standard deviation, range) are presented for each instrument and the gold standard instruments used to measure construct validity. Accompanying papers provide details on each instrument, including information about instrument development, psychometric properties, age and education effects on performance, and convergent and discriminant construct validity. One study in the series is devoted to a factor analysis of the NIHTB-CB in adults and another describes the psychometric properties of three composite scores derived from the individual measures representing fluid and crystallized abilities and their combination. The NIHTB-CB is designed to provide a brief, comprehensive, common set of measures to allow comparisons among disparate studies and to improve scientific communication.