Ag20 Nanoclusters with Surface Azides as an Easily Functionalized Platform for Diverse Chemical Applications.

Modifying atomically precise nanocluster surfaces while maintaining the cluster core remains a key challenge. Herein, the synthesis, structure, and properties of two targeted Ag20 nanoclusters (NCs) with eight surface azide moieties, [CO3@Ag20(StBu)10(m-N3-C6H4COO)8(DMF)4] (1-m) and [CO3@Ag20(StBu)10(p-N3-C6H4COO)8(DMF)4] (1-p) are reported, where DMF is N,N-dimethylformamide. These AgNCs are designed to undergo cluster surface strain-promoted azide-alkyne cycloaddition (CS-SPAAC) reactions, introducing new functionality to the cluster surface. Reactivity is screened using model strained cyclooctynes. Reaction products and parent clusters are characterized by UV-vis, FT-IR, and NMR spectroscopies. The structure of the parent clusters and presence of surface azides is confirmed by single crystal X-ray diffraction (SCXRD) analysis. Clusters 1-m and 1-p are found to be amenable to CS-SPAAC reactions with retention of the NC frameworks, opening new routes for efficient modification of AgNC for applications.

Model of Care for Chronic Brain Injury.

There is growing evidence that long-term outcomes after traumatic brain injury (TBI) are more dynamic than stable. People continue to change, both improving and declining, many years postinjury. Research, practice, and medical education have not yet fully embraced the implications of TBI as a chronic, dynamic condition. In 2020, the National Institute on Disability Independent Living and Rehabilitation Research funded the BeHEALTHY project to develop a model for long-term support of persons with chronic brain injury. Based on initial reviews of the available evidence and expert input from researchers, clinicians, and persons with lived experience, the BeHEALTHY model was proposed. Among existing chronic disease treatment models, Wagner's Chronic Care Model was selected as a starting point, with several critical refinements. The BeHEALTHY model endorses a person-centered approach, recognizing the individual with brain injury, and their social support system, as the primary source of goals in care planning. The model also acknowledges the critical importance of self-management and the need for health care programs to actively promote self-direction by the person using their social supports. The model also recognizes that outcomes are not determined solely by the person and the injury incurred but also by the environment in which a person lives and recovers. The importance of integrating health care with community resources is underscored by embracing environmental influences as a shared responsibility of the community and the health care system. This article recounts the impetus for developing the BeHEALTHY model and describes those it is intended to serve and its structural features and core components.

Development of Composite Measures of Neighborhood Economic Factors for Use in Spinal Cord Injury Outcomes Studies: A Spinal Cord Injury Model Systems Database Study.

OBJECTIVE: To develop composite measures of neighborhood economic factors for use with the national Spinal Cord Injury Model Systems (SCIMSs) database in cross-sectional and longitudinal investigations of the social determinants of health. DESIGN: Secondary data analysis of administrative data from the 2009, 2014, and 2019 American Community Survey (ACS) 5-year estimates and survey data collected for the SCIMS database. SETTING: Community. PARTICIPANTS: The validity of the neighborhood economic measures developed from the ACS data was tested with a sample of SCIMS participants who completed a follow-up interview between 2017 and 2021 (N=8,130). The predictive validity of the neighborhood measures was assessed with a subsample of cases with complete data on the outcome and covariate measures (N=6,457). INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: A binary measure of self-rated health status (1=poor/fair health; 0=good/very good/excellent). RESULTS: A combination of panel review and data reduction techniques yielded 2 distinct measuring neighborhood socioeconomic status (SES) and neighborhood socioeconomic disadvantage that were validated using 3 waves of ACS data and the SCIMS data. The odds of reporting poor health were lower among people living in moderate- and high-SES neighborhoods and highest among people living in moderately and highly disadvantaged neighborhoods. The negative association between neighborhood SES and poor health was fully attenuated by differences in participants' individual demographic and economic characteristics whereas the positive association between neighborhood disadvantage and poor health persisted after adjusting for individual differences. CONCLUSIONS: The two composite measures of neighborhood economic factors developed by this study are robust in samples from different periods of time and valid for use with the SCIMS database. Future investigations conducting surveillance of the needs of the SCI population using this resource may consider using these measures to assess the effect of the social determinants of health in outcomes after SCI.

Neurobehavioral Symptoms in Spanish-Speaking Individuals With Subconcussive Injuries.

OBJECTIVE: To examine whether exposure to high-risk events causing injury to the head or neck has an effect on neurobehavioral symptoms in the absence of an alteration of consciousness in Spanish-speakers. SETTING: Web-based survey. PARTICIPANTS: Seven hundred forty-eight individuals from Spain and Latin America, aged 18 to 65 years, with 10 years or more of education. Thirty-nine participants failed quality checks and were excluded. Seven hundred nine participants were included in the analyses. DESIGN: Cross-sectional study. Subconcussive exposure was defined as endorsing exposure to one or more high-risk scenarios in the absence of any alteration of consciousness. Three injury groups were derived: No Head Injury, Subconcussive Exposure, and traumatic brain injury (TBI). The Subconcussive Exposure group was further divided into Single and Multiple Exposures. Two analyses were conducted: the effect of lifetime exposure to injury (No Head Injury, Subconcussive Exposure, TBI) on neurobehavioral symptoms; the effect of Subconcussive Exposure Frequency (No Head Injury, Single Exposure, Multiple Exposures) on neurobehavioral symptoms. MAIN MEASURES: Spanish Ohio State University Traumatic Brain Injury Identification Method Self-Administered-Brief (OSU TBI-ID SAB); Neurobehavioral Symptom Inventory (NSI). RESULTS: There was a significant effect for Injury group on the NSI partial eta-squared (η p2 = 0.053) and a significant effect of Exposure Frequency group on the NSI (η p2 = 0.40). Individuals with subconcussive exposures reported significantly more neurobehavioral symptoms than those with no history of head injury and significantly less symptoms than those with TBI. Individuals with multiple subconcussive exposures reported significantly more neurobehavioral symptoms than those with single and no exposure. CONCLUSION: This research expands the utility of the OSU-TBI-ID SAB as a lifetime TBI history assessment tool to one capable of evaluating subconcussive exposure dosing effects in Spanish-speakers. Such an index may facilitate establishment of subconcussive exposure prevalence rates worldwide, leading to improved understanding of the chronic effects of high-risk exposures.

Rationale for the Development of a Traumatic Brain Injury Case Definition for the Pilot National Concussion Surveillance System.

BACKGROUND: Current methods of traumatic brain injury (TBI) morbidity surveillance in the United States have primarily relied on hospital-based data sets. However, these methods undercount TBIs as they do not include TBIs seen in outpatient settings and those that are untreated and undiagnosed. A 2014 National Academy of Science Engineering and Medicine report recommended that the Centers for Disease Control and Prevention (CDC) establish and manage a national surveillance system to better describe the burden of sports- and recreation-related TBI, including concussion, among youth. Given the limitations of TBI surveillance in general, CDC took this recommendation as a call to action to formulate and implement a robust pilot National Concussion Surveillance System that could estimate the public health burden of concussion and TBI among Americans from all causes of brain injury. Because of the constraints of identifying TBI in clinical settings, an alternative surveillance approach is to collect TBI data via a self-report survey. Before such a survey was piloted, it was necessary for CDC to develop a case definition for self-reported TBI. OBJECTIVE: This article outlines the rationale and process the CDC used to develop a tiered case definition for self-reported TBI to be used for surveillance purposes. CONCLUSION: A tiered TBI case definition is proposed with tiers based on the type of sign/symptom(s) reported the number of symptoms reported, and the timing of symptom onset.

Refinement of a Preliminary Case Definition for Use in Traumatic Brain Injury Surveillance.

OBJECTIVE: Current methods used to measure incidence of traumatic brain injury (TBI) underestimate its true public health burden. The use of self-report surveys may be an approach to improve these estimates. An important step in public health surveillance is to define a public health problem using a case definition. The purpose of this article is to outline the process that the Centers for Disease Control and Prevention undertook to refine a TBI case definition to be used in surveillance using a self-report survey. SETTING: Survey. PARTICIPANTS: A total of 10 030 adults participated via a random digit-dial telephone survey from September 2018 to September 2019. MAIN MEASURES: Respondents were asked whether they had sustained a hit to the head in the preceding 12 months and whether they experienced a series of 12 signs and symptoms as a result of this injury. DESIGN: Head injuries with 1 or more signs/symptoms reported were initially categorized into a 3-tiered TBI case definition (probable TBI, possible TBI, and delayed possible TBI), corresponding to the level of certainty that a TBI occurred. Placement in a tier was compared with a range of severity measures (whether medical evaluation was sought, time to symptom resolution, self-rated social and work functioning); case definition tiers were then modified in a stepwise fashion to maximize differences in severity between tiers. RESULTS: There were statistically significant differences in the severity measure between cases in the probable and possible TBI tiers but not between other tiers. Timing of symptom onset did not meaningfully differentiate between cases on severity measures; therefore, the delayed possible tier was eliminated, resulting in 2 tiers: probable and possible TBI. CONCLUSION: The 2-tiered TBI case definition that was derived from this analysis can be used in future surveillance efforts to differentiate cases by certainty and from noncases for the purpose of reporting TBI prevalence and incidence estimates. The refined case definition can help researchers increase the confidence they have in reporting survey respondents' self-reported TBIs as well as provide them with the flexibility to report an expansive (probable + possible TBI) or more conservative (probable TBI only) estimate of TBI prevalence.

Characterizing Health Literacy and Its Correlates Among Individuals With Traumatic Brain Injury (TBI): A TBI Model Systems Study.

OBJECTIVE: To characterize health literacy among individuals with traumatic brain injury (TBI) at least a year postinjury and to explore its relationship to sociodemographic variables, injury severity, and cognition. SETTING: Community following discharge from inpatient rehabilitation. PARTICIPANTS: In total, 205 individuals with complicated mild to severe TBI who completed follow-up as part of a national longitudinal study of TBI and completed a web-based health literacy measure. DESIGN: Multicenter, cross-sectional, observational study. MAIN MEASURES: Health Literacy Assessment Using Talking Touchscreen Technology. RESULTS: Thirty-one percent of the sample demonstrated marginal/inadequate health literacy; 69% demonstrated adequate health literacy. A higher proportion of non-Hispanic White adults had adequate health literacy than non-Hispanic Black and Hispanic adults. Individuals with greater than a high school education were more likely to have adequate health literacy than those with a high school education or less. Better executive functioning performance was related to adequate health literacy. Better episodic memory performance was related to adequate health literacy, but only for those with complicated mild to moderate injury. CONCLUSIONS: A substantial proportion of individuals with TBI have marginal/inadequate health literacy, which may impact their understanding, appreciation, and use of health-related information and recommendations. While low health literacy may be preexisting, directly related to TBI, or a combination of both, it should be screened and considered by professionals when communicating with persons with TBI. Healthcare providers should tailor their communication approaches and presentation of health information, particularly for those with low health literacy.

The Effects of Repetitive Head Impact Exposure on Mental Health Symptoms Following Traumatic Brain Injury.

OBJECTIVE: This study aimed to characterize the types and timing of repetitive head impact (RHI) exposures in individuals with moderate to severe traumatic brain injury (TBI) and to examine the effects of RHI exposures on mental health outcomes. SETTING: TBI Model Systems National Database. PARTICIPANTS: 447 patients with moderate to severe TBI who reported RHI exposure between 2015 and 2022. DESIGN: Secondary data analysis. MAIN MEASURES: RHI exposures reported on the Ohio State University TBI Identification Method (OSU TBI-ID) were characterized by exposure category, duration, and timing relative to the index TBI. Mental health outcomes were evaluated at the 5-year follow-up assessment using the Patient Health Questionnaire-9 (PHQ-9) for depression symptoms and the Generalized Anxiety Disorder-7 (GAD-7) for anxiety symptoms. RESULTS: The majority of RHI exposures were sports-related (61.1%), followed by other causes (20.8%; including falls), repetitive violence/assault (18.8%), and military exposures (6.7%). Males predominantly reported sports and military exposures, while a larger proportion of females reported violence and falls. Sports exposures were most common before the index TBI, while exposures from falls and violence/abuse were most common after TBI. RHI exposures occurring after the index TBI were associated with higher levels of depression (ß = 5.05; 95% CI, 1.59-8.50) and anxiety (ß = 4.53; 95% CI, 1.02-8.05) symptoms than exposures before the index TBI. CONCLUSION: The findings emphasize the need to consider RHI exposures and their interaction with TBI when assessing mental health outcomes. Understanding the prevalence and challenges associated with RHI post-TBI can inform targeted interventions and improve the well-being of individuals with TBI. Preventive measures and ongoing care should be implemented to address the risks posed by RHI, particularly in individuals with prior TBI, especially surrounding fall and violence/abuse prevention.

The Relationship of Health Literacy to Health Outcomes Among Individuals With Traumatic Brain Injury: A Traumatic Brain Injury Model Systems Study.

OBJECTIVE: To examine the associations between health literacy and health outcomes among individuals with traumatic brain injury (TBI) at least a year post-injury. SETTING: Community following discharge from inpatient rehabilitation. PARTICIPANTS: A total of 205 individuals with complicated mild to severe TBI who completed a TBI Model Systems National Database follow-up interview and a web-based health literacy measure. DESIGN: A multicenter, cross-sectional, observational study. MAIN MEASURES: The Health Literacy Assessment Using Talking Touchscreen Technology (Health LiTT), number of comorbid conditions (Medical and Mental Health Comorbidities Interview [MMHCI]), perceived physical and mental health (PROMIS Global Physical and Mental Health subscales), Patient Health Questionnaire-9 (PHQ-9), and Generalized Anxiety Disorder-7 (GAD-7). RESULTS: After controlling for sociodemographic, injury, cognition, and time post-injury, adequate health literacy was associated with higher odds of greater perceived physical health compared with participants with marginal/inadequate health literacy (odds ratio = 4.10; CI = 1.52-11.70]. Participants with inadequate/marginal health literacy had 3.50 times greater odds of depression (PHQ-9 ≥ 10) compared with those with adequate health literacy. Participants 45 years and older reported a greater number of MMHCI physical health conditions, but fewer MMHCI mental health conditions and GAD-7 anxiety symptoms compared with those who were younger. Non-Hispanic White participants and those with mild/moderate TBI were more likely to report a greater number of MMHCI mental health conditions compared with non-Hispanic Black participants or those with severe TBI. Greater time post-injury was associated with greater number of chronic physical and mental health conditions, and less odds of good-to-excellent perceived global mental health. CONCLUSIONS: Inadequate health literacy is associated with worse perceived physical health and greater depressive symptoms among adults with TBI. Greater efforts are needed to explore the mechanisms by which health literacy influences chronic disease management and mental health after TBI to improve postinjury health status and outcomes, particularly among those with limited health literacy skills.

An Umbrella Review of Self-Management Interventions for Health Conditions With Symptom Overlap With Traumatic Brain Injury.

OBJECTIVE: To synthesize evidence for the effectiveness of self-management interventions for chronic health conditions that have symptom overlap with traumatic brain injury (TBI) in order to extract recommendations for self-management intervention in persons with TBI. DESIGN: An umbrella review of existing systematic reviews and/or meta-analyses of randomized controlled trials or nonrandomized studies targeting self-management of chronic conditions and specific outcomes relevant to persons with TBI. METHOD: A comprehensive literature search of 5 databases was conducted using PRISMA guidelines. Two independent reviewers conducted screening and data extraction using the Covidence web-based review platform. Quality assessment was conducted using criteria adapted from the Assessing the Methodological Quality of Systematic Reviews-2 (AMSTAR-2). RESULTS: A total of 26 reviews met the inclusion criteria, covering a range of chronic conditions and a range of outcomes. Seven reviews were of moderate or high quality and focused on self-management in persons with stroke, chronic pain, and psychiatric disorders with psychotic features. Self-management interventions were found to have positive effects on quality of life, self-efficacy, hope, reduction of disability, pain, relapse and rehospitalization rates, psychiatric symptoms, and occupational and social functioning. CONCLUSIONS: Findings are encouraging with regard to the effectiveness of self-management interventions in patients with symptoms similar to those of TBI. However, reviews did not address adaptation of self-management interventions for those with cognitive deficits or for populations with greater vulnerabilities, such as low education and older adults. Adaptations for TBI and its intersection with these special groups may be needed.

The Interaction of Opiate Misuse and Marijuana Use on Behavioral Health Outcomes Using the Traumatic Brain Injury Model Systems Pain Collaborative Dataset.

OBJECTIVE: To determine if the interaction of opiate misuse and marijuana use frequency is associated with behavioral health outcomes. SETTING: Community. PARTICIPANTS: Three thousand seven hundred fifty participants enrolled in the Traumatic Brain Injury Model Systems who completed the Pain Survey and had complete opioid use and marijuana use information. DESIGN: Cross-sectional, secondary analysis from a multisite observational cohort. MAIN OUTCOME MEASURES: Clinically significant behavioral health symptoms for posttraumatic stress disorder (PTSD), depression, anxiety, and sleep quality. RESULTS: Three thousand five hundred thirty-five (94.3%) participants did not misuse opiates, 215 (5.7%) did misuse opiates (taking more opioid pain medication than prescribed and/or using nonprescription opioid pain medication); 2683 (70.5%) participants did not use marijuana, 353 (9.3%) occasionally used marijuana (less than once a week), and 714 (18.8%) regularly used marijuana (once a week or more frequently). There was a statistically significant relationship (P < .05) between the interaction of opiate misuse and marijuana use frequency and all behavioral health outcomes and several covariates (age, sex, cause of injury, severity of injury, and pain group category). Pairwise comparisons confirm that statistically significant associations on behavioral health outcomes are driven by endorsing opiate misuse and/or regular marijuana use, but occasional marijuana use was not associated. CONCLUSIONS: Higher odds of clinically significant PTSD, depression, anxiety, and poor sleep quality are present in people with traumatic brain injury (TBI) who misuse opiates and/or who use marijuana regularly. In the absence of opiate misuse, regular marijuana use had higher odds of worse behavioral health outcomes than occasional and no use. The interaction of opiate misuse and regular marijuana use yielded the highest odds. Individuals with TBI should be informed of the relationship of substance use and behavioral health outcomes and that current chronic pain may mediate the association.

The TBI Model Systems Neighborhood Socioeconomic Disadvantage Index (TBIMS-NSDI): Development and Comparison to Individual Socioeconomic Characteristics.

OBJECTIVE: To create a census-based composite neighborhood socioeconomic deprivation index (NSDI) from geocoded residential addresses and to quantify how NSDI aligns with individual-level socioeconomic factors among people with traumatic brain injury (TBI). SETTING: Community. PARTICIPANTS: People enrolled in the TBI Model Systems National Database (TBIMS NDB). DESIGN: Secondary analysis of a longitudinal cohort study. MAIN MEASURES: The TBIMS-NSDI was calculated at the census tract level for the United States population based on a principal components analysis of eight census tract-level variables from the American Community Survey. Individual socioeconomic characteristics from the TBIMS NDB were personal household income, education (years), and unemployment status. Neighborhood:Individual NSDI residuals represent the difference between predicted neighborhood disadvantage based on individual socioeconomic characteristics versus observed neighborhood disadvantage based on the TBIMS-NSDI. RESULTS: A single principal component was found to encompass the eight socioeconomic neighborhood-level variables. It was normally distributed across follow-up years 2, 5, and 10 post-injury in the TBIMS NDB. In all years, the TBIMS-NDSI was significantly associated with individual-level measures of household income and education but not unemployment status. Males, persons of Black and Hispanic background, Medicaid recipients, persons with TBI caused by violence, and those living in urban areas, as well as in the Northeast or Southern regions of the United States, were more likely to have greater neighborhood disadvantage than predicted based on their individual socioeconomic characteristics. CONCLUSIONS: The TBIMS-NSDI provides a neighborhood-level indicator of socioeconomic disadvantage, an important social determinant of outcomes from TBI. The Neighborhood:Individual NSDI residual adds another dimension to the TBIMS-NSDI by summarizing how a person's socioeconomic status aligns with their neighborhood socioeconomics. Future studies should evaluate how both measures affect TBI recovery and life quality. Research studying neighborhood socioeconomic disadvantage may improve our understanding of how systemic adversity influences outcomes after TBI.

Cognitive Performance is Associated With 1-Year Participation and Life Satisfaction Outcomes: A Traumatic Brain Injury Model Systems Study.

OBJECTIVE: To determine, in persons with traumatic brain injury (TBI), the association between cognitive change after inpatient rehabilitation discharge and 1-year participation and life satisfaction outcomes. DESIGN: Secondary analysis of prospectively collected TBI Model Systems (TBIMS) data. SETTING: Inpatient rehabilitation and community. PARTICIPANTS: 499 individuals with TBI requiring inpatient rehabilitation who completed the Brief Test of Adult Cognition by Telephone (BTACT) at inpatient rehabilitation discharge (ie, baseline) and 1-year postinjury. MAIN OUTCOME MEASURES: Participation Assessment with Recombined Tools-Objective (PART-O) and Satisfaction with Life Scale (SWLS). RESULTS: Of 2,840 TBIMS participants with baseline BTACT, 499 met inclusion criteria (mean [standard deviation] age = 45 [19] years; 72% male). Change in BTACT executive function (EF) was not associated with 1-year participation (PART-O; ß = 0.087, 95% CI [-0.004, 0.178], P = .061) when it was the sole model predictor. Change in BTACT episodic memory (EM) was associated with 1-year participation (ß = 0.096, [0.007, 0.184], P = .035), but not after adjusting for demographic, clinical, and functional status covariates (ß = 0.067, 95% CI [-0.010, 0.145], P = .089). Change in BTACT EF was not associated with life satisfaction total scores (SWLS) when it was the sole model predictor (ß = 0.091, 95% CI [-0.001, 0.182], P = .0503). Change in BTACT EM was associated with 1-year life satisfaction before (ß = 0.114, 95% CI [0.025, 0.202], P = .012) and after adjusting for covariates (ß = 0.103, [0.014, 0.191], P = .023). In secondary analyses, change in BTACT EF was associated with PART-O Social Relations and Out and About subdomains before (Social Relations: ß = 0.127, 95% CI [0.036, 0.217], P = .006; Out and About: ß = 0.141, 95% CI [0.051, 0.232], P = .002) and after (Social Relations: ß = 0.168, 95% CI [0.072, 0.265], P < .002; Out and About: ß = 0.156, 95% CI [0.061, 0.252], P < .002) adjusting for functional status and further adjusting for covariates (Social Relations: ß = 0.127, 95% CI [0.040, 0.214], P = .004; Out and About: ß = 0.136, 95% CI [0.043, 0.229], P = .004). However, only the models adjusting for functional status remained significant after multiple comparison correction (ie, Bonferroni-adjusted alpha level = 0.002). CONCLUSION: EF gains during the first year after TBI were related to 1-year social and community participation. Gains in EM were associated with 1-year life satisfaction. These results highlight the potential benefit of cognitive rehabilitation after inpatient rehabilitation discharge and the need for interventions targeting specific cognitive functions that may contribute to participation and life satisfaction after TBI.

Controlling the Structure, Properties and Surface Reactivity of Clickable Azide-Functionalized Au25 (SR)18 Nanocluster Platforms Through Regioisomeric Ligand Modifications.

To fine-tune structure-property correlations of thiolate-protected gold nanoclusters through post-assembly surface modifications, we report the synthesis of the o, m, and p regioisomeric forms of the anionic azide-functionalized [Au25 (SCH2 CH2 -C6 H4 -N3 )18 ]1- platform. They can undergo cluster-surface strain-promoted alkyne-azide cycloaddition (CS-SPAAC) chemistry with complementary strained-alkynes. Although their optical properties are similar, the electrochemical properties appear to correlate with the position of the azido group. The ability to conduct CS-SPAAC chemistry without altering the parent nanocluster structure is different as the isomeric form of the surface ligand is changed, with the [Au25 (SCH2 CH2 -p-C6 H4 -N3 )18 ]1- isomer having the highest reaction rates, while the [Au25 (SCH2 CH2 -o-C6 H4 -N3 )18 ]1- isomer is not stable following CS-SPAAC. Single-crystal X-ray diffraction provide the molecular structure of the neutral forms of the three regioisomeric clusters, [Au25 (SCH2 CH2 -o/m/p-C6 H4 -N3 ]0 , which illustrates correlated structural features of the central core as the position of the azido moiety is changed.

Outcomes 1 and 2 Years After Moderate to Severe Traumatic Brain Injury: An International Comparative Study.

OBJECTIVE: This study compared traumatic brain injury (TBI) outcomes from 2 cohorts: the National Institute on Disability, Independent Living, and Rehabilitation Research Traumatic Brain Injury Model Systems (TBIMS) in the United States and Longitudinal Head Injury Outcome Study conducted in Victoria, Australia, by the Monash Epworth Rehabilitation Research Centre (MERRC). DESIGN: Cohort study with 1- and 2-year follow-up. SETTING: Acute trauma care and inpatient rehabilitation with follow-up. PARTICIPANTS: Patients (N=1056) with moderate-severe TBI admitted in 2000-2012 to inpatient rehabilitation after motor vehicle-related collisions, who completed follow-up, were matched using 1:2 matching algorithm based on age at injury, days of posttraumatic amnesia, and years education, resulting in groups of 352 (MERRC) and 704 patients (TBIMS). INTERVENTION: The cohorts had received acute trauma care and inpatient rehabilitation for a median 38 (MERRC) or 33 days (TBIMS). The MERRC group also had routine access to community-based support and rehabilitation for return to work or school, attendant care, and home help as justified, funded by an accident compensation system, whereas the TBIMS cohort had variable access to these services. MAIN OUTCOME MEASURES: Outcomes were assessed 1 and 2 years post injury in terms of employment, living situation, marital status, and Glasgow Outcome Scale-Extended (GOS-E) scores. RESULTS: At 2 years post injury, MERRC participants were more likely to be competitively employed. At both 1 and 2 years post injury, MERRC participants were more likely to be married and living independently. On GOS-E, the TBIMS group had higher percentages of patients in Lower Severe Disability/Vegetative State and Upper Good Recovery than MERRC participants, whereas the MERRC cohort had higher percentages of Lower Moderate Disability than TBIMS. CONCLUSIONS: Findings may suggest that routine provision of community-based supports could confer benefits for long-term TBI outcomes. Further studies documenting rehabilitation services are needed to explore this.

Association of Lifetime History of Traumatic Brain Injury With Prescription Opioid Use and Misuse Among Adults.

OBJECTIVE: To investigate associations of lifetime history of traumatic brain injury (TBI) with prescription opioid use and misuse among noninstitutionalized adults. PARTICIPANTS: Ohio Behavioral Risk Factor Surveillance System (BRFSS) participants in the 2018 cohort who completed the prescription opioid and lifetime history of TBI modules (n = 3448). DESIGN: Secondary analyses of a statewide population-based cross-sectional survey. MAIN MEASURES: Self-report of a lifetime history of TBI using an adaptation of the Ohio State University TBI-Identification Method. Self-report of past year: (1) prescription pain medication use (ie, prescription opioid use); and (2) prescription opioid misuse, defined as using opioids more frequently or in higher doses than prescribed and/or using a prescription opioid not prescribed to the respondent. RESULTS: In total, 22.8% of adults in the sample screened positive for a lifetime history of TBI. A quarter (25.5%) reported past year prescription opioid use, and 3.1% met criteria for prescription opioid misuse. A lifetime history of TBI was associated with increased odds of both past year prescription opioid use (adjusted odds ratio [AOR] = 1.52; 95% CI, 1.27-1.83; P < .01) and prescription opioid misuse (AOR = 1.65; 95% CI, 1.08-2.52; P < .05), controlling for sex, age, race/ethnicity, and marital status. CONCLUSION: Results from this study support the "perfect storm" hypothesis-that persons with a history of TBI are at an increased risk for exposure to prescription opioids and advancing to prescription opioid misuse compared with those without a history of TBI. Routine screening for a lifetime history of TBI may help target efforts to prevent opioid misuse among adults.

Marital Stability Over 10 Years Following Traumatic Brain Injury.

OBJECTIVE: To examine the stability of marriage from the time of traumatic brain injury (TBI) to 10 years postinjury. DESIGN: Retrospective cohort. SETTING: TBI Model Systems centers. PARTICIPANTS: In total, 1423 participants in the TBI Model Systems National Database who experienced TBI 10 years prior and were married at the time of injury. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURE: Remaining married to the same partner from the time of injury to 10-year follow-up. RESULTS: At 10 years, 66% (938) remained married to the same person. Significant associations were found with age at injury (P < .0001), sex (P = .0028), and preinjury problematic substance use (P = .0092). Marital stability over the 10-year period was higher for those who were older, were female, and had no problematic substance use history. Marital instability was greatest in the first year postinjury. CONCLUSIONS: Most married adults who received inpatient rehabilitation for TBI remained married to the same individual 10 years later. Those who were younger, were male, and had a history of problematic substance use were at a highest risk for relationship dissolution. Findings have implications for content, timing, and delivery of marital interventions. Substance use education and prevention appear to be important aspects of marital support.

Staff Traumatic Brain Injury Skill Builder: Evaluation of an Online Training Program for Paraprofessional Staff Serving Adults With Moderate-Severe TBI.

OBJECTIVE: To evaluate the online, self-guided, interactive Staff TBI Skill Builder training program for paraprofessional staff. DESIGN: A within-subjects, nonexperimental evaluation involving 79 paraprofessionals and professionals working across a range of settings. Participants completed a pretest (T1), a posttest immediately upon program completion (T2), and follow-up (T3) 60 days after program completion. MEASURES: (1) Knowledge of basic traumatic brain injury facts; (2) knowledge application; (3) self-efficacy in responding to text-based application scenarios; (4) self-report of skill utilization and effectiveness; and (5) program satisfaction (ease-of-use and usefulness). RESULTS: Participants demonstrated high levels of knowledge, knowledge application, and self-efficacy at pretest. Despite the high pretest levels, participants showed significant improvements in knowledge application (d = 0.50) after using the program. Nonsignificant gains in knowledge (d = 0.13) and self-efficacy (d = 0.02) were found. The use of selected skills significantly increased from posttest to follow-up. Participants reported high program satisfaction; 99% of the participants indicated that they would recommend the program to others. CONCLUSION: These results demonstrate the feasibility of providing interactive, online training for paraprofessionals serving adults with moderate-severe traumatic brain injury.

Demographic and Mental Health Predictors of Arrests Up to 10 Years Post-Traumatic Brain Injury: A Veterans Affairs TBI Model Systems Study.

OBJECTIVE: Examine rates and predictors of arrests in Veterans and Service Members (V/SM) who received inpatient rehabilitation for traumatic brain injury (TBI). SETTING: Veterans Administration (VA) Polytrauma Rehabilitation Centers. PARTICIPANTS: A total of 948 V/SM drawn from the VA TBI Model Systems cohort with arrest data up to 10 years post-TBI. DESIGN: Longitudinal cohort study; secondary analysis of pre-TBI characteristics predicting post-TBI arrests. MAIN MEASURES: Disclosure of arrests pre-TBI and up to10 years post-TBI. RESULTS: Thirty-six percent of the sample had been arrested prior to their TBI; 7% were arrested post-TBI. When considering all variables simultaneously in a multivariate model, pre-TBI mental health treatment (adjusted odds ratio [aOR] = 4.30; 95% confidence interval [CI]: 2.03-9.14), pre-TBI heavy alcohol use (aOR = 3.04; CI: 1.08-8.55), and number of follow-up interviews (aOR = 2.05; CI: 1.39-4.50) were significant predictors of post-TBI arrest. CONCLUSION: Arrest rates of V/SM prior to TBI were consistent with rates of arrest for people of similar ages in the United States. Post-TBI rates were lower for V/SM than published rates of post-TBI arrests in civilians with TBI. As part of rehabilitation planning for V/SM with TBI, providers should assess for preinjury mental health services and alcohol misuse to (1) identify those who may be at risk for postinjury arrests and (2) provide relevant resources and/or supports.

Quasi-Contextualized Speech Treatment in Traumatic Brain Injury Inpatient Rehabilitation: Effects on Outcomes During the First Year After Discharge.

OBJECTIVE: To evaluate the effect of providing quasi-contextualized speech therapy, defined as metacognitive, compensatory, or strategy training applied to cognitive and language impairments to facilitate the performance of future real-life activities, on functional outcomes up to 1 year following traumatic brain injury (TBI). SETTING: Acute inpatient rehabilitation. PARTICIPANTS: Patients enrolled during the TBI-Practice-Based Evidence (TBI-PBE) study (n = 1760), aged 14 years or older, who sustained a severe, moderate, or complicated mild TBI, received speech therapy in acute inpatient rehabilitation at one of 9 US sites, and consented to follow-up 3 and 9 months postdischarge from inpatient rehabilitation. DESIGN: Propensity score methods applied to a database consisting of multisite, prospective, longitudinal observational data. MAIN MEASURES: Participation Assessment with Recombined Tools-Objective-17, FIM Motor and Cognitive scores, Satisfaction With Life Scale, and Patient Health Questionnaire-9. RESULTS: When at least 5% of therapy time employed quasi-contextualized treatment, participants reported better community participation during the year following discharge. Quasi-contextualized treatment was also associated with better motor and cognitive function at discharge and during the year after discharge. The benefit, however, may be dependent upon a balance of rehabilitation time that relied on contextualized treatment. CONCLUSIONS: The use of quasi-contextualized treatment may improve outcomes. Care should be taken, however, to not provide quasi-contextualized treatment at the expense of contextualized treatment.