Positive Traumatic Brain Injury Research Articles

Two Decades of Department of Veterans Affairs Traumatic Brain Injury Care and Benefits for Veterans of Post-9/11 Conflicts.

To describe the background, methodology, and results of the congressionally mandated Department of Veterans Affairs (VA) Traumatic Brain Injury (TBI) Veterans Health Registry. Veterans Health Administration (VHA) and Veterans Benefit Administration (VBA). A total of 441 639 Veterans of post-9/11 conflicts who exhibited symptoms associated with TBI and sought care or benefits from the VA between September 2001 and September 2021. Design: Retrospective analysis of VHA and VBA administrative records. (1) VA/Department of Defense Identity Repository to identify Veterans with a deployment to the Southwest Asia theater of operations; (2) the VA TBI Screening and Evaluation Program data; (3) Inpatient and Outpatient Encounter data; and (4) an extract of the VBA Corporate Database to identify Veterans filing benefit claims based on TBI. An unduplicated total of 441 639 post-9/11 Veterans were identified in the Registry via three different pathways to entry: 369 909 Veterans through a positive TBI Screen, 253 177 Veterans receiving healthcare including a TBI diagnosis, and 108 541 Veterans filing TBI disability claims. Among Veterans reporting current TBI symptoms who completed a clinical evaluation, a diagnosis of TBI was confirmed by a TBI specialist in 68.7% of the cases. The TBI severity of confirmed cases was classified as mild in 86.6% of the cases, moderate in 8.3%, and severe in 4.1%. The TBI Registry Veterans were hospitalized 66 503 times and seen 1 521 898 times as outpatients in VHA facilities with diagnoses including TBI. Among Veterans filing TBI disability claims, 67.3% were adjudicated as service-connected. The VA TBI Health Registry has identified over 440 000 Veterans of post-9/11 conflicts who presented to the VA for care or benefits with TBI symptomatology. This large number and the volume of TBI health care and benefits provided over the two decades since 9/11 demonstrate the need for the VA's strong ongoing focus on screening, evaluation, and rehabilitation of TBI.

A-093 Clinical Performance of Biomarkers for Traumatic Brain Injury

Abstract Background An estimated 5 million people are evaluated in emergency departments (ED) for Traumatic Brain Injury (TBI) in the United States each year. The vast majority (80%) of patients evaluated for TBI in the ED will receive head CT scans, however less than 10% of those will have any findings of acute traumatic abnormalities. This highlights the need for objective, rapid, accurate tools to help clinicians evaluate and triage TBI patients and reduce unnecessary radiation exposure. The Alinity i TBI test is a panel of in vitro diagnostic chemiluminescent microparticle immunoassays used to measure glial fibrillary acidic protein (GFAP) and ubiquitin carboxyl-terminal hydrolase L1 (UCH-L1) in human plasma and serum. TBI performance was evaluated in a multi-center study by performing reproducibility and a pivotal study. Methods A pivotal study using prospectively collected archived (frozen) plasma specimens was conducted to establish the clinical performance of the TBI test on the Alinity i system. The testing of the archived specimens was performed at three clinical sites in the United States. The specimens tested were originally collected in a prospective, multi-center clinical study and were from individuals 18 years of age or older who presented to a health care facility or emergency department with suspected traumatic brain injury. These subjects had an initial Glasgow Coma Scale (GCS) score of 13–15 and had a computed tomography (CT) scan of the head performed per the clinical site’s standard of care. Reproducibility was assessed using multiple panel/control members for 5 days based on guidance from Clinical and Laboratory Standards Institute EP05-A3. Testing was conducted using 3 lots of GFAP and UCH-L1 reagents, and 1 Alinity i system at each of 3 testing sites. Results Of the 1899 mild TBI subjects, 120 had positive head CT scan results; 116 of the 120 specimens had a positive TBI interpretation (Sensitivity 96.7%;95%CI:91.7%,98.7%). Of the 1779 subjects with negative CT scan results, 713 had a negative TBI interpretation (Specificity 40.1%;95%CI:37.8%,42.4%). The negative predictive value (NPV) of the test was 99.4% (713/717, 95%CI:98.6%,99.8%). Within-Laboratory imprecision (includes repeatability, between-run, and between-day variance components) results ranged from 2.2% to 3.5% CV for GFAP and 1.8 to 3.2 %CV for UCH-L1. The Overall Reproducibility (includes repeatability, between-run, between-day, between-lot, between-site, and site-lot interaction variance components) results ranged from 2.5% to 4.7% CV for GFAP and 2.6 to 6.6 %CV for UCH-L1. Conclusion The Alinity i TBI clinical performance results demonstrated that the TBI test is characterized by high sensitivity and high NPV, which supports the clinical utility to assist in determining the need for a CT scan of the head in subjects presenting with suspected mild TBI. The GFAP and UCH-L1 assays demonstrated acceptable reproducibility across a wide dynamic range. These assays can report results within 18 min and be conveniently loaded into the Electronic Health Records to aid clinicians in their triage (or imaging) decisions. Funding The study was funded by Abbott Laboratories and in collaboration with the US Army Medical Materiel Development Activity, US Army Medical Research and Development Command CRADA 20-1266-CRA.

Traumatic brain injury in college students and the influence of alcohol consumption: A retrospective review from a rural state.

There is a strong association between alcohol consumption and traumatic brain injury (TBI). Students are known to consume alcohol at a high rate. Despite the connection between alcohol and TBI, this is one of few studies to examine the connection between students, alcohol, and TBI. The objective of this study was to explore the relationship between students, alcohol, and TBI. A retrospective chart review utilizing the institutional trauma data back was performed for patients 18-26 years of age, admitted to the emergency department with a diagnosis of a TBI and positive blood alcohol. Patient diagnosis, injury mechanism, alcohol level on admission, urine drug screen, mortality, injury severity score, and discharge disposition were recorded. The data were analyzed using Wilcoxon rank-sum tests and Chi-square tests to identify differences between students and non-student groups. Six hundred and thirty-six charts were reviewed for patients aged 18-26 with a positive blood alcohol level and TBI. The sample included 186 students, 209 non-students, and 241 uncertain of status. The student group had significantly higher levels of alcohol than the non-student group (P < 0.0001). P < 0.0001 showed that overall alcohol levels for males are significantly higher than levels of alcohol for females in the student group. Alcohol consumption contributes to significant injuries such as TBI in college students. Male students had a higher prevalence of TBI, and higher alcohol levels than female students. These results can be used to inform and better target harm reduction and alcohol awareness programs.

Self-reported physical functioning, cardiometabolic health conditions, and health care utilization patterns in Million Veteran Program enrollees with Traumatic Brain Injury Screening and Evaluation Program data

BackgroundExamining the health outcomes of veterans who have completed the United States Veterans Health Administration’s (VHA’s) Traumatic Brain Injury (TBI) Screening and Evaluation Program may aid in the refinement and improvement of clinical care initiatives within the VHA. This study compared self-reported physical functioning, cardiometabolic health conditions, and health care utilization patterns in Million Veteran Program enrollees with TBI Screening and Evaluation Program data (collected between 2007 and 2019), with the goal of enhancing understanding of potentially modifiable health conditions in this population.MethodsIn this observational cohort study, veterans (n = 16,452) were grouped based on the diagnostic outcome of the TBI Screening and Evaluation Program: 1) negative TBI screen (Screen–); 2) positive TBI screen but no confirmed TBI diagnosis [Screen+/ Comprehensive TBI Evaluation (CTBIE)–]; or 3) positive TBI screen and confirmed TBI diagnosis (Screen+/CTBIE+). Chi-square tests and analysis of covariance were used to explore group differences in physical functioning, cardiometabolic health conditions, and health care utilization patterns, and logistic regressions were used to examine predictors of Screen+/– and CTBIE+/– group status.ResultsThe results showed that veterans in the Screen+/CTBIE– and Screen+/CTBIE+ groups generally reported poorer levels of physical functioning (P’s < 0.001, np2 = 0.02 to 0.03), higher rates of cardiometabolic health conditions (P’s < 0.001, φ = 0.14 to 0.52), and increased health care utilization (P’s < 0.001, φ = 0.14 to > 0.5) compared with the Screen– group; however, health outcomes were generally comparable between the Screen+/CTBIE– and Screen+/CTBIE+ groups. Follow-up analyses confirmed that while physical functioning, hypertension, stroke, healthcare utilization, and prescription medication use reliably distinguished between the Screen– and Screen+ groups (P’s < 0.02, OR’s 0.78 to 3.38), only physical functioning distinguished between the Screen+/CTBIE– and Screen+/CTBIE+ groups (P < 0.001, OR 0.99).ConclusionsThe findings suggest that veterans who screen positive for TBI, regardless of whether they are ultimately diagnosed with TBI, are at greater risk for negative health outcomes, signifying that these veterans represent a vulnerable group that may benefit from increased clinical care and prevention efforts.

Psychiatric symptoms influence social support in VA Million Veteran Program enrollees screening positive for traumatic brain injury

ObjectiveTo examine measures of social support and associations with neurobehavioral, psychiatric, and cognitive symptoms in Veterans who underwent the Veterans Health Administration's Traumatic Brain Injury (TBI) Screening and Evaluation Program. SettingNationally representative sample of U.S. Veterans enrolled in the Veterans Affairs Million Veteran Program. ParticipantsVeterans (N = 9,837) were classified into the following three diagnostic groups based on results from the TBI Screening and Evaluation Program: (1) negative TBI screen (Screen–; n = 6,523), (2) positive TBI screen but no TBI diagnosis (Screen+/TBI-; n = 1,308), or (3) positive TBI screen and TBI diagnosis (Screen+/TBI+; n = 2,006). DesignEpidemiological cross-sectional study. Main measuresMedical Outcomes Study Social Support Survey Instrument (MOS-SSSI), with subscales representing emotional, tangible, and affectionate support and positive social interaction; Neurobehavioral Symptom Inventory (NSI); PTSD Checklist (PCL); Patient Health Questionnaire-4 (PHQ-4); and Medical Outcomes Study Cognitive Functioning-Revised Scale (MOS-Cog-R). ResultsANCOVAs showed significant associations between diagnostic group and all aspects of social support. Pairwise comparisons revealed that Veterans in the two Screen+ groups (Screen+/TBI+ and Screen+/TBI-) reported comparable levels of social support, but that both Screen+ groups reported significantly lower levels of social support compared to the Screen– group. Among the Screen+ groups, adjusted linear regression models controlling for age, sex, and race/ethnicity showed significant associations between social support indices and all symptom measures, such that lower levels of social support were associated with more severe neurobehavioral and psychiatric symptoms and worse cognitive functioning. Finally, mediation analyses showed that psychiatric symptoms mediated the association between TBI screen group and social support. ConclusionsOur results are clinically informative and suggest (1) that the relationship between TBI screen status and social support is influenced by psychiatric symptoms and (2) that implementing distress reduction techniques before social support interventions may be most beneficial for Veterans screening positive for TBI.

Subjective cognitive and psychiatric well-being in U.S. Military Veterans screened for deployment-related traumatic brain injury: A Million Veteran Program Study

The purpose of this study was to examine subjective cognitive and psychiatric functioning in post-deployed military Veterans who underwent the Veterans Health Administration's Traumatic Brain Injury (TBI) Screening and Evaluation Program and enrolled in the VA's Million Veteran Program (MVP). Veterans (N = 7483) were classified into three groups based on outcomes from the TBI Screening and Evaluation Program: (1) negative TBI screen (‘Screen-’), (2) positive TBI screen but no TBI diagnosis (‘Screen+/TBI-’), or (3) positive TBI screen and TBI diagnosis (‘Screen+/TBI+’). Chi-square analyses revealed significant group differences across all self-reported cognitive and psychiatric health conditions (e.g., memory loss, depression), and ANCOVAs similarly showed a significant association between group and subjective symptom reporting. Specifically, the relationship between TBI group and clinical outcome (i.e., health conditions and symptoms) was such that the Screen+/TBI+ group fared the worst, followed by the Screen+/TBI- group, and finally the Screen- group. However, evaluation of effect sizes suggested that Veterans in the two Screen+ groups (Screen+/TBI+ and Screen+/TBI-) are faring similarly to one another on subjective cognitive and psychiatric functioning, but that both Screen+ groups are faring significantly worse than the Screen- group. Our results have meaningful clinical implications and suggest that Veterans who screen positive for TBI, regardless of ultimate TBI diagnosis, be eligible for similar clinical services so that both groups can benefit from valuable treatments and therapeutics. Finally, this research sets the stage for follow-up work to be conducted within MVP that will address the neurobiological underpinnings of cognitive and psychiatric distress in this population.

Aldolase C Profiling in Serum after Mild Traumatic Brain Injury: A Prospective Cohort Study.

Background: After a traumatic brain injury (TBI), in addition to clinical indices, the serum level of neurological biomarkers may provide valuable diagnostic and prognostic information. The present study aimed to investigate the aldolase C (ALDOC) profile in serum for early diagnosis of brain damage in patients with mild TBI (mTBI) presented to the Emergency Department (ED).Methods: A single-center prospective cohort study was carried out in 2018-2019 at Imam Khomeini Hospital affiliated with Mazandaran University of Medical Sciences, Sari, Iran. A total of 89 patients with mTBI were enrolled in the study. Blood samples were taken within three hours after head trauma to measure ALDOC serum levels. Brain CT scan was used as the gold standard. Statistical analysis was performed using the Kruskal Wallis, Mann-Whitney U, and Chi square tests. The receiver-operating characteristic (ROC) curve plot was used to determine the optimal cutoff point for ALDOC. The sensitivity and specificity of the determined cutoff point were calculated. P values less than 0.05 were considered statistically significant.Results: Of the 89 patients, the CT scan findings showed a positive TBI in 30 (33.7%) of the patients and in 59 (66.3%) a negative TBI. The median ALDOC serum level in the patients with positive CT scan findings (8.35 ng/mL [IQR: 1.65]) was significantly higher than those with negative CT scan findings (5.3 ng/mL [IQR: 6.9]) (P<0.001). The optimal cutoff point for ALDOC serum level was 6.95 ng/mL, and the area under the curve was 99.6% (P<0.001). The sensitivity and specificity of the determined cutoff point were 100% and 98%, respectively. Conclusion: The ALDOC serum level in patients with mTBI significantly correlates with the pathologic findings of the brain CT scan. This biomarker, with 100% sensitivity, is a suitable tool to detect brain structural abnormalities in mTBI patients.

Traumatic Brain Injury Screening and the Unmet Health Needs of Shelter-Seeking Women with Head Injuries Related to Intimate Partner Violence.

Background: Unmet health needs of women with head injuries sustained by intimate partner violence (IPV) include risk of traumatic brain injury (TBI). The purpose of this evaluation was to explore the potential effectiveness of TBI screening as a health promotion strategy for shelter-seeking women with IPV head injuries. We wanted to learn if shelter-seeking women, willing to disclose IPV, would accept TBI screening if offered.Methods: An extended version of the HELPS TBI screening tool and survey of daily symptoms and health needs were used to screen new residents of an urban shelter for women.Results: The participants (N = 18) primarily were educated black women with one or more self-reported IPV-related head injury. Most participants (77.8%) had positive TBI screens for probable brain injury. The majority (88.8%) lived with one or more daily symptoms they did not have before sustaining a IPV head injury. The symptoms reported most frequently were depression (88.9%), anxiety (77.8%), and headache (66.7%). All participants had one or more unmet health need. Although most (77.8%) needed to see a primary care provider, mental health care was the most important health need identified.Conclusions: TBI screening could be considered an effective health promotion strategy for IPV survivors if screening facilitates treatment for positive screens and other unmet health needs. Further research is needed to properly assess this.

Enhancing Language Access: A Pilot Study to Examine the Importance of Understanding the Language Preference and Acculturalization Level in the Provision of Healthcare for Hispanics Veterans With Traumatic Brain Injury.

The purpose of this pilot study was to obtain preliminary data to culturally adapt the Veteran Health Administration Traumatic Brain Injury (TBI) assessment instruments for the Hispanic Veteran population. A qualitative analysis explored the cognitive processes used by Hispanic Veterans whose preferred language was Spanish to understand a specific set of screening questions within the Initial TBI Screening, the Comprehensive TBI Evaluation, the Neurobehavioral Symptom Inventory (NSI), and the La Trobe Communication Questionnaire (LTCQ). A certified translator completed translation of the TBI instruments, an expert panel resolved inadequate expressions of the translations, and translated instruments were back translated. Male and female Hispanic Veterans with a positive TBI screening underwent a recorded administration of the TBI instruments, including LTCQ, followed by systematic debriefing using semi-structured cognitive interviews which then underwent qualitative analysis. The Marin's Short Acculturation Scale for Hispanics, the Tropp's Psychological Acculturation Scale, the English-Language Proficiency Test Series, and the TBI Demographic and Language Preference interview were administered to the subjects. Fifteen subjects were enrolled for the TBI instruments intervention; 11 of them completed all the additional procedures. The TBI instruments intervention seemed to produce very few variations, indicating adequate cultural equivalence. However, the LTCQ instrument showed suggested cultural variations, but did not suggest a lack of understanding or misinterpretation. The population studied displayed preferential connectedness to the Hispanic/Latino culture and to the Spanish language. The LTCQ indicated that subjects perceived themselves as having a worse execution in terms of communication skills than historical control and TBI groups. English-Language Proficiency Test Series found that most of the subject population did not demonstrate mastery of grade-appropriate basic social and academic vocabulary in English. Current findings highlight the importance of using linguistically and culturally appropriate materials upon evaluating Hispanic Veterans with a suspected TBI who have Spanish as their primary or preferred language.

Admission Levels of Interleukin 10 and Amyloid β 1-40 Improve the Outcome Prediction Performance of the Helsinki Computed Tomography Score in Traumatic Brain Injury.

Background: Blood biomarkers may enhance outcome prediction performance of head computed tomography scores in traumatic brain injury (TBI).Objective: To investigate whether admission levels of eight different protein biomarkers can improve the outcome prediction performance of the Helsinki computed tomography score (HCTS) without clinical covariates in TBI.Materials and methods: Eighty-two patients with computed tomography positive TBIs were included in this study. Plasma levels of β-amyloid isoforms 1–40 (Aβ40) and 1–42 (Aβ42), glial fibrillary acidic protein, heart fatty acid-binding protein, interleukin 10 (IL-10), neurofilament light, S100 calcium-binding protein B, and total tau were measured within 24 h from admission. The patients were divided into favorable (Glasgow Outcome Scale—Extended 5–8, n = 49) and unfavorable (Glasgow Outcome Scale—Extended 1–4, n = 33) groups. The outcome was assessed 6–12 months after injury. An optimal predictive panel was investigated with the sensitivity set at 90–100%.Results: The HCTS alone yielded a sensitivity of 97.0% (95% CI: 90.9–100) and specificity of 22.4% (95% CI: 10.2–32.7) and partial area under the curve of the receiver operating characteristic of 2.5% (95% CI: 1.1–4.7), in discriminating patients with favorable and unfavorable outcomes. The threshold to detect a patient with unfavorable outcome was an HCTS > 1. The three best individually performing biomarkers in outcome prediction were Aβ40, Aβ42, and neurofilament light. The optimal panel included IL-10, Aβ40, and the HCTS reaching a partial area under the curve of the receiver operating characteristic of 3.4% (95% CI: 1.7–6.2) with a sensitivity of 90.9% (95% CI: 81.8–100) and specificity of 59.2% (95% CI: 40.8–69.4).Conclusion: Admission plasma levels of IL-10 and Aβ40 significantly improve the prognostication ability of the HCTS after TBI.

Improving Military Readiness and Reducing Suicide Risk: The Role Between Positive TBI Screens, Severe Insomnia, and Suicidal Outcomes

This study examined how insomnia severity and a positive traumatic brain injury (TBI) screen relate to suicidal outcomes across military branches. Data were compiled from 1,635 participants across seven studies. A series of analyses were conducted by military branch to identify which significantly differed on the variables of interest. A series of multiple regression analyses were conducted to explore whether insomnia severity and a positive TBI screen predicted suicidal outcomes and whether the effect varied as a function of military branch. Insomnia severity and a positive TBI screen each had independent relationships with the suicide risk outcomes. The relationship between insomnia and suicide risk varied by military branch. However, a positive TBI screen had a significant effect on suicidal behavior and thoughts and the effect was similar across the four groups. Efforts to identify and intervene on insomnia and TBI sequelae may improve quality of care for service members at risk of suicide. Insomnia and post-TBI symptoms are important targets of intervention as they are often less stigmatized and can be easily assessed by brief self-report measures.

The Relationship between Suicidal Responses and Traumatic Brain Injury and Severe Insomnia in Active Duty, Veteran, and Civilian Populations

This study examined how a positive traumatic brain injury (TBI) screening and insomnia severity relate to suicidal outcomes across active duty, veteran, and civilian samples. Data were used from 3,993 participants from 19 studies. We conducted a series of analyses by group to identify which significantly differed on the variables of interest. TBI and insomnia each had independent relationships with outcomes over and above the impact of the other factor. Veterans presented as clinically worse across the outcomes. However, the relationship between insomnia and suicidal responses was stronger for active duty military compared to veterans. Continued research on TBIs and insomnia severity across groups will improve quality of care for those at risk of suicide.

Responses to Traumatic Brain Injury Screening Questions and Suicide Attempts among Those Seeking Veterans Health Administration Mental Health Services.

Psychometrically sound screening tools available to aid in the identification of lifetime history of traumatic brain injury (TBI) are limited. As such, the Traumatic Brain Injury-4 (TBI-4) was developed and implemented in a Veterans Health Administration (VHA) mental health clinic. To provide information regarding both the predictive validity and clinical utility of the TBI-4, the relationship between screening results and future suicide attempts was evaluated. The aim of this study was to determine whether a positive screen on the TBI-4 was associated with increased risk for suicide attempt within 1-year post screening. The TBI-4 was administered to 1,097 Veterans at the time of mental health intake. Follow-up data regarding suicide attempts for the year post-mental health intake were obtained from suicide behavior reports (SBRs) in Veteran electronic medical records (EMRs). Fisher's exact tests were used to determine the proportion of suicide attempts by TBI-4 status. In the year post TBI-4 screening, significantly more Veterans who screened positive had a documented suicide attempt as compared to those who screened negative (p = 0.003). Those with a positive TBI screen at mental health intake had a higher proportion of SBRs than those who screened negative for TBI. Findings provided further psychometric support for the TBI-4. Moreover, results suggest the inclusion of this screen could prove to be helpful in identifying those who may be at risk for future suicide attempt within 1-year post screening.

Current Suicidal Ideation Among Treatment-Engaged Active-Duty Soldiers and Marines

We examined suicidal ideation among 399 active-duty Soldiers and Marines engaged in mental health treatment. Using a generalized linear model (GLM) controlling for demographic and military factors, depression, and positive traumatic brain injury (TBI) screen, we confirmed our hypothesis that self-report measures of current post-traumatic stress disorder (PTSD) symptoms uniquely predicted suicidal ideation. The association between PTSD severity and suicidal ideation was moderated by gender, with women at higher risk as PTSD severity increased. Female Soldiers and Marines with high levels of PTSD should receive additional monitoring and intervention. Self-report measures may aid with risk assessment and identify symptom-related distress associated with suicide risk.

Resilience, traumatic brain injury, depression, and posttraumatic stress among Iraq/Afghanistan war veterans.

We examined the prospective influence of the resilient, undercontrolled, and overcontrolled personality prototypes on depression and posttraumatic stress disorder (PTSD) symptoms among Iraq/Afghanistan war veterans. After accounting for the possible influence of combat exposure, we expected that the resilient prototype would predict lower depression and PTSD over time and would be associated with adaptive coping strategies, higher social support, lower psychological inflexibility, and higher self-reported resilience relative to overcontrolled and undercontrolled prototypes, independent of traumatic brain injury (TBI) status. One hundred twenty-seven veterans (107 men, 20 women; average age = 37) participated in the study. Personality was assessed at baseline, and PTSD and depression symptoms were assessed 8 months later. Path analysis was used to test the direct and indirect effects of personality on distress. No direct effects were observed from personality to distress. The resilient prototype did have significant indirect effects on PTSD and depression through its beneficial effects on social support, coping and psychological inflexibility. TBI also had direct effects on PTSD. A resilient personality prototype appears to influence veteran adjustment through its positive associations with greater social support and psychological flexibility, and lower use of avoidant coping. Low social support, avoidant coping, and psychological inflexibility are related to overcontrolled and undercontrolled personality prototypes, and these behaviors seem to characterize veterans who experience problems with depression and PTSD over time. A positive TBI status is directly and prospectively associated with PTSD symptomology independent of personality prototype. Implications for clinical interventions and future research are discussed.

(400) Migraine management in the Veterans Health Administration clinics

Migraines are a common cause of pain and lost productivity. Veterans are particularly vulnerable to developing migraines because of their relatively high rate of traumatic brain injury (TBI). Migraine provides an opportunity to explore pain management among Veterans since its guidelines are well-established across settings. We have conducted a cross-sectional study using administrative and clinical data from the VA National Patient Care Database, Decision Support Systems and the Corporate Data Warehouse. The study population is composed of Veterans from the VA’s Operation Enduring Freedom/Operation Iraqi Freedom/Operation New Dawn roster (N=749,037, discharged 10/1/2001-9/30/2010). Veterans with migraines were identified by ICD-9 code (346.X) for migraine headache. We counted “confirmed” migraines that were coded at least once in an inpatient stay and/or at least twice in outpatient visits. Prescriptions were examined in the year following migraine diagnosis. Covariates examined included sociodemographic variables as well as psychiatric and medical comorbidity including traumatic brain injury (TBI). The comorbidity timeframe was set to be 1 year before and up to six months following migraine diagnosis. Chi-squares and logistic regression were utilized. A total of 21,050 Veterans were diagnosed with migraine headache (2.8%), with women significantly more likely to be diagnosed (7.0% vs. 2.3%, p<.0001). Triptans were prescribed to 24% of migraineurs, with no difference between men and women. However, the examination of triptan prescriptions by the year of migraine diagnosis revealed four-fold increase over the years [8.7% prior to 2004 to 43.4% in 2010; chi square for trend=1028.81, p<.0001]. Statistically, but not clinically, significant differences in triptan prescription were observed in the presence of comorbidity, including increased triptan prescription with positive TBI screen. The current rate of triptan treatment surpasses estimates reported in the general population. Preventive medicines (e.g. anti-hypertensive, anti-depressant, anti-seizure) showed a significant but smaller increase over the year of migraine diagnosis (range 42-52%). Migraines are a common cause of pain and lost productivity. Veterans are particularly vulnerable to developing migraines because of their relatively high rate of traumatic brain injury (TBI). Migraine provides an opportunity to explore pain management among Veterans since its guidelines are well-established across settings. We have conducted a cross-sectional study using administrative and clinical data from the VA National Patient Care Database, Decision Support Systems and the Corporate Data Warehouse. The study population is composed of Veterans from the VA’s Operation Enduring Freedom/Operation Iraqi Freedom/Operation New Dawn roster (N=749,037, discharged 10/1/2001-9/30/2010). Veterans with migraines were identified by ICD-9 code (346.X) for migraine headache. We counted “confirmed” migraines that were coded at least once in an inpatient stay and/or at least twice in outpatient visits. Prescriptions were examined in the year following migraine diagnosis. Covariates examined included sociodemographic variables as well as psychiatric and medical comorbidity including traumatic brain injury (TBI). The comorbidity timeframe was set to be 1 year before and up to six months following migraine diagnosis. Chi-squares and logistic regression were utilized. A total of 21,050 Veterans were diagnosed with migraine headache (2.8%), with women significantly more likely to be diagnosed (7.0% vs. 2.3%, p<.0001). Triptans were prescribed to 24% of migraineurs, with no difference between men and women. However, the examination of triptan prescriptions by the year of migraine diagnosis revealed four-fold increase over the years [8.7% prior to 2004 to 43.4% in 2010; chi square for trend=1028.81, p<.0001]. Statistically, but not clinically, significant differences in triptan prescription were observed in the presence of comorbidity, including increased triptan prescription with positive TBI screen. The current rate of triptan treatment surpasses estimates reported in the general population. Preventive medicines (e.g. anti-hypertensive, anti-depressant, anti-seizure) showed a significant but smaller increase over the year of migraine diagnosis (range 42-52%).

An Evaluation of the Veterans Affairs Traumatic Brain Injury Screening Process Among Operation Enduring Freedom and/or Operation Iraqi Freedom Veterans

To describe the early results of the U.S. Department of Veterans Affairs (VA) screening program for traumatic brain injury (TBI) and to identify patient and facility characteristics associated with receiving a TBI screen and results of the screening. National retrospective cohort study. VA Medical facilities. A total of 170,681 Operation Enduring Freedom and/or Operation Iraqi Freedom (OEF/OIF) Veterans who sought care at VA medical facilities from April 2007 to September 30, 2008. Data were abstracted from VA administrative and operational databases, including patient demographics, facility characteristics, and outcomes. The main outcomes were receipt of and results of the TBI screen. The majority of veterans eligible received the TBI screen (91.6%). Screening rates varied by patient and facility characteristics. In all, 25% of screened veterans had probable TBI exposure, in which the majority of the exposures were blasts (85.0%). The rate of a positive TBI screen was 20.5% for the screened cohort. Male gender, service in the army, multiple deployments, and mental health diagnoses in the previous year were associated with a positive screen. TBI screening rates are high in VA; concomitant mental health diagnoses were highly prevalent in individuals with positive TBI screens. These data indicate that there will be a significant need for long-term health care services for veterans with TBI symptomatology.

Do Sleep Problems Mediate the Relationship between Traumatic Brain Injury and Development of Mental Health Symptoms after Deployment?

Military members screening positive for blast-related traumatic brain injury (TBI) may subsequently screen positive for posttraumatic stress disorder (PTSD) or depression. The role of sleep as a mediating factor in the development of mental health symptoms was explored. Prospective study with symptoms evaluated at two time points. Postdeployment service in Iraq, Afghanistan, or Kuwait during 2008 and 2009. There were 29,640 US Navy and Marine Corps men (29,019 who did not screen positive for PTSD at baseline, 27,702 who did not screen positive for depression at baseline, and 27,320 who did not screen positive at baseline for either condition). After controlling for sleep problems, the adjusted odds of receiving a positive PTSD screening at follow-up decreased from 1.61 (95% confidence interval [CI] 1.21-2.14) to 1.32 (95% CI 0.99-1.77) for a subject screening positive for TBI relative to a subject screening negative, suggesting that sleep problems mediated 26% of TBI's effect on development of PTSD. Likewise, after controlling for sleep problems, the adjusted odds of receiving a positive depression screening decreased from 1.41 (95% CI 1.11-1.80) to 1.15 (95% CI 0.90-1.47), suggesting that sleep problems mediated 41% of TBI's effect on development of depression. Results were similar for those with either PTSD or depression (37% mediated). These results suggest that sleep problems mediate the effect of a positive TBI screening on the development of mental health disorders, and sleep problems may be an early indicator of risk for PTSD or depression.

The Velestino study: are traumatic brain injuries in the life-course linked to cognitive impairment among seniors?

BackgroundSeveral publications have reported persistent changes of cognition/earlier cognitive impairment among individuals, especially athletes, with a concussion history, even following a single traumatic brain injury (TBI).ObjectiveTo explore the impact on...

Factors Associated With Completing Comprehensive Traumatic Brain Injury Evaluation

This study examined factors associated with Iraq and Afghanistan Veterans following up with the Department of Veterans Affairs (VA) comprehensive traumatic brain injury (TBI) evaluation after a positive first-level VA TBI screen. Participants included 465 Iraq and Afghanistan Veterans at one VA Medical Center and its five affiliated community-based outpatient clinics, with a positive initial TBI screen between April 1, 2007 and June 1, 2010. We found that 75% of Veterans completed the comprehensive TBI evaluation. Women were three times less likely to complete the comprehensive TBI evaluation than men, and those who endorsed post-traumatic stress disorder avoidance symptoms were nearly two times less likely to complete the comprehensive TBI evaluation. In contrast, headaches, Hispanic ethnicity, and the season of the initial TBI screen (summer vs. winter) were positively associated with completing a comprehensive TBI evaluation. A substantial minority of Veterans who screen positive on the VA initial TBI screen fail to present for the comprehensive TBI evaluation. Addressing specific gender-related issues, avoidance, and the timing of referrals in the context of VA polytrauma programs may increase the likelihood that Veterans receive further assessment, education, and early intervention for TBI or other mental health problems to prevent chronic postdeployment disability.