Quality Of Survival Research Articles

The use of technology-based weight loss intervention for endometrial cancer survivors with obesity

Objectives: Presently, more than one third of women in the United State are obese (BMI ≥30). Obesity significantly increases the relative risk of the development of both endometrial hyperplasia and cancer. However, once diagnosed, quality of survivorship of obese women is worse than that for nonobese patients. Our objective was to assess the feasibility of technology-based weight loss interventions in this patient population.

Comprehensive evaluation of the incidence of late effects in 5-year survivors of breast cancer

Late effects of breast cancer affect the quality of survivorship. Using administrative data, we compared the occurrence of almost all ICD9 codes among older breast cancer survivors to that among a matched comparison cohort to generate new hypotheses. Breast cancer patients 65 years or older diagnosed 1990-1994 in 6 integrated care settings and who survived at least 5 years were matched with a cohort of women without a history of breast cancer on care setting, age, and calendar time. We collected data on the occurrence of incident ICD9 codes beginning 6 years after the breast cancer diagnosis date and continuing to year 15, and comparable data for the matched woman. We calculated hazard ratios (HRs) and 95 % confidence intervals associating breast cancer survivorship with incidence of each ICD9 code. We used semi-Bayes methods to address multiple comparisons. Older breast cancer survivors had about the same occurrence of diseases and conditions 6-15 years after breast cancer diagnosis as comparable women. The median of 564 adjusted HRs equaled 1.06, with interquartile range 0.92-1.3. The distribution of HRs pertaining to cancer-related ICD codes was shifted toward positive associations, and the distribution pertaining to cardiovascular-related ICD codes was shifted toward negative associations. In this hypothesis-scanning study, we observed little difference in the occurrence of non-breast cancer-related diseases and conditions among older, long-term breast cancer survivors, and comparable women without a history of breast cancer.

Evidence-Based Guideline Recommendations

Cancer survivorship is expected to increase in coming years. Survivors include recipients of hematopoietic stem cell transplantations, signaling the necessity for evidence-based guidelines that focus on long-term follow-up needs. Studies have shown that evidence-based care can improve cancer survivors' quality of life and long-term outcomes. The implication is that early identification and intervention in chronic health problems such as graft-versus-host disease result in improved outcomes and a higher quality of survivorship. These discoveries signal a need to provide specific care management with appropriate and timely screening and preventive services. Recommendations for long-term follow-up post-hematopoietic stem cell transplantation are an important guide to direct clinical practice with this patient population and optimize their outcomes.

Processing Speed, Attention, and Working Memory After Treatment for Medulloblastoma: An International, Prospective, and Longitudinal Study

The current study prospectively examined processing speed (PS), broad attention (BA), and working memory (WM) ability of patients diagnosed with medulloblastoma over a 5-year period. The study included 126 patients, ages 3 to 21 years at diagnosis, enrolled onto a collaborative protocol for medulloblastoma. Patients were treated with postsurgical risk-adapted craniospinal irradiation (n = 36 high risk [HR]; n = 90 average risk) followed by four cycles of high-dose chemotherapy with stem-cell support. Patients completed 509 neuropsychological evaluations using the Woodcock-Johnson Tests of Cognitive Abilities Third Edition (median of three observations per patient). Linear mixed effects models revealed that younger age at diagnosis, HR classification, and higher baseline scores were significantly associated with poorer outcomes in PS. Patients treated as HR and those with higher baseline scores are estimated to have less favorable outcomes in WM and BA over time. Parent education and marital status were significantly associated with BA and WM baseline scores but not change over time. Of the three key domains, PS was estimated to have the lowest scores at 5 years after diagnosis. Identifying cognitive domains most vulnerable to decline should guide researchers who are aiming to develop efficacious cognitive intervention and rehabilitation programs, thereby improving the quality of survivorship for the pediatric medulloblastoma population.

Building platforms for collaborative care and clinical research in testicular cancer (TC): New approaches for care delivery for a model neoplasm.

308 Background: TC is a “model of a curable neoplasm.” In expert centers, more than 95% of patients are cured and enjoy long, high quality survivorship. Unfortunately, emerging data demonstrate variations in quality outcomes seen in high volume centers. Result are not fully replicated in U.S. community settings, low resources countries or in settings of uneven access. We hypothesize that real time, electronic information exchange in TC can influence favorably clinical decision making, patient-centered outcomes, value and quality of survivorship across business and geographic boundaries. Further, we speculate that aggregated, de-identified clinical/ biological information will serve as a template for a rapid learning system to refine clinical management and advance biological understanding. Methods: Our primary objectives were to (1) Build organizational/administrative capacity. (2) Engage patients/local providers. (3) Develop the information infrastructure to accomplish real time exchange of live patient-permitted clinical data (patient reported inputs, laboratory, imaging) and timely transmission of clinical decision support and ongoing oversight of care delivery in the community. (4) Establish a proof-of-principle demonstration in a community-based, electronically organized care delivery system. Results: Organizational: TC Commons, a nonprofit organization, was founded to house this effort. Leading academic institutions form the knowledge base, initial data sharing network and administrative structure for this electronic cooperative group. Early implementation has utilized cloud-based resources and telepresence. Community Engagement: We are utilizing organized social media efforts and partnering with patient advocacy groups. IT Infrastructure: We are creating public/private collaboratives to house the electronic capacity with appropriate privacy concerns. Proof of Principle: We are selecting community partner organizations and planning grant submissions. Conclusions: Expert platforms to enhance care delivery, patient value and experience, and clinical research can be built using a “bootstapping,” cost-sensitive approach.

Development of an evidence-based, patient-centered breast cancer chemotherapy and survivorship quality measures (QM) by the Oncology Nursing Society (ONS).

273 Background: QM focused on areas illustrating high-quality cancer care valued by nurses and patients are needed to complement existing measures in the ambulatory oncology setting. ONS has utilized a reproducible process for pilot testing two sets of evidence-based QM for validity and reliability in the breast cancer population, drawing on evidence from ONS Putting Evidence into Practice (PEP), Institute of Medicine (IOM) recommendations and other resources. Methods: The ONS Foundation supported teams of expert nurses to review evidence, draft and prioritize topic areas for potential QM. Final QM were selected after soliciting national public comment from stakeholders, and were judged on importance to clinical care, prevalence and potential for impact, scientific basis and link between process and outcome. The Joint Commission (TJC) was contracted to conduct testing, and diverse pilot sites were recruited to perform retrospective data abstraction on patient charts. The Breast Cancer Care (BCC) QM set focused on symptom management for patients receiving chemotherapy, and the Breast Cancer Survivorship (BCS) set explores needs in the first year post-treatment. TJC and ONS staff co-managed development of QM specifications, abstractor training, clinical and technical support of pilot sites, and re-abstracted 15% of 2,835 submitted cases for reliability testing. Results: QM scores were examined for gaps in care; there are clear opportunities to improve the consistency of symptom assessment and management. Symptom intensity, trajectory over time, success/failure of interventions are frequently undocumented, impacting coordination of care. Post-treatment/transition to survivorship education and resource provision as recommended by the IOM are lacking. Conclusions: Audit and feedback to practices using valid and reliable QM provide a strategy to link high-level evidence-based interventions and practice changes to improve quality cancer care. National testing across diverse practice sites illustrates a strong need to improve the consistency of symptom assessment/management and post-treatment survivorship interventions.

Missing content from health-related quality of life instruments: interviews with young adult survivors of childhood cancer.

Young adult survivors of childhood cancer (YASCC) are an ever-growing cohort of survivors due to increasing advances in technology. Today, there is a shift of focus to not just ensuring survivorship but also the quality of survivorship, which can be assessed with standardized instruments. The majority of standardized health related quality of life (HRQoL) instruments, however, are non-specific to this age group and the unique late effects within YASCC populations. The purpose of this study was to investigate the relevance and accuracy of standardized HRQoL instruments used with YASCC. In a previous study, HRQoL items from several instruments (SF-36, QLACS, QLS-CS) were examined for relevance with a population of YASCC. Participants (n = 30) from this study were recruited for a follow-up qualitative interview to expand on their perceptions of missing content from existing instruments. Respondents reported missing, relevant content among all three of the HRQoL instruments. Results identified three content areas of missing information: (1) Perceived sense of self, (2) Relationships, and (3) Parenthood. Existing HRQoL instruments do not take into account the progression and interdependence of emotional development impacted by a cancer diagnosis. The themes derived from our qualitative interviews may serve as a foundation for the generation of new items in future HRQoL instruments for YASCC populations. Further testing is required to examine the prevalence, frequency, and breadth of these items in a larger sample.

Assessment of genetic predisposition to lymphedema.

195 Background: In the United States, 203,000 women are diagnosed annually with breast cancer (BC). Currently, over 2.3 million women in the United States are breast cancer survivors. With the increased incidence and survivorship, more women are living with the long-term treatment effects such as lymphedema (LE). We are nearing completion of stage one of a three-stage research project to examine genetic factors that potentially predispose BC survivors to develop LE. In stage one, we are working to identify novel genetic polymorphisms pointing to genomic regions and genes associated with LE risk. In stage two, we will use exome sequencing to examine both rare and common genetic variants potentially associated with variation in symptom manifestations of LE in breast cancer survivors; to examine phenotypic and genotypic variation in LE emerging following cancer treatment; and to examine associations between LE phenotypes among breast cancer survivors with LE and genomic factors and non-genomic factors. In stage three, we will replicate at the genetic level the associations detected. Methods: Institutional funding was obtained for a GWAS-design feasibility study with 96 breast cancer survivors with and without LE (48/48). Genetic material (from buccal swabs), limb volume (by perometry and circumferences), and self-reported LE-related symptoms were collected in one laboratory appointment. Results: Ninety-five percent of survivors participating in an on-going longitudinal study consented to participate in the genetic pilot (N=96). Buccal swabs provided yield for DNA extraction (concentration average 174.94 ng/ul). An additional 96 specimens have been collected for a second pilot GWAS (N =192). Conclusions: The pilot findings form the basis for a larger multisite proposed study to examine genetic predisposition to secondary LE. The findings of the larger study will lead to the design and timing of subsequent interventions aimed at reducing LE risk and improving overall survivorship quality of life. Findings concerning interactions among best cancer treatments and LE genetic predisposition will have the potential to guide the selection of cancer treatment to minimize complications when survival outcomes are equivalent across competing treatment approaches.

Abstract P5-08-01: Oncology Clinicians’ Knowledge, Attitudes and Practices Regarding Fertility Preservation

Abstract Background: Many breast cancer survivors of child-bearing age wish to become parents after therapy and are concerned about the possibility of treatment-induced infertility. Educating patients about the effects of therapy on fertility, early menopause, and fertility preservation options prior to treatment may optimize a survivor's quality of life after treatment. It is unclear whether oncologists feel qualified to discuss fertility issues with their patients, and if not, what barriers prevent such discussions. Methods: An IRB approved cross-sectional survey was developed at Memorial Sloan-Kettering Cancer Center (MSKCC) in order for clinicians to self-evaluate their knowledge, attitudes, and behaviors regarding fertility preservation. Survey items were derived from existing surveys in the literature and input from a multidisciplinary committee. The web-based survey was systematically administered to all MSKCC ambulatory clinicians. Repeated email reminders were sent to optimize responses. Results: 76 breast cancer clinicians at MSKCC and our regional network sites completed the survey between 2/9/09 and 2/25/09. Among respondents, there was widespread agreement (97% (70/72)) that patients should be informed of fertility preservation options, but fewer respondents (51% (37/72)) consistently discussed effects of treatment on fertility with their patients. Only 47% of clinicians (35/74) reported access to information about effects of treatment on fertility. Many physicians cited lack of training in fertility preservation, time constraints, and lack of referral information as barriers to educating patients. No significant difference existed in practice or knowledge between physicians who were practicing for ≤ 5 years vs ≥ 5 years. Conclusions: Physicians report that lack of education, resources and insufficient time hinder fertility preservation discussions with patients. Physicians might benefit from educational efforts regarding the effects of treatment on fertility and new fertility preservation techniques in order to effectively counsel their patients. Time limitations may be overcome by developing educational resources and collaborating with other clinical staff (e.g., nurses) to provide this vital information to patients. These findings are informing an institution-wide educational fertility program. Citation Information: Cancer Res 2010;70(24 Suppl):Abstract nr P5-08-01.

Adolescent and Young Adult Oncology: An Emerging Field

Adolescent and Young Adult Oncology: An Emerging Field

Gynecologic Oncology Group quality assurance audits: analysis and initiatives for improvement

The Gynecologic Oncology Group (GOG) is a multi-institution, multi-discipline Cooperative Group funded by the National Cancer Institute (NCI) to conduct clinical trials which investigate the treatment, prevention, control, quality of survivorship, and translational science of gynecologic malignancies. In 1982, the NCI initiated a program of on-site quality assurance audits of participating institutions. Each is required to be audited at least once every 3 years. In GOG, the audit mandate is the responsibility of the GOG Quality Assurance Audit Committee and it is centralized in the Statistical and Data Center (SDC). Each component (Regulatory, Investigational Drug Pharmacy, Patient Case Review) is classified as Acceptable, Acceptable, follow-up required, or Unacceptable. To determine frequently occurring deviations and develop focused innovative solutions to address them. A database was created to examine the deviations noted at the most recent audit conducted at 57 GOG parent institutions during 2004-2007. Cumulatively, this involved 687 patients and 306 protocols. The results documented commendable performance: Regulatory (39 Acceptable, 17 Acceptable, follow-up, 1 Unacceptable); Pharmacy (41 Acceptable, 3 Acceptable, follow-up, 1 Unacceptable, 12 N/A): Patient Case Review (31 Acceptable, 22 Acceptable, follow-up, 4 Unacceptable). The nature of major and lesser deviations was analyzed to create and enhance initiatives for improvement of the quality of clinical research. As a result, Group-wide proactive initiatives were undertaken, audit training sessions have emphasized recurring issues, and GOG Data Management Subcommittee agendas have provided targeted instruction and training. The analysis was based upon parent institutions only; affiliate institutions and Community Clinical Oncology Program participants were not included, although it is assumed their areas of difficulty are similar. The coordination of the GOG Quality Assurance Audit program in the SDC has improved data quality by enhancing our ability to identify frequently occurring deviations and develop innovative solutions to avoid or minimize their occurrence in the future.

Curing Hodgkin's lymphoma: quantity and quality

The most common treatment for patients with early-stage (stage I–II) Hodgkin's lymphoma is two to four cycles of chemotherapy followed by involved-field radiation therapy.1 The long-term disease-free survival rates (ie, cure) for early-stage Hodgkin's lymphoma are 90–95%. Given the high cure rate, and bearing in mind that most patients diagnosed with Hodgkin's lymphoma are under 40 years, quality of survivorship is an important consideration.

Older Breast Cancer Survivors: Factors Associated with Self-reported Symptoms of Persistent Lymphedema Over 7 years of Follow-up

Lymphedema of the arm is a common complication of breast cancer with symptoms that can persist over long periods of time. For older women (over 50% of breast cancer cases) it means living with the potential for long-term complications of persistent lymphedema in conjunction with the common diseases and disabilities of aging over survivorship. We identified women > or =65 years diagnosed with primary stage I-IIIA breast cancer. Data were collected over 7 years of follow-up from consenting patients' medical records and telephone interviews. Data collected included self-reported symptoms of persistent lymphedema, breast cancer characteristics, and selected sociodemographic and health-related characteristics. The overall prevalence of symptoms of persistent lymphedema was 36% over 7 years of follow-up. Having stage II or III (OR = 1.77, 95% CI: 1.07-2.93) breast cancer and having a BMI >30 (OR = 3.04, 95% CI: 1.69-5.45) were statistically significantly predictive of symptoms of persistent lymphedema. Women > or =80 years were less likely to report symptoms of persistent lymphedema when compared to younger women (OR = 0.44, 95% CI: 0.18-0.95). Women with symptoms of persistent lymphedema consistently reported worse general mental health and physical function. Symptoms of persistent lymphedema were common in this population of older breast cancer survivors and had a noticeable effect on both physical function and general mental health. Our findings provide evidence of the impact of symptoms of persistent lymphedema on the quality of survivorship of older women. Clinical and research efforts focused on risk factors for symptoms of persistent lymphedema in older breast cancer survivors may lead to preventative and therapeutic measures that help maintain their health and well-being over increasing periods of survivorship.

Effectiveness assessment of a neonatal intensive care program for very low birth weight infants. Impact of surfactant administration

Although many therapeutic interventions have proven efficacy through randomized control trials (RCT) with extensive use in Neonatal Intensive Care Units (NICU) for Very Low Birth Weight Infants (VLBWI), doubts remain about its overall effectiveness. To determine changes in the effectiveness of NICU practices on VLBWI over 14 years in the quality of neonatal survival in a General Hospital, with emphasis in the change in reanimation practices by the introduction of the spread use of surfactant. We included all consecutive VLBWI admitted in our NICU during a period of 14 years: 1989-1992 (n= 145); 1993-2002 (n= 342). All survivors were included in our follow-up program; 80% and 85% were available for assessment at two years of corrected age. The patients were assigned to 4 groups by weight in 250 g categories, between 500 and 1500 g. Survival and adjusted quality of survival (QS). The QS was expressed in life-years gained. We create categories for the estimation of disabilities. We also analyzed time of NICU stay by weight and mortality categories during the 2 periods. The survival rate improved significantly between the 2 periods (23%) from 52% to 75%. The actuarial survival showed a significant increase in all weight groups (p <0.001), especially between 500-749 g (4% vs. 33%). The life-years gained showed differences in the BW <750 g (p <0.002, 3.6 vs. 23.4) y 750-999 g (p <0.001, 22.3 vs. 48); no differences were found in the others groups. The time of stay showed an increase of 30 days in the <750 g group (p <0.01) and decreased 8 days in the> or =1250 g group (p <0.01). The effectiveness of neonatal intensive care for VLBWI improved in the period 1993-2002, after surfactant introduction, especially in the group <1000 g.

Employment and Quality of Survivorship among Women with Cancer: Domains not Captured by Quality of Life Instruments

Many quality of life instruments assess the amount of paid work in combination with role function at home in the same items and do not specifically assess social support in the workplace. The goal of this study was to obtain women's views on the relationship between employment and health-related quality of life. A focus group and questionnaire study was conducted among 73 women with gynecologic cancer who were employed at diagnosis and 25 people who provided them with psychosocial support. The women held a variety of blue collar and white collar jobs at diagnosis. Employment provided a strong sense of accomplishment and a welcome distraction during treatment. The employment experience was described as distinct from role function at home. No one equated working more hours with better quality of life. Social support at work could be poor at the same time that support from family and friends grew stronger. The contribution to their quality of life that cancer survivors feel they receive from employment may not be linearly related to the quantity of their role function in the workplace. Employment-related items could be useful as an adjunct to standard quality of life measures.

Skin lesions after intensive care procedures: Results of a prospective study

Purpose To define the skin lesions produced by procedures used in the intensive care unit (ICU) and to examine patients 12 months after discharge from the ICU. Material and Methods This was a prospective clinical study in the 14-bed multidisciplinary ICU of a university hospital. Iatrogenic skin lesions (ISL) were examined in 316 patients after ICU discharge. Results A total of 189 patients were interviewed 12 months after ICU discharge. More than 85% of the patients had ISL after being discharged from the ICU. The patients with the highest Acute Physiology and Chronic Health Evaluation II score and longest average stay presented the highest number of ISLs. A total of 93 patients (49%) reported some skin lesions after 12 months. All patients who had undergone surgical tracheostomy reported the presence of a scar, but 4 of 24 patients who had undergone percutaneous tracheostomy reported no tracheostomy scar. Only 22% of all patients reported scars caused by vascular catheter access. About half (54.5%) of the patients reported secondary lesions caused by chest draining, and these were predominantly caused by the large-bore tube drainage. All patients reported the presence of a laparatomy scar. Conclusions Most patients had identified skin lesions resulting from ICU procedures. Half of all patients were aware of their lesions and reported them at 12 months. Future research is needed to understand whether these lesions cause problems to survivor's quality of life and whether the lesions lead to increased health care utilization.

Systemic and global toxicities of head and neck treatment

The increased use of aggressive, combined modality therapy for the treatment of head and neck cancer has resulted in a marked increase in acute and late adverse effects. The acute effects of therapy have long been appreciated; however, it is now being recognized that the late effects of therapy result in a significant symptom burden, diminished functional capacity and decreased quality of survivorship. Furthermore, head and neck cancer has historically been considered a locoregional disease that is treated predominantly with locoregional therapy. It is now recognized that there are systemic effects of therapy that need to be considered. Potential systemic effects of therapy include: fatigue, weight loss, nutritional deficiencies, altered physical functioning and mood disorders. It is important for clinicians to be aware of these late effects in order to provide patients with appropriate support services and referrals. This paper examines the global and systemic effects of therapy.

Subclinical cardiac toxicity and health-related quality of life (hql) in childhood cancer survivors

9018 Background: Despite substantial information about late cardiotoxicity, little is known about its impact on the adolescent/young adult survivor's health-related quality of life (HQL). Using cross-sectional data, we assessed how HQL and New York Heart Association (NYHA) functional classification are related to survivors’ cardiac performance, cardiac risk factors, and treatment history. Methods: HQL indicators were examined in 164 long-term survivors of pediatric cancer (age 16–40 years), who had (n=132; 10 years (mean) after diagnosis of predominantly leukemia or lymphoma) or had not (n=32; 11 years (mean) after diagnosis of predominantly solid tumors) received anthracyclines and/or thoracic irradiation. Survivors underwent extensive noninvasive clinical and laboratory cardiac risk evaluation and completed a self-report questionnaire on selected subscales of the SF-36 (HQL). Results: Reported general health was lower in the cardiotoxic-therapy group (P = 0.05). Sex, current age, time since diagnosis, cardiac function, and cardiac risk factors were independent predictors of HQL subscales and NYHA class in multivariable analysis. Female sex and higher LDL cholesterol interacted to predict diminished reported vitality (P = 0.04) and physical health (P = 0.05) shown in table . Conclusions: Even in the absence of clinically evident cardiotoxicity, cardiac dysfunction and cardiac risk were strongly linked to decreased HQL and NYHA class, particularly among female survivors. Reduced HQL may be an indicator of unidentified sequelae that should be investigated and monitored. No significant financial relationships to disclose. [Table: see text]

Preparing professional staff to care for cancer survivors

Oncology health care professionals frequently lack the background to implement needed survivorship activities and follow-up care. The purpose of this project is to assist providers in the clarification and initiation of potentially durable changes in survivorship care by developing a health professional curriculum, recruiting participants, implementing the course, conducting course evaluation and following participants' defined goals over time. The curriculum was developed based on recommendations from the Institute of Medicine Report-From Cancer Patient to Cancer Survivor--Lost in Transition. Three concepts were used to structure the course: cancer survivorship quality of life, changing practice via performance improvement, and principles of adult education. Expert faculty designed and implemented the curriculum and teaching methods using adult learning principles and an interactive approach. Competitively-selected, two-person interdisciplinary teams for the first course (July 12-15, 2006, Pasadena, California) were selected based on stated interests, three projected goals, and letters of commitment from administrators. Participants represented 52 cancer care settings from 28 states. Teams included Nurses (48.1%), Social Workers (20.7%), Physicians (18.8%), Directors/Administrators (6.6%), Psychologists (2.8%), and others (3%). The institutional barriers identified by teams were lack of survivorship knowledge (94 %), financial constraints (61%), lack of administrative support (6%), and staff philosophy that excluded survivorship (15%). Evaluation of content from the first course was consistently positive. Dissemination of survivorship education for health care professionals stimulates participants to define and begin to implement goals for improving survivors' care. A training program such as the one described provides professional knowledge regarding survivorship that has the potential to facilitate change in the health care that cancer survivors receive thus ideally improving long term health and well being.

Correlates to Traumatic Brain Injury in Nonhuman Primates

Traumatic brain injury (TBI) is a major health problem, both in terms of the economic cost to society and the survivor's quality of life. The development of devices to protect against TBI requires criteria that relate observed injury to measurements of head kinematics. The objective of this study is to find the best statistical correlates to impact-induced TBI in nonhuman primates using a qualified, self-consistent set of historical kinematic and TBI data from impact tests on nonhuman primates. A database was constructed and qualified from historical head impact tests on nonhuman primates. Multivariate logistic regression analysis with backwards stepwise elimination was performed. Variables considered are the peak rotational acceleration (Omegamax), the peak linear acceleration (Amax), and the number of impacts (N). Bivariate combinations of angular acceleration and the number of impacts are the best correlates to all modes of TBI considered, i.e., concussion, subarachnoid hemorrhage, brain contusion, and subdural hematoma. For a nonhuman primate with 100-g brain mass, the criteria that the probability of TBI is less than 10% by injury mode are:Concussion: OmegamaxN(0.84) < 70 krad/s/s SAH: OmegamaxN(0.70) < 160 krad/s/s Contusion: Omegamax N(0.35) < 160 krad/s/s SDH: Omegamax N(0.60) < 280 krad/s/s Based on this dataset, the best statistically based risk factor for all modes of TBI in nonhuman primates is the bivariate combination of rotational acceleration and number of impacts.