Survivors Of Severe Traumatic Brain Injury Research Articles

Applying the Sliding Scale Approach to Quantifying Functional Outcomes Up to Two Years After Severe Traumatic Brain Injury.

Outcomes after severe traumatic brain injury (TBI) can be represented by a sliding score that compares actual functional recovery to that predicted by illness severity models. This approach has been applied in clinical trials because of its statistical efficiency and interpretability but has not been used to describe change in functional recovery over time. The objective of this study was to use a sliding scoring system to describe the magnitude of change in Glasgow Outcome Scale Extended (GOSE) score at 6, 12, and 24 months after severe TBI and to compare patients who improved after 6 months to those who did not. This study included consecutive severe TBI patients (Glasgow Coma Scale ≤8; n = 482) from a single center. We grouped patients into four strata based on probability of unfavorable outcome (GOSE = 1-4) using the International Mission on Prognosis and Analysis of Clinical Trials (IMPACT) model, selected a dichotomous GOSE threshold within each stratum, and compared each patient's GOSE to this threshold to calculate a score (GOSE-Sliding Scale [SS]) from -5 to +4 at 6, 12, and 24 months. We compared GOSE-SS at 6 months with GOSE-SS at 12 and 24 months and also compared characteristics of participants who improved after 6 months with characteristics of those who did not using χ2 and t tests. Compared with at 6 months, 40% of patients (n = 74) had improved GOSE-SS at 12 months, and 53% had improved GOSE-SS by 24 months (n = 72). Among those who improved at 12 months, the average magnitude of improvement was 1.7 ± 0.9 and among those who improved at 24 months, the average magnitude of improvement was 1.9 ± 1.0. Those who improved their GOSE-SS score from 6 to 24 months had longer hospital stays (mean-difference = 8.6 days; p = 0.03), longer intensive care unit (ICU) stays (mean-difference = 5.5 days; p = 0.02), and longer ventilator time (mean-difference = 5 days; p = 0.02) than those who worsened. These results support an optimistic long-term outlook for severe TBI patients and emphasize the importance of long-term follow-up in severe TBI survivors.

Commentary: Time to Follow Commands in Severe Traumatic Brain Injury Survivors With Favorable Recovery at 2 Years.

Commentary: Time to Follow Commands in Severe Traumatic Brain Injury Survivors With Favorable Recovery at 2 Years.

Time to Follow Commands in Severe Traumatic Brain Injury Survivors With Favorable Recovery at 2 Years.

The recovery of severe traumatic brain injury (TBI) survivors with long-term favorable outlook is understudied. Time to follow commands varies widely in this patient population but has important clinical implications. To (1) evaluate time to follow commands in severe patients with TBI with favorable outcomes, (2) characterize their trajectory of recovery, and (3) identify predictors associated with delayed cognitive improvement. Participants were recruited prospectively at a Level I trauma center through the Brain Trauma Research Center from 2003 to 2018. Inclusion criteria were age 16 to 80 years, Glasgow Coma Scale score ≤8 and motor score <6, and Glasgow Outcome Scale-Extended measure ≥4 at 2 years postinjury. In 580 patients, there were 229 (39.5%) deaths and 140 (24.1%) patients had favorable outcomes at 2 years. The mean age was 33.7 ± 14.5 years, median Glasgow Coma Scale was 7 (IQR 6-7), and median Injury Severity Score was 30 (IQR 26-38). The mean time to follow commands was 12.7 ± 11.8 days. On multivariable linear regression, the presence of diffuse axonal injury (B = 9.2 days [4.8, 13.7], P < .0001) or intraventricular hemorrhage (B = 6.4 days [0.5, 12.3], P < .035) was associated with longer time before following commands and patients who developed nosocomial infections (B = 6.5 days [1.6-11.4], P < .01). In severe TBI survivors with favorable outcomes, time to follow commands varied widely. Most patients began to follow commands within 2 weeks. Evidence of diffuse axonal injury, intraventricular hemorrhage, and infections can delay cognitive improvement in the acute period. Patients make considerable recovery up to 2 years after their injury.

Pediatric Severe Traumatic Brain Injury : Updated Management.

Traumatic brain injury (TBI) is the leading cause of death and disability in children. Survivors of severe TBI are more susceptible to functional deficits, resulting in disability, poor quality of life, cognitive decline, and mental health problems. Despite this, little is known about the pathophysiology of TBI in children and how to manage it most effectively. Internationally, efforts are being made to expand knowledge of pathophysiology and develop practical clinical treatment recommendations to improve outcomes. Here we discuss recently updated evidence and management of severe pediatric TBI.

Caregivers' perspectives of the challenges faced with survivors of traumatic brain injury: A scoping review.

Traumatic brain injury (TBI) has wide-ranging neuropsychological, physical, social and financial implications. The impact on caregivers of moderate to severe TBI survivors, particularly in low- and middle-income countries, is under-investigated. Identify and describe the experiences of caregivers' of moderate to severe TBI survivors postdischarge from healthcare facilities. A scoping review was conducted utilising seven electronic databases. Two reviewers screened articles using eligibly criteria related to setting (postdischarge), caregiving (informal), age of TBI survivors (> 18 years) and injury severity (moderate-severe). Studies published in English between 1999 -2018 were included. Fourteen articles met the inclusion criteria. Articles reporting on the same sample were merged during data charting. The final analyses included 11 articles comprised of qualitative, quantitative and mixed-methods studies. Ten themes were identified: psychological distress, social functioning, financial burden, family experiences, coping strategies, access to services, time burdens and physical, cognitive and behavioural difficulties. Characteristics of caregivers and TBI survivors were also reported. Caregivers of moderate to severe TBI survivors experience challenges in various life domains, and there is limited research concerning caregivers in low- and middle-income countries. Future research should focus on understanding more nuanced experiences across various environments, which may increase comprehensive, flexible and long-term support.

Recovery of Consciousness and Functional Outcome in Moderate and Severe Traumatic Brain Injury

Traumatic brain injury (TBI) leads to 2.9 million visits to US emergency departments annually and frequently involves a disorder of consciousness (DOC). Early treatment, including withdrawal of life-sustaining therapies and rehabilitation, is often predicated on the assumed worse outcome of disrupted consciousness. To quantify the loss of consciousness, factors associated with recovery, and return to functional independence in a 31-year sample of patients with moderate or severe brain trauma. This cohort study analyzed patients with TBI who were enrolled in the Traumatic Brain Injury Model Systems National Database, a prospective, multiyear, longitudinal database. Patients were survivors of moderate or severe TBI who were discharged from acute hospitalization and admitted to inpatient rehabilitation from January 4, 1989, to June 19, 2019, at 1 of 23 inpatient rehabilitation centers that participated in the Traumatic Brain Injury Model Systems program. Follow-up for the study was through completion of inpatient rehabilitation. Traumatic brain injury. Outcome measures were Glasgow Coma Scale in the emergency department, Disability Rating Scale, posttraumatic amnesia, and Functional Independence Measure. Patient-related data included demographic characteristics, injury cause, and brain computed tomography findings. The 17 470 patients with TBI analyzed in this study had a median (interquartile range [IQR]) age at injury of 39 (25-56) years and included 12 854 male individuals (74%). Of these patients, 7547 (57%) experienced initial loss of consciousness, which persisted to rehabilitation in 2058 patients (12%). Those with persisting DOC were younger; had more high-velocity injuries; had intracranial mass effect, intraventricular hemorrhage, and subcortical contusion; and had longer acute care than patients without DOC. Eighty-two percent (n = 1674) of comatose patients recovered consciousness during inpatient rehabilitation. In a multivariable analysis, the factors associated with consciousness recovery were absence of intraventricular hemorrhage (adjusted odds ratio [OR], 0.678; 95% CI, 0.532-0.863; P = .002) and intracranial mass effect (adjusted OR, 0.759; 95% CI, 0.595-0.968; P = .03). Functional improvement (change in total functional independence score from admission to discharge) was +43 for patients with DOC and +37 for those without DOC (P = .002), and 803 of 2013 patients with DOC (40%) became partially or fully independent. Younger age, male sex, and absence of intraventricular hemorrhage, intracranial mass effect, and subcortical contusion were associated with better functional outcome. Findings were consistent across the 3 decades of the database. This study found that DOC occurred initially in most patients with TBI and persisted in some patients after rehabilitation, but most patients with persisting DOC recovered consciousness during rehabilitation. This recovery trajectory may inform acute and rehabilitation treatment decisions and suggests caution is warranted in consideration of withdrawing or withholding care in patients with TBI and DOC.

Addressing Key Clinical Care and Clinical Research Needs in Severe Pediatric Traumatic Brain Injury: Perspectives From a Focused International Conference.

Traumatic brain injury (TBI) is a leading cause of morbidity and mortality in children and adolescents. Survivors of severe TBI are more prone to functional deficits, resulting in poorer school performance, poor health-related quality of life (HRQoL), and increased risk of mental health problems. Critical gaps in knowledge of pathophysiological differences between children and adults concerning TBI outcomes, the paucity of pediatric trials and prognostic models and the uncertain extrapolation of adult data to pediatrics pose significant challenges and demand global efforts. Here, we explore the clinical and research unmet needs focusing on severe pediatric TBI to identify best practices in pathways of care and optimize both inpatient and outpatient management of children following TBI.

The Experience of Caregivers Following a Moderate to Severe Traumatic Brain Injury Requiring ICU Admission.

Survivors of moderate and severe traumatic brain injury (TBI) require substantial care, much of which is ultimately provided by friends and family. We sought to describe the unmet needs of informal caregivers. Qualitative, semistructured interviews with informal caregivers of moderate and severe TBI survivors were conducted 72 hours, 1 month, 3 months, and 6 months after injury. Intensive care unit of a level 1 trauma center. Informal caregivers were friends or family who planned to provide care for the patient. Patients were 18 years or older with a moderate to severe TBI, and not expected to imminently die of their injuries. Eighteen patient-caregiver dyads were enrolled. Fifty-three interviews with caregivers were completed and analyzed over the course of 6 months. Three themes were identified in the qualitative analysis: caregiver burden, caregiver health-related quality of life, and caregiver needs for information and support. This study provides new information about the experience of informal caregivers during the 6 months after their friend or family member survived a moderate to severe TBI. Interventions to promote caregiving may be a substantial opportunity to improve patient-centered outcomes following TBI.

Tau immunophenotypes in chronic traumatic encephalopathy recapitulate those of ageing and Alzheimer's disease.

Traumatic brain injury (TBI) is a risk factor for neurodegenerative disease, including chronic traumatic encephalopathy (CTE). Preliminary consensus criteria define the pathognomonic lesion of CTE as patchy tau pathology within neurons and astrocytes at the depths of cortical sulci. However, the specific tau isoform composition and post-translational modifications in CTE remain largely unexplored. Using immunohistochemistry, we performed tau phenotyping of CTE neuropathologies and compared this to a range of tau pathologies, including Alzheimer's disease, primary age-related tauopathy, ageing-related tau astrogliopathy and multiple subtypes of frontotemporal lobar degeneration with tau inclusions. Cases satisfying preliminary consensus diagnostic criteria for CTE neuropathological change (CTE-NC) were identified (athletes, n = 10; long-term survivors of moderate or severe TBI, n = 4) from the Glasgow TBI Archive and Penn Neurodegenerative Disease Brain Bank. In addition, material from a range of autopsy-proven ageing-associated and primary tauopathies in which there was no known history of exposure to TBI was selected as non-injured controls (n = 32). Each case was then stained with a panel of tau antibodies specific for phospho-epitopes (PHF1, CP13, AT100, pS262), microtubule-binding repeat domains (3R, 4R), truncation (Tau-C3) or conformation (GT-7, GT-38) and the extent and distribution of staining assessed. Cell types were confirmed with double immunofluorescent labelling. Results demonstrate that astroglial tau pathology in CTE is composed of 4R-immunoreactive thorn-shaped astrocytes, echoing the morphology and immunophenotype of astrocytes encountered in ageing-related tau astrogliopathy. In contrast, neurofibrillary tangles of CTE contain both 3R and 4R tau, with post-translational modifications and conformations consistent with Alzheimer's disease and primary age-related tauopathy. Our observations establish that the astroglial and neurofibrillary tau pathologies of CTE are phenotypically distinct from each other and recapitulate the tau immunophenotypes encountered in ageing and Alzheimer's disease. As such, the immunohistochemical distinction of CTE neuropathology from other mixed 3R/4R tauopathies of Alzheimer's disease and ageing may rest solely on the pattern and distribution of pathology.

THE FAMILY CAREGIVERS’ NEEDS ON CARE AT HOME WITH SEVERE TRAUMATIC BRAIN INJURY SURVIVORS: A REVIEW

This paper aims to review the literature with regards to the family caregivers of severe traumatic brain injury survivors and their needs for care at home. The search started by finding the relevant keywords from EBSCOhost: MeSH database. There were many related studies found by searching the following multiple databases. They are from Evidence Based Medicine (EBM) reviews @ Ovid, Journal @ Ovid Full text, Medline with Full text via EBSCOhost, CINAHL Plus with Full Text, Science Direct, and Google scholars’ articles. The search terms were limited to publications ranging from 2010 to 2016. Several points were highlighted regarding the needs of family caregivers who had been taking care of traumatic brain injury survivors. It also provided information on the needs of family caregivers in terms of care, traumatic brain injury, TBI survivor complications, family caregiver’s burden, caregiver challenges and the impact of traumatic brain injury to family caregiver’s quality of life. Overall, the study shows that family caregivers face significant challenges toward care of TBI survivors. The review highlighted the support needed from the family caregivers, and other important facts about severe traumatic brain injury in order to understand the condition. Further research should focus on rehabilitation efforts on traumatic brain injury survivors.

Favorable Functional Recovery in Severe Traumatic Brain Injury Survivors beyond Six Months.

Favorable long-term functional outcomes after severe traumatic brain injury (TBI) may be underestimated. We analyzed 24-month functional outcomes from a consecutive series of severe TBI survivors. A prospective, observational database of severe TBI survivors from a single institution was analyzed. Glasgow Outcome Scale-Extended (GOS-E) scores were obtained at 3, 6, 12, and 24 months post-injury. GOS-E scores were dichotomized into unfavorable and favorable outcomes, and the proportion of survivors changing from unfavorable to favorable outcomes was calculated using Wilcoxon signed-rank tests. Surviving adults (N = 304; mean age ± standard deviation = 35.06 ± 15.11; 80.92% male; mode of initial GCS = 7) were analyzed. A statistically significant mean increase in GOS-E was noted from 3 to 6, 6 to 12, 12 to 24, and 6 to 24 months after injury (0.65 [p < 0.0001], 0.42 [p < 0.0001], 0.23 [p = 0.020], and 0.61 [p < 0.0001], respectively). Moreover, 43% of survivors from 3 to 6 months, 36% from 6 to 12 months, 38% from 12 to 24 months, and 54% from 6 to 24 months progressed from an unfavorable to a favorable outcome. Two thirds of survivors in the unfavorable category at 3 months had favorable outcomes at 2 years. Overall, 74% of surviving adults with a documented GOS-E at 2 years after injury had a favorable outcome. Severe TBI survivors demonstrated significant improvement in functional outcomes from 3 to 24 months after injury. At 2 years, three fourths of survivors had a favorable outcome. Long-term prognosis in severe TBI is better than broadly appreciated.

Health-related quality of life after 6 months post-injury on severe traumatic brain injury: A cohort study in two Malaysian hospitals

Severe traumatic brain injury (TBI) survivors show physical and functional improvement but remain with the cognitive and psycho-social problem through our recovery. This study aims to measure the health-related quality of life of TBI survivors within 6 months post-injury. A cohort study was conducted where 33 severe TBI survivors recruited at two tertiary hospitals. The health-related quality of life was measured using the Quality of Life after Brain Injury (QOLIBRI) tool. Participants mean age was 31.79 years old. The impaired range of health-related quality of life on 6 months post-injury seen, but an improvement occurs within 3-6 months post-injury. Age and ventilation duration showed a moderate negative correlation in all domains and length of hospital stay showed a moderate negative correlation to social, daily life and self-domains. Nevertheless, small sample size and time constraint were the limitations of this study.

Mild, moderate and severe: terminology implications for clinical and experimental traumatic brain injury.

When describing clinical or experimental traumatic brain injury (TBI), the adjectives 'mild,' 'moderate' and 'severe' are misleading. 'Mild' clinical TBI frequently results in long-term disability. 'Severe' rodent TBI actually resembles mild or complicated mild clinical TBI. Many mild TBI patients appear to have recovered completely but have postconcussive symptoms, deficits in cognitive and executive function and reduced cerebral blood flow. After moderate TBI, 31.8% of patients died or were discharged to skilled nursing or hospice. Among survivors of moderate and severe TBI, 44% were unable to return to work. On MRI, 88% of mild TBI patients have evidence of white matter damage, based on measurements of fractional anisotropy and mean diffusivity/apparent diffusion coefficient. After sports concussion, clinically recovered patients have abnormalities in functional connectivity on functional MRI. Methylphenidate improved fatigue and cognitive impairment and, combined with cognitive rehabilitation, improved memory and executive functioning. In comparison to clinical TB, because the entire spectrum of experimental rodent TBI, although defined as moderate or severe, more closely resembles mild or complicated mild clinical TBI. Many patients after mild or moderate TBI suffer long-term sequelae and should be considered a major target for translational research. Treatments that improve outcome in rodent TBI, even when the experimental injuries are defined as severe, might be most applicable to mild or moderate TBI.

Functional Outcomes and Health-Related Quality of Life After Severe Traumatic Brain Injury: A Review.

Throughout recovery, patients with severe traumatic brain injury (TBI) show physical and functional improvement, but continue to have cognitive and psychosocial problems. The aim of this article was to review the literature regarding the functional and health-related quality of life (HRQOL) outcomes in severe TBI. There were 15 articles reviewed, 13 of them were quantitative studies and two were narrative review. Most of the articles showed an improvement occurs rapidly at 6 months post-injury. There were several factors that influence the outcome after TBI, most of it was the Glasgow Coma Scale (GCS) on admission, age, educational level, duration of posttraumatic amnesia (PTA), and length of stay (LOS) in the Intensive Care Unit (ICU). Thus, health care workers should help the survivors of severe TBI in the recovery process to ensure the latter can attain maximum function and quality of life.

Urinary dysfunction in traumatic brain injury survivors – A retrospective study

Survivors of a traumatic brain injury (TBI) frequently suffer from urinary dysfunction. Possible causes are midbrain dysfunction and primary lesions, but cognitive and behavior factors may also play a role. Overactive bladder (OAB) is a frequent urinary disturbance as opposed to urinary retention. In this study, we aim to investigate altered findings in urodynamic tests and possible relations to other TBI outcomes. A retrospective study was conducted with 24 post-TBI patients (21 male, 3 female) admitted to our unit during a 3 year period. Exclusion criteria included stroke, spinal cord injury, previous history of urological pathology or surgery and absence of urodynamic evaluation. Information was gathered relative to results of urodynamics, TBI imaging, initial GCS scale, urinary symptoms, vesical regime, neuropsychological and ultrasound results. Of the 24 patients studied, all had severe TBI with a mean age of 40.1 years and a predominance of motor vehicle related accidents (66.7%) and axonal diffuse injury (62.5%). Median time from TBI was 7.5 months and only 2 patients had a normal urodynamic study. Urinary symptoms were present in 17 (70.8%) patients and the majority (58.3%) had filling symptoms. There was previous history of urinary tract infection in 32% patients. Neuropsychological evaluation was altered in all but one of the assessed patients. The majority had OAB (62.4%) and altered bladder sensation (70.8%). Mean total vesical capacity was 343.6 mL. Elevated postvoid residual volume (37.5%) and detrusor sphincter dyssynergia (37.5%) was observed. Most patients had urinary symptoms and an overactive bladder. A subset of patients showed detrusor sphincter dyssynergia, a finding not frequently described. Cognitive impairment can play a role in urologic dysfunction and pseudodyssynergia might be present during the urodynamic test. Further studies are needed to assess urologic dysfunction in severe TBI survivors.

Functional Outcomes 6 Months After Severe Traumatic Brain Injury Following Admission Into Intensive Care Unit: A Cohort Study in Two Tertiary Hospitals.

Severe traumatic brain injury (TBI) survivors show physical and functional improvements but continue to have cognitive and psychosocial problems throughout recovery. However, the functional outcome of severe TBI in Malaysia is unknown. The objective of this study is to measure the functional outcomes of severe TBI within 6 months post-injury. A cohort study was done on 33 severe TBI survivors. The Glasgow Outcome Scale-Extended (GOSE) was used in this study. The mean age of the participants was 31.79 years (range: 16-73 years). The logistic regression model was statistically significant, χ²(5, N = 33) = 29.09, p < .001. The length of stay (LOS) in incentive care unit (p = .049, odds ratio = 6.062) and duration on ventilator (p = .048, odds ratio = 0.083) were good predictors of the functional outcomes. Future research should focus on larger sample size of severe TBI in Malaysia.

A subgroup analysis of penetrating injuries to the pancreas: 777 patients from the National Trauma Data Bank, 2010-2014

BackgroundThis study is the first to analyze penetrating injuries to the pancreas within subgroups of severe traumatic brain injury (TBI), early deaths, and potential survivors. Our objectives were to identify national patterns of injury, predictors of mortality, and to validate the American Association for Surgery of Trauma Organ Injury Scale (AAST-OIS) pancreas injury grades by mortality. Secondary outcomes included hospital and intensive care unit length of stay and days on mechanical ventilation. MethodsUsing the Abbreviated Injury Scale 2005 and ICD-9-CM E-codes, we identified 777 penetrating pancreatic trauma patients from the National Trauma Data Bank that occurred between 2010 and 2014. Severe TBI was identified by ICD-9-CM diagnosis codes and Glasgow Coma Score (GCS; n = 7), early deaths were those that occurred within 24 h of admission (n = 82), and potential survivors included patients without severe TBI who survived longer than 24 h following admission (n = 690). We estimated multivariable generalized linear mixed models to predict mortality to account for the nesting of potential survivors within trauma centers. ResultsOur results indicated that overall mortality decreased from 16.9% to 6.8% after excluding severe TBI and early deaths. Approximately, 11% of patients died within 24 h of admission, of whom 78% died in the first 6 h. Associated injuries to the stomach, liver, and major vasculature occurred in approximately 50% of patients; rates of associated injuries were highest in patients who died within 6 h of admission. In potential survivors, mortality increased by AAST-OIS grade: 3.5% I/II; 8.3% III; 9.6% IV; and 13.8% V. Predictors of mortality with significantly increased odds of death were patients with increasing age, lower admission GCS, higher admission pulse rate, and more severe injuries as indicated by Organ Injury Scale grade. ConclusionsFrom 777 patients, we identified national patterns of injury, predictors of outcome, and mortality by AAST-OIS grade within the subgroups of severe TBI, early deaths, and potential survivors. Because AAST-OIS is not a reported element in the National Trauma Data Bank, we correlated Abbreviated Injury Scale 2005 codes to injury grade and identified an increase in mortality. After controlling for covariance, we found that greater age, lower GCS in stab wounds, higher pulse, and presence of a grade V pancreatic injury independently predicted the likelihood of death in patients surviving beyond 24 h following penetrating injuries to the pancreas.

Group-Based Trajectory Analysis of Emotional Symptoms Among Survivors After Severe Traumatic Brain Injury.

Depressive symptoms and anxiety are fairly common emotional outcomes after severe traumatic brain injury (TBI). Life satisfaction is a main factor in the general construct of subjective well-being. However, there is limited literature available on the interrelationship between emotional outcomes and life satisfaction post-severe TBI over time. The purpose of this study was to characterize distinct patterns of change in depressive symptoms, anxiety, and life satisfaction over 24 months after severe TBI and evaluate the interrelationship of different trajectory groups among them as well as associated subject characteristics. This prospective study used longitudinal data collected from the University of Pittsburgh Brain Trauma Research Center from survivors of severe TBI (N = 129). In addition to demographic and injury-related data, depressive symptoms, anxiety, and life satisfaction were collected at 3, 6, 12, and 24 months postinjury. A group-based trajectory model was performed to identify distinct longitudinal patterns of depressive symptoms, anxiety, and life satisfaction. The interrelationships of distinct trajectory groups were examined using χ tests. A multivariate logistic regression model was used to examine the predictors of different emotional symptom trajectories. The group-based trajectory model identified 2 distinct patterns of each of 3 outcomes: constantly low and constantly high depressive symptoms group (70.4% vs 29.6%), constantly low and constantly high anxiety group (69.1% vs 30.9%), and low-decreasing and high-stable life satisfaction groups (56.3% vs 43.7%). A strong pairwise association was observed between trajectory group membership for depressive symptoms and anxiety (P < .0001), depressive symptoms and life satisfaction (P < .0001), and anxiety and life satisfaction (P < .001). Subjects with increased severe injury were more likely to belong to the high-stable depressive symptoms group, while there were no significant associations between age, gender, race, education, marriage status and distinct depressive symptoms, anxiety, and life satisfaction trajectory groups. A group-based trajectory model revealed patterns of emotional symptoms that have not been fully explored among survivors of severe TBI. There appear to be distinct trajectory patterns for depressive symptoms, anxiety, and life satisfaction, respectively. There was strong interrelationship among emotional symptoms. The findings add to our understanding of psychosocial outcomes experienced over time after severe TBI.

Acute Ischemic Stroke After Moderate to Severe Traumatic Brain Injury: Incidence and Impact on Outcome.

Traumatic brain injury (TBI) leads to nearly 300 000 annual US hospitalizations and increased lifetime risk of acute ischemic stroke (AIS). Occurrence of AIS immediately after TBI has not been well characterized. We evaluated AIS acutely after TBI and its impact on outcome. A prospective database of moderate to severe TBI survivors, admitted to inpatient rehabilitation at 22 Traumatic Brain Injury Model Systems centers and their referring acute-care hospitals, was analyzed. Outcome measures were AIS incidence, duration of posttraumatic amnesia, Functional Independence Measure, and Disability Rating Scale, at rehabilitation discharge. Between October 1, 2007, and March 31, 2015, 6488 patients with TBI were enrolled in the Traumatic Brain Injury Model Systems National Database. One hundred and fifty-nine (2.5%) patients had a concurrent AIS, and among these, median age was 40 years. AIS was associated with intracranial mass effect and carotid or vertebral artery dissection. High-velocity events more commonly caused TBI with dissection. AIS predicted poorer outcome by all measures, accounting for a 13.3-point reduction in Functional Independence Measure total score (95% confidence interval, -16.8 to -9.7; P<0.001), a 1.9-point increase in Disability Rating Scale (95% confidence interval, 1.3-2.5; P<0.001), and an 18.3-day increase in posttraumatic amnesia duration (95% confidence interval, 13.1-23.4; P<0.001). Ischemic stroke is observed acutely in 2.5% of moderate to severe TBI survivors and predicts worse functional and cognitive outcome. Half of TBI patients with AIS were aged ≤40 years, and AIS patients more often had cervical dissection. Vigilance for AIS is warranted acutely after TBI, particularly after high-velocity events.

"We all need employment" - An exploration of the factors which influence the return-to-work after a severe traumatic brain injury

INTRODUCTION: While individuals with mild and moderate traumatic brain injury (TBI) manage to achieve some degree of successful return-to-work, individuals with severe TBI have a reduced chance of returning to work. This study aimed at investigating how personal factors, workplace environment and vocational rehabilitation influenced the return-to-work and assumption of the worker role of individuals with severe TBI. METHOD: A phenomenographic study design with purposive sampling was used to select 11 participants. Data were collected through semi-structured interviews using the Worker Role Interview as a guide. Data were thematically analysed using Clarke and Braun's six phases of thematic analysis. RESULTS: Two themes emerged: It's all about me, which addressed the internal aspects of the role of a worker and The support for me which focused the external factors of personal, work and rehabilitative support. CONCLUSION: Results showed that rehabilitation, personal factors and work support were critical for successful return-to-work for survivors of severe TBI. Results indicated that participation in work was as important in developing self-worth as participation in any other area of daily living. With regard to personal factors, rehabilitation and support were vital in maintaining self-worth after an injury. This could be enhanced through vocational rehabilitation. Key words: Traumatic brain injury, return-to-work, vocational rehabilitation.