Prophylaxis for venous thromboembolism during rehabilitation for traumatic brain injury: a multicenter observational study.

BACKGROUND: Deep venous thrombosis (DVT) is a major cause of mortality and morbidity after traumatic brain injury (TBI). There is no consensus regarding appropriate screening, prophylaxis, or treatment during acute rehabilitation. METHODS: This prospective observational study evaluated prophylactic anticoagulation during rehabilitation in patients with TBI aged 16 years or older admitted to 12 TBI Model Systems rehabilitation centers (July 2004-December 2007). After propensity score stratification within center, the odds ratio associated with incidence of symptomatic DVT or pulmonary embolism (PE) for patients who did and did not receive prophylactic anticoagulation was estimated using conditional logistic regression in patients who were not screened for DVT on rehabilitation admission or who screened negative; the analysis was repeated in these two subgroups. RESULTS: Patients with identified DVTs at rehabilitation admission (n = 266) were excluded, leaving 1,897 patients: 1,002 screened negative, 895 unscreened; 932 received prophylactic anticoagulation, and 965 did not. Symptomatic DVT/PE was detected in 32 patients (15 of 932 [1.6%] with prophylaxis, 17 of 965 [1.8%] without). After propensity score adjustment, the odds ratio (95% confidence interval) for symptomatic DVT/PE with prophylaxis versus no prophylaxis was 0.80 (0.33-1.94) in the full analytic population and 0.46 (0.12-1.84) in the screened-negative subgroup. The only probable venous thromboembolism-related death occurred in the prophylactic anticoagulation group. Fewer new/expanded intracranial hemorrhages occurred among patients who received prophylactic anticoagulation. CONCLUSIONS: Prophylactic anticoagulation during rehabilitation seemed safe for TBI patients whose physicians deemed it appropriate, but did not conclusively reduce venous thromboembolism. Given the number of DVTs present before rehabilitation, screening and prophylaxis during acute care may be more important.

Impact of age on long-term recovery from traumatic brain injury.

OBJECTIVE: To determine whether older persons are at increased risk for progressive functional decline after traumatic brain injury (TBI). DESIGN: Longitudinal cohort study. SETTING: Traumatic Brain Injury Model Systems (TBIMS) rehabilitation centers. PARTICIPANTS: Subjects enrolled in the TBIMS national dataset. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Disability Rating Scale (DRS), FIM instrument cognitive items, and the Glasgow Outcome Scale-Extended. RESULTS: Participants were separated into 3 age tertiles: youngest (16-26y), intermediate (27-39y), and oldest (> or =40y). DRS scores were comparable across age groups at admission to a rehabilitation center. The oldest group was slightly more disabled at discharge from rehabilitation despite having less severe acute injury severity than the younger groups. Although DRS scores for the 2 younger groups improved significantly from year 1 to year 5, the greatest magnitude of improvement in disability was seen among the youngest group. In addition, after dividing patients into groups according to whether their DRS scores improved (13%), declined (10%), or remained stable (77%) over time, the likelihood of decline was found to be greater for the 2 older groups than for the youngest group. A multiple regression model showed that age has a significant negative influence on DRS score 5 years post-TBI after accounting for the effects of covariates. CONCLUSIONS: This study supported our primary hypothesis that older patients show greater decline over the first 5 years after TBI than younger patients. In addition, the greatest amount of improvement in disability was observed among the youngest group of survivors. These results suggest that TBI survivors, especially older patients, may be candidates for neuroprotective therapies after TBI.

Usefulness of the abbreviated injury score and the injury severity score in comparison to the Glasgow Coma Scale in predicting outcome after traumatic brain injury.

BACKGROUND: Assessment of injury severity is important in the management of patients with brain trauma. We aimed to analyze the usefulness of the head abbreviated injury score (AIS), the injury severity score (ISS), and the Glasgow Coma Scale (GCS) as measures of injury severity and predictors of outcome after traumatic brain injury (TBI). METHODS: Data were prospectively collected from 410 patients with TBI. AIS, ISS, and GCS were recorded at admission. Subjects' outcomes after TBI were measured using the Glasgow Outcome Scale (GOS-E) at 12 months postinjury. Uni- and multivariate analyses were performed. RESULTS: Outcome information was obtained from 270 patients (66%). ISS was the best predictor of GOS-E (rs = -0.341, p < 0.001), followed by GCS score (rs = 0.227, p < 0.001), and head AIS (rs = -0.222, p < 0.001). When considered in combination, GCS score and ISS modestly improved the correlation with GOS-E (R = 0.335, p < 0.001). The combination of GCS score and head AIS had a similar effect (R = 0.275, p < 0.001). Correlations were stronger from patients 8). CONCLUSIONS: GCS score, AIS, and ISS are weakly correlated with 12-month outcome. However, anatomic measures modestly outperform GCS as predictors of GOS-E. The combination of GCS and AIS/ISS correlate with outcome better than do any of the three measures alone. Results support the addition of anatomic measures such as AIS and ISS in clinical studies of TBI. Additionally, most of the variance in outcome is not accounted for by currently available measures of injury severity.

Racial disparities in long-term functional outcome after traumatic brain injury.

OBJECTIVE: Ethnic disparities have been demonstrated in several diseases, but not in trauma. We hypothesized that access to acute rehabilitation and long-term functional outcomes among traumatic brain injury (TBI) patients are influenced by patient race and ethnicity. METHODS: Patients with severe TBI (Abbreviated Injury Scale [AIS] score, 3-5) who were discharged alive from initial hospitalization were recruited from an urban Level I trauma center (1998-2005). Functional outcome was measured 6 to 12 months after injury using the Glasgow Outcome Scale-Extended (GOSE) score, and classified as good recovery (GOSE score, 7 and 8) or moderate to severe disability (GOSE score, 1-6). Ethnic minorities (n = 114) were compared with non-Hispanic Whites (NHW, n = 230). Logistic regression was used to measure the association between ethnicity and functional outcome while controlling for age, gender, Injury Severity Score (ISS), head AIS score, Glasgow Coma Scale (GCS) score, discharge disposition, and insurance. RESULTS: Minority and NHW groups had similar ISS, GCS score, and head AIS score. Ethnic minorities were less likely to be insured (uninsured, 66% vs. 31%, p < 0.001), but were equally likely to be placed in a rehabilitation facility upon trauma center discharge (47% vs. 42%, p = 0.417). Minority patients were more likely to have moderate to severe disability at follow-up (74% vs. 61%; adjusted odds ratio [OR], 2.17; 95% confidence interval [CI], 1.27-3.69). The relationship between ethnicity and functional outcome became insignificant when insurance was taken into account (OR, 1.52; 95% CI, 0.81-2.72). CONCLUSION: Despite equal access to acute rehabilitation, ethnic minorities have significantly worse long-term functional outcomes after TBI, which is related to lack of health insurance.

Deep venous thrombosis management following traumatic brain injury: a practice survey of the traumatic brain injury model systems.

OBJECTIVE: To determine national patterns of screening, prophylaxis, and treatment of deep venous thrombosis (DVT) following traumatic brain injury (TBI) within the Traumatic Brain Injury Model Systems (TBIMS). DESIGN: e-mail survey instrument. SETTING: Multicenter Regional TBIMS. RESULTS: Fifteen of the 16 rehabilitation centers within the TBIMS responded to the survey (94% response rate). Approximately half of these centers routinely screen to detect subclinical DVTs (56% venous duplex ultrasonography, 12% plasma D-dimer) on admission to inpatient rehabilitation. Fifty-six percent of respondents use anticoagulation prophylactically, while 69% use mechanical means for DVT prophylaxis. Eighty fatal pulmonary emboli were reported for TBI patients in 189 practice-years, corresponding to 0.42 fatalities per year of practice. CONCLUSIONS: No consensus exists regarding the optimal methods for screening, prevention, or treatment of DVT in TBI patients in the acute rehabilitation setting of the TBIMS. The number of fatal pulmonary emboli reported among these centers emphasizes the need to develop evidence-based clinical practice guidelines for the prevention and treatment of venous thromboembolism in this patient population.

Functional outcome scales in traumatic brain injury: a comparison of the Glasgow Outcome Scale (Extended) and the Functional Status Examination.

Clinical trials aimed at developing therapies for traumatic brain injury (TBI) require outcome measures that are reliable, validated, and easily administered. The most widely used of these measures, the Glasgow Outcome Scale (GOS) and the GOS-Extended (GOS-E), have been criticized as suffering from ceiling effects. In an attempt to develop a more useful and dynamic outcome measure, the Functional Status Examination (FSE) was developed, which grades outcome across 10 functional domains. The FSE has been demonstrated to be reliable and sensitive in monitoring recovery after TBI. This manuscript compares FSE with GOS-E in a cohort of patients with a wide range of injury severities. 177 individuals who survived at least 6 months after TBI were studied. The FSE and GOS-E were administered 6-12 months after injury. FSE and GOS-E scores correlated well with each other. FSE scores were distributed throughout the range, indicating that ceiling and floor effects were not present. Physiologic measures of injury severity (Glasgow Coma Score [GCS]) did not correlate with anatomic measures (Abbreviated Injury Scale [AIS] and Injury Severity Score [ISS]). GCS correlated weakly with both outcome measures, but AIS/ISS did not. We conclude that FSE and GOS-E are reliable outcome measures for TBI survivors, and FSE may offer some advantages over GOS-E due its ability to provide a more detailed description of deficits. The majority of the variance in outcome is not accounted for by currently available measures of injury severity.

Motorcycle-related injuries: the high costs of riding.

Statistical information showing an upward trend in trauma and health care costs for injured motorcycle riders in recent years has been presented by the Centers for Disease Control and Prevention, the National Center for Injury Prevention and Control, the National Highway Traffic Safety Administration, the National Trauma Data Bank, the Texas Department of Health (TDH), and the EMS/Trauma Registry. Using the National Hospital Discharge Survey and the TDH Bureau of State Health Data and Policy Analysis, the TDH Injury Epidemiology and Surveillance Program confirms this alarming development. Current Texas motorcycle laws in the Transportation Code (revised 661.003 [c] in 1997) allow exemptions for offenses related to not wearing protective headgear, otherwise covered by federal law. Adult riders of motorcycles in Texas are exempted from the helmet requirement if they possess either a minimum of $10,000 of medical insurance benefits or proof of successful completion of a safety course. Members of the Texas Medical Association Committee on Rehabilitation and other Texas and US physicians involved in the care of motorcycle trauma patients have expressed concern about this public health issue. A commitment to the prevention of disabling injuries such as traumatic brain injury, spinal cord injury, and multiple trauma has motivated these physician groups to further study the problem. Research shows that the cost of standard medical treatment for these traumatic injuries exceeds the funding available from mandated minimum medical insurance and private pay sources. Data from national and state figures show that the public bears the burden for these costs in many cases. A new look at current state Transportation Code motorcycle rules is needed to investigate these issues and to highlight the costs of this problem.

Increased risk of late posttraumatic seizures associated with inheritance of APOE epsilon4 allele.

BACKGROUND: Late posttraumatic seizures are a common complication of moderate and severe traumatic brain injury. Inheritance of the apolipoprotein E (APOE) epsilon4 allele is associated with increased risk of Alzheimer disease, progression to disability in multiple sclerosis, and poor outcome after traumatic brain injury. OBJECTIVE: To determine whether inheritance of APOE epsilon4 is associated with increased risk of developing late posttraumatic seizures. DESIGN: Prospective study. SETTING: Neurosurgical service at an urban level I trauma center.Patients Patients admitted with a diagnosis of moderate and severe traumatic brain injury were enrolled. METHODS: Six months after injury, patients were contacted to determine functional outcome (according to the Glasgow Outcome Scale-Expanded [GOS-E]) and the presence of late posttraumatic seizures. Genotype at the APOE locus was determined by restriction fragment length polymorphism analysis. RESULTS: DNA and outcome information was obtained from 106 subjects. Six months after injury, 31 (29%) had a poor outcome (GOS-E score, 1-4), 47 (44%) had an intermediate outcome (GOS-E score, 5-6), and 28 (26%) had a favorable outcome (GOS-E score, 7-8). Twenty-one patients (20%) had at least 1 late posttraumatic seizure. The relative risk of late posttraumatic seizures for patients with the epsilon4 allele was 2.41 (95% confidence interval, 1.15-5.07; P =.03). In this cohort, inheritance of APOE epsilon4 was not associated with an unfavorable GOS-E score 6 (P =.47). CONCLUSIONS: Inheritance of the APOE epsilon4 allele is associated with increased risk of late posttraumatic seizures. In this cohort, this risk appears to be independent of an effect of epsilon4 on functional outcome. A better understanding of the molecular role of APOE in neurodegenerative diseases may be helpful in developing antiepileptogenic therapies.