The prevalence and symptom rates of depression after traumatic brain injury: a comprehensive examination.

PRIMARY OBJECTIVE: Differing definitions of depression, limited sample sizes, and variability in methodologies have contributed to equivocal findings about the prevalence of depression among persons with traumatic brain injury. The present investigation used standardized diagnostic criteria and a large sample to identify the manifestations of depression after TBI. METHODS AND PROCEDURES: 722 outpatients with brain injury, referred for comprehensive assessment at a regional Level I trauma centre, were studied. Depressive symptoms were characterized utilizing standard DSM-IV criteria and the Neurobehavioural Functioning Inventory. RESULTS: Forty-two per cent of patients with brain injury met the prerequisite number of symptoms for a DSM-IV diagnosis of major depressive disorder. Fatigue (46%), frustration (41%), and poor concentration (38%) were the most commonly cited manifestations of depression. CONCLUSIONS: Many patients with brain injury are at great risk for developing depressive disorders. Future research should focus on prognostic factors, developing protocols for identification of high risk patients, and examining the efficacy of treatment interventions.

Spinal cord injury "outliers": an analysis of etiology, outcomes, and length of stay.

Spinal cord injury (SCI) requires significant and expensive medical intervention, including prolonged hospitalization and intense in-patient treatment and rehabilitation. Development of predictive models for lengths of stay in spinal cord injury patients provides a method for early prediction of patients that will require greater care, incur greater costs, and need more intensive medical and rehabilitative services. Early identification of SCI patients at high risk of extended lengths of stay will also allow physicians to treat those patients more aggressively, and permit families, as well as sponsors, to estimate the costs of long-term care. Results of a forward-conditional stepwise multiple logistic regression indicate that the model including age at injury, number of days to rehabilitation admission, number of pressure ulcers, number of medical complications, level of injury, and sponsor of initial hospitalization significantly (chi2 = 220.063, p < 0.001) predicts outliers in terms of rehabilitation length of stay. Overall, the percentage of persons who were correctly classified by the multivariate model was 96.92% (chi2 = 66.85, p < 0.001). The correct prediction rate for outliers was 46% and nonoutliers 97%. This model provides a tool that can be used by health providers, sponsors and patients to aid in the identification of individuals with SCI that may require extended lengths of stay. Today, unfortunately, our health care system is burdened by the heavy influence of economics rather than functional outcome. We maintain that implementation of this model will help to improve care of the SCI patient by early identification of those in need of more extensive resources and improve the economic efficiency needed to provide maximal functional outcome.

U.S. Army air ambulance operations in El Paso, Texas: a descriptive study and system review.

OBJECTIVES: To analyze a high-volume military air ambulance unit and review the U.S. Army air medical transport system and Military Assistance to Safety and Traffic (MAST) program. METHODS: The setting was a remote medical system with numerous ground emergency medical services. All patients transported between January 1, 1996, and February 28, 1998, were included. Patients who were dead on scene or for whom records were unavailable were excluded. A retrospective review of transport and available inpatient records was conducted. RESULTS: Five hundred seventeen patients were transported during the study period; 461 patients met inclusion criteria (89%). Of these, 70% were classified as trauma; 30% possessed medical or other surgical diagnoses. Prehospital responses numbered 71.6%, while 28.4% were interhospital transfers. Missions averaged 23.4 minutes per flight, with no major aircraft mishaps. Prehospital utilization review showed appropriate use; 35% of interhospital trauma and 11% of interhospital nontrauma missions were staffed inadequately by these criteria. Time intervals, procedures, and program impact are discussed. CONCLUSION: This and similar units participating in the MAST program provide effective air transport in settings underserved by civilian programs. Quality and wartime readiness could be improved by centralized medical direction, treatment and transfer protocols, and enhanced training of medics. Further investigations of the clinical impact of advanced training and a two-medic aircrew model are warranted.

Military assistance to safety and traffic services in El Paso: a retrospective analysis.

This study was performed to evaluate the performance of military rotary air medical transport in the El Paso, Texas, region with regard to mortality. A retrospective review of transport and inpatient medical records was undertaken. All trauma patients air transported from January 1, 1996, to February 28, 1998, were included. Patients for whom records were unavailable were excluded. Mean time intervals for prehospital and interhospital transport were calculated. Injury severity and survival data were calculated using Revised Trauma Score, Injury Severity Score, and Trauma and Injury Severity Score (TRISS) methodology. Two hundred sixty-seven patients were eligible for analysis (83% of the total). TRISS analysis predicted 241 survivors; the actual number of survivors was 241 (mean = 0.98, z = 0.03) despite the fact that 6 individuals died who were predicted to live and 3 individuals lived who were predicted to die. We conclude that the actual mortality rate of those patients transported by military aeromedical lift equaled that predicted by TRISS methodology.

Pre-injury substance abuse among persons with brain injury and persons with spinal cord injury.

Alcohol and drug use at the time of injury have been strongly implicated as causal factors of spinal cord injury (SCI) and traumatic brain injury (TBI). Researchers have only begun their efforts to investigate the pre-injury incidence of substance abuse in an effort to identify persons at risk for traumatic injury. No studies have compared brain and spinal cord injury populations. This investigation was based in an urban, level one trauma center federally designated as a model system of comprehensive rehabilitative services for persons with TBI and persons with SCI. Pre-injury patterns of alcohol and illicit drug use were compared among patients with SCI and patients with TBI, matched for age, gender, race, and mechanism of injury (n= 52). In accordance with previous research, participants were primarily young, unmarried, males with at least a high school education. Eighty-one percent of patients with TBI and 96% of patients with SCI reported pre-injury alcohol use. The rate of pre-injury heavy drinking for both groups was alarmingly high. Fifty-seven percent of persons with SCI and 42% of persons with TBI were heavy drinkers. Implications for risk identification, treatment, and future research are discussed.