Challenges associated with post-deployment screening for mild traumatic brain injury in military personnel.

There is ongoing debate regarding the epidemiology of mild traumatic brain injury (MTBI) in military personnel. Accurate and timely estimates of the incidence of brain injury and the prevalence of long-term problems associated with brain injuries among active duty service members and veterans are essential for (a) operational planning, and (b) to allocate sufficient resources for rehabilitation and ongoing services and supports. The purpose of this article is to discuss challenges associated with post-deployment screening for MTBI. Multiple screening methods have been used in military, Veterans Affairs, and independent studies, which complicate cross-study comparisons of the resulting epidemiological data. We believe that post-deployment screening is important and necessary--but no screening methodology will be flawless, and false positives and false negatives are inevitable. Additional research is necessary to refine the sequential screening methodology, with the goal of minimizing false negatives during initial post-deployment screening and minimizing false positives during follow-up evaluations.

Prevalence of long-term disability from traumatic brain injury in the civilian population of the United States, 2005.

OBJECTIVE: To estimate the prevalence of long-term disability associated with traumatic brain injury (TBI) in the civilian population of the United States. METHODS: We first estimated how many people experienced long-term disability from TBI each year in the past 70 years. Then, accounting for the increased mortality among TBI survivors, we estimated their life expectancy and calculated how many were expected to be alive in 2005. RESULTS: An estimated 1.1% of the US civilian population or 3.17 million people (95% CI: 3.02-3.32 million) were living with a long-term disability from TBI at the beginning of 2005. Under less conservative assumptions about TBI's impact on lifespan, this estimate is 3.32 million (95% CI: 3.16-3.48 million). CONCLUSION: Substantial long-term disability occurs among the US civilians hospitalized with a TBI.

"Help seniors live better, longer: prevent brain injury": an overview of CDC's education initiative to prevent fall-related TBI among older adults.

BACKGROUND: Falls are the leading cause of traumatic brain injury (TBI) among older adults aged 75 and older. Despite this burden, many older adults, their caregivers, and professionals are not aware of the importance of TBI as an outcome of falls among older adults. METHODS: To address this important public health problem, the Centers for Disease Control and Prevention (CDC) developed the "Help Seniors Live Better, Longer: Prevent Brain Injury" initiative to help raise awareness about methods to prevent, recognize and respond to fall-related TBIs among older adults aged 75 and older. RESULTS: The initiative was launched in March 2008, in collaboration with 26 participating organizations, and included a multipronged outreach strategy to help blanket the country with the messages of the initiative at the national, state, and local levels. CONCLUSION: Adherence to a logical, comprehensive health-education approach has proven to be highly effective in furthering the initial goals of the project.

Improving identification of traumatic brain injury after nonmilitary bomb blasts.

OBJECTIVE: To improve identification of traumatic brain injury (TBI) in survivors of nonmilitary bomb blasts during the acute care phase. METHODS: The Centers for Disease Control and Prevention convened a meeting of experts in TBI, emergency medicine, and disaster response to review the recent literature and make recommendations. RESULTS: Seven key recommendations were proposed: (1) increase TBI awareness among medical professionals; (2) encourage use of standard definitions and consistent terminology; (3) improve screening methods for TBI in the acute care setting; (4) clarify the distinction between TBI and acute stress disorder; (5) encourage routine screening of hospitalized trauma patients for TBI; (6) improve identification of nonhospitalized TBI patients; and (7) integrate the appropriate level of TBI identification into all-hazards mass casualty preparedness. CONCLUSIONS: By adopting these recommendations, the United States could be better prepared to identify and respond to TBI following future bombing events.

Incidence of long-term disability following traumatic brain injury hospitalization, United States, 2003.

OBJECTIVE: Develop and validate a predictive model of the incidence of long-term disability following traumatic brain injury (TBI) and obtain national estimates for the United States in 2003. DATA/METHODS: A logistic regression model was built, using a population-based sample of persons with TBI from the South Carolina Traumatic Brain Injury Follow-up Registry. The regression coefficients were applied to the 2003 Healthcare Cost and Utilization Project-Nationwide Inpatient Sample data to estimate the incidence of long-term disability following traumatic brain injury hospitalization. RESULTS: Among 288,009 (95% CI, 287,974-288,043) hospitalized TBI survivors in the United States in 2003, an estimated 124,626 (95% CI, 123,706-125,546) had developed long-term disability. CONCLUSION: TBI-related disability is a significant public health problem in the United States. The substantial incidence suggests the need for comprehensive rehabilitative care and services to maximize the potential of persons with TBI.

Violence, abuse, and neglect among people with traumatic brain injuries.

BACKGROUND: Violence, abuse, and neglect (VAN) among people with physical and other disabilities has been reported; however, little is known about VAN experiences among people with traumatic brain injuries (TBI). METHODS: Nine people who reported experiencing VAN post-TBI were interviewed for this phenomenological study. The data were analyzed to understand VAN as experienced by those with TBI. RESULTS: Participants detailed many VAN experiences along with contributing factors, barriers in obtaining help, and recommendations for improving preventive and assistance services. CONCLUSIONS: Greater efforts are needed to identify and prevent VAN among people with TBI. Services following VAN must be improved.

Employment after traumatic brain injury: differences between men and women.

OBJECTIVE: To determine whether there are sex differences in employment 1 year after traumatic brain injury. DESIGN: Prospective cohort. SETTING: Acute care hospitals in South Carolina and Traumatic Brain Injury Model Systems (TBIMS) rehabilitation centers. PARTICIPANTS: Subjects in the TBIMS national dataset and the South Carolina Traumatic Brain Injury Follow-up Registry who were expected to be working before injury and followed at 1 year postinjury. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURE: Change in employment from preinjury to 1 year postinjury. RESULTS: When other measured influences on change in hours worked were held constant, there were significant interactions for sex by age and sex by marital status. Compared with men, women were more likely to decrease hours or stop working, except in the oldest age group (55-64y) in which men were more likely to stop working. For women, there was a pattern showing better employment outcomes as age increased. Decreased employment for women was most evident for married women, who were much more likely to reduce hours or stop working. There was also a tendency for divorced women to be more likely to stop working when compared with divorced men. CONCLUSIONS: These findings run counter to the current literature. Although definitive explanations must await future studies, causal factors arising from differential societal behavior toward women as well as discriminatory attitudes about women and employment deserve further study.

Traumatic brain injuries after mass-casualty incidents: lessons from the 11 September 2001 World Trade Center attacks.

INTRODUCTION: The 11 September 2001 terrorist attacks on the World Trade Center (WTC) resulted in thousands of deaths and injuries. Research on previous bombings and explosions has shown that head injuries, including traumatic brain injuries (TBIs), are among the most common injuries. OBJECTIVE: The objective of this study was to identify diagnosed and undiagnosed (undetected) TBIs among persons hospitalized in New York City following the 11 September 2001 WTC attacks. METHODS: The medical records of persons admitted to 36 hospitals in New York City with injuries or illnesses related to the WTC attacks were abstracted for signs and symptoms of TBIs. Diagnosed TBIs were identified using the International Classification of Diseases, 9th Revision, Clinical Modification diagnosis codes. Undiagnosed TBIs were identified by an adjudication team of TBI experts that reviewed the abstracted medical record information. Persons with an undiagnosed TBI were contacted and informed of the diagnosis of potential undetected injury. RESULTS: A total of 282 records were abstracted. Fourteen cases of diagnosed TBIs and 21 cases of undiagnosed TBIs were identified for a total of 35 TBI cases (12% of all of the abstracted records). The leading cause of TBI was being hit by falling debris (22 cases). One-third of the TBIs (13 cases) occurred among rescue workers. More than three years after the event, four out of six persons (66.67%) with an undiagnosed TBI who were contacted reported they currently were experiencing symptoms consistent with a TBI. CONCLUSIONS: Not all of the TBIs among hospitalized survivors of the WTC attacks were diagnosed at the time of acute injury care. Some persons with undiagnosed TBIs reported problems that may have resulted from these TBIs three years after the event. For hospitalized survivors of mass-casualty incidents, additional in-hospital, clinical surveys could help improve pre-discharge TBI diagnosis and provide the opportunity to link patients to appropriate outpatient services. The use and adequacy of head protection for rescue workers deserves re-evaluation.

A population-based outcomes study of persons hospitalized with traumatic brain injury: operations of the South Carolina Traumatic Brain Injury Follow-up Registry.

OBJECTIVE: To describe the design and operations of the South Carolina Traumatic Brain Injury (TBI) Follow-up Registry. DESIGN: Statewide prospective cohort study. SETTING: State of South Carolina. PARTICIPANTS: 2118 persons discharged from acute care hospitals after experiencing TBI. INTERVENTION: Telephone interviews. MAIN OUTCOME MEASURES: Service needs, alcohol and drug use, psychosocial health, health-related quality of life, functional status, symptoms of TBI, employment, global life satisfaction, and death. RESULTS: Selected initial and 1-year follow-up findings concerning demographic, insurance status, income, and employment factors. CONCLUSIONS: Population-based outcome studies that describe longer term problems associated with TBI, the need for services, and estimated disability could be useful to inform public policy.

Incidence of traumatic brain injury in the United States, 2003.

Traumatic brain injury (TBI) is an important public health problem in the United States. In 2003, there were an estimated 1,565,000 TBIs in the United States: 1,224,000 emergency department visits, 290,000 hospitalizations, and 51,000 deaths. Findings were similar to those from previous years in which rates of TBI were highest for young children (aged 0-4) and men, and the leading causes of TBI were falls and motor vehicle traffic.

The epidemiology and impact of traumatic brain injury: a brief overview.

Traumatic brain injury (TBI) is an important public health problem in the United States and worldwide. The estimated 5.3 million Americans living with TBI-related disability face numerous challenges in their efforts to return to a full and productive life. This article presents an overview of the epidemiology and impact of TBI.

Self-reported psychosocial health among adults with traumatic brain injury.

OBJECTIVE: To measure the subjective psychosocial health of a population-based sample of adults with traumatic brain injury (TBI). DESIGN: Retrospective, cohort study involving a 1-year postinjury interview. SETTING: Sixty-two acute care, nonfederal hospitals in South Carolina. PARTICIPANTS: Persons (> or =15y) hospitalized with TBI. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURE: The psychosocial health scales of the Medical Outcomes Study 36-Item Short-Form Health Survey. RESULTS: Of the 7612 participants, 29% reported poor psychosocial health. Factors associated with poor psychosocial well-being included younger age, female sex, Medicaid coverage, no health insurance, inadequate or moderate social support, comorbidities (eg, a preinjury substance abuse problem), cognitive complaints, and some or a lot of limitation with activities of daily living. Only 36% of participants who reported poor psychosocial health reported receiving any mental health services. CONCLUSIONS: A substantial proportion of persons hospitalized with TBI reported poor psychosocial health at 1 year postinjury. To optimize recovery, clinicians need to ensure that patients' psychosocial health needs are addressed during the postacute period.

The public health approach to traumatic brain injury: an overview of CDC's research and programs.

Every year, 50,000 people die with a traumatic brain injury (TBI). At least 5.3 million Americans live with long-term disabilities related to TBI. Through its TBI-associated research and programs, CDC's National Center for Injury Prevention and Control (NCIPC) seeks to reduce the adverse consequences of TBIs by ensuring that data, data systems, and public awareness about TBI are in place. The public health model provides a useful framework for identifying important efforts needed to reduce the impact of this potentially disabling injury.

Tracking the silent epidemic and educating the public: CDC's traumatic brain injury-associated activities under the TBI Act of 1996 and the Children's Health Act of 2000.

The Traumatic Brain Injury Act of 1996 and the Children's Health Act of 2000 authorized the Centers for Disease Control and Prevention to conduct several activities associated with traumatic brain injury. This article describes how the Centers for Disease Control and Prevention responded to the legislation in 2 key areas: traumatic brain injury surveillance, and education and awareness.

The incidence of traumatic brain injury among children in the United States: differences by race.

OBJECTIVE: This report summarizes the epidemiology of traumatic brain injury (TBI) deaths, hospitalizations, and emergency department (ED) visits by race among children aged 0-14 years in the United States. Few other studies have reported the incidence of TBI in this population by race. METHODS: Data from 3 nationally representative sources maintained by the National Center for Health Statistics were used to report the annual numbers and rates of TBI-related deaths, hospitalizations, and ED visits during 1995-2001 by race, age, and external cause of injury. RESULTS: An estimated 475,000 TBIs occurred among children aged 0-14 each year. Rates were highest among children aged 0-4. For children aged 0-9 years, both death and hospitalization rates were significantly higher for blacks than whites for motor vehicle-traffic-related TBIs. CONCLUSION: With nearly half a million children affected each year, TBI is a serious public health problem. Variation in rates by race suggest the need to more closely examine the factors that contribute to these differences, such as the external causes of the injury and associated modifiable factors (e.g., the use of seatbelts and child safety seats).

Traumatic brain injury hospitalizations among American Indians/Alaska Natives.

OBJECTIVES: To compare the incidence of nonfatal traumatic brain injury (TBI) hospitalization among American Indians/Alaska Natives (AI/AN) with that of other race groups and to assess alcohol and protective equipment (PE) use among those who sustained TBI related to a motor vehicle (MV) incident. METHODS: Data were obtained from 13 states funded by the Centers for Disease Control and Prevention to conduct TBI surveillance from 1997 to 1999. Rates by race and by cause were calculated for the 13 states combined. Blood alcohol concentration (BAC) levels and PE use were compared between AI/AN and "other" races in a subgroup of these states. RESULTS: Although not significantly different, AI/AN had the highest overall age-adjusted TBI hospitalization rate (71.5 per 100,000). Rates were significantly higher among AI/AN than among whites for ages 20 to 44 years (78.5 per 100,000 vs 54.7 per 100,000, P < .0001). MV incidents were the leading cause of TBI (40.1% of cases) among AI/AN, and AI/AN injured in MV incidents had higher BAC levels (65.7% > or = 0.08 g/dL vs 31.6% > or = 0.08 g/dL, P < .0001) and lower PE use (22.0% vs 40.4%, P < .0001) than the "other" race group. CONCLUSION: AI/AN have high rates of TBI hospitalization compared with other races. High BAC levels and low use of PE in MV incidents appear to be associated with the higher rates in this population.

Risk of posthospitalization mortality among persons with traumatic brain injury, South Carolina 1999-2001.

Traumatic brain injury (TBI) negatively impacts long-term survival. However, little is known about the likelihood of death within the first year following hospital discharge. This study examined mortality among a representative sample of 3679 persons within 1 year of being discharged from any of 62 acute care hospitals in South Carolina following TBI and identified the factors associated with early death using a multivariable Cox proportional hazards model. The mortality experience of the cohort was also compared with that of the general population by using standardized mortality ratios for selected causes of death by age, adjusted for race and sex.

Linking people with traumatic brain injury to services: successes and challenges in Colorado.

People with traumatic brain injury (TBI)-related disability often need services and other types of support to return to productive lives; thus, improving access to available TBI services is a priority for a variety of states' agencies, such as Human Services and Public Health. Although infrastructure and resources vary from state to state, each can benefit by learning about how other states link people with TBI to services. In this report, we summarize Colorado's experience in exploring and developing better ways to link state residents with TBI to services. Recommendations for improving the system of linking people to services in Colorado included the following: (1) expanding the population targeted for linkage to services beyond those who are hospitalized; (2) improving access to information about available services; and (3) increasing the availability of services.

Disability among adults injured in motor-vehicle crashes in the United States.

INTRODUCTION: Little population-based information exists about the long-term effects of motor-vehicle crash-related injuries. METHOD: We analyzed data from the 1995 National Health Interview Survey Disability (NHIS-D) Supplement to estimate the prevalence of crash-related disability among noninstitutionalized U.S. adults aged 18 years and older. RESULTS: More than 1.2 million adults were living in their homes with the disabling effects of motor-vehicle crash-related injuries in 1995. The prevalence of crash-related disability was highest for persons in their mid-life years, ages 35-64. Half of the respondents had sustained the injuries more than 5 years before the interview. Forty-one percent of working-aged individuals reported being unable to work because of their disability. CONCLUSIONS: Because crash-related disability is most prevalent during the mid-life years, quality of life and productivity may be affected for decades. These findings highlight the personal and societal burden associated with motor-vehicle crash-related disability in the United States.