Interpreting Change in Disorders of Consciousness Using the Coma Recovery Scale-Revised.

The purpose of this study was to differentiate clinically meaningful improvement or deterioration from normal fluctuations in patients with disorders of consciousness (DoC) following severe brain injury. We computed indices of responsiveness for the Coma Recovery Scale-Revised (CRS-R) using data from a clinical trial of 180 participants with DoC. We used CRS-R scores from baseline (enrollment in a clinical trial) and a 4-week follow-up assessment period for these calculations. To improve precision, we transformed ordinal CRS-R total scores (0-23 points) to equal-interval measures on a 0-100 unit scale using Rasch Measurement theory. Using the 0-100 unit total Rasch measures, we calculated distribution-based 0.5 standard deviation (SD) minimal clinically important difference, minimal detectable change using 95% confidence intervals, and conditional minimal detectable change using 95% confidence intervals. The distribution-based minimal clinically important difference evaluates group-level changes, whereas the minimal detectable change values evaluate individual-level changes. The minimal clinically important difference and minimal detectable change are derived using the overall variability across total measures at baseline and 4 weeks. The conditional minimal detectable change is generated for each possible pair of CRS-R Rasch person measures and accounts for variation in standard error across the scale. We applied these indices to determine the proportions of participants who made a change beyond measurement error within each of the two subgroups, based on treatment arm (amantadine hydrochloride or placebo) or categorization of baseline Rasch person measure to states of consciousness (i.e., unresponsive wakefulness syndrome and minimally conscious state). We compared the proportion of participants in each treatment arm who made a change according to the minimal detectable change and determined whether they also changed to another state of consciousness. CRS-R indices of responsiveness (using the 0-100 transformed scale) were as follows: 0.5SD minimal clinically important difference = 9 units, minimal detectable change = 11 units, and the conditional minimal detectable change ranged from 11 to 42 units. For the amantadine and placebo groups, 70% and 58% of participants showed change beyond measurement error using the minimal detectable change, respectively. For the unresponsive wakefulness syndrome and minimally conscious state groups, 54% and 69% of participants changed beyond measurement error using the minimal detectable change, respectively. Among 115 participants (64% of the total sample) who made a change beyond measurement error, 29 participants (25%) did not change state of consciousness. CRS-R indices of responsiveness can support clinicians and researchers in discerning when behavioral changes in patients with DoC exceed measurement error. Notably, the minimal detectable change can support the detection of patients who make a "true" change within or across states of consciousness. Our findings highlight that the continued use of ordinal scores may result in incorrect inferences about the degree and relevance of a change score.

An Initial miRNA Profile of Persons With Persisting Neurobehavioral Impairments and States of Disordered Consciousness After Severe Traumatic Brain Injury.

OBJECTIVE: To examine the merits of using microRNAs (miRNAs) as biomarkers of disorders of consciousness (DoC) due to traumatic brain injury (TBI). SETTINGS: Acute and subacute beds. PARTICIPANTS: Patients remaining in vegetative and minimally conscious states (VS, MCS), an average of 1.5 years after TBI, and enrolled in a randomized clinical trial ( n = 6). Persons without a diagnosed central nervous system disorder, neurotypical controls ( n = 5). DESIGN: Comparison of whole blood miRNA profiles between patients and age/gender-matched controls. For patients, correlational analyses between miRNA profiles and measures of neurobehavioral function. MAIN MEASURES: Baseline measures of whole blood miRNAs isolated from the cellular and fluid components of blood and measured using miRNA-seq and real-time polymerase chain reaction (RT-PCR). Baseline neurobehavioral measures derived from 7 tests. RESULTS: For patients, relative to controls, 48 miRNA were significantly ( P < .05)/differentially expressed. Cluster analysis showed that neurotypical controls were most similar to each other and with 2 patients (VS: n = 1; and MCS: n = 1). Three patients, all in MCS, clustered separately. The only female in the sample, also in MCS, formed an independent group. For the 48 miRNAs, the enriched pathways identified are implicated in secondary brain damage and 26 miRNAs were significantly ( P < .05) correlated with measures of neurobehavioral function. CONCLUSIONS: Patients remaining in states of DoC an average of 1.5 years after TBI showed a different and reproducible pattern of miRNA expression relative to age/gender-matched neurotypical controls. The phenotypes, defined by miRNA profiles relative to persisting neurobehavioral impairments, provide the basis for future research to determine the miRNA profiles differentiating states of DoC and the basis for future research using miRNA to detect treatment effects, predict treatment responsiveness, and developing targeted interventions. If future research confirms and advances reported findings, then miRNA profiles will provide the foundation for patient-centric DoC neurorehabilitation.

Feasibility of a Combined Neuromodulation and Yoga Intervention for Mild Traumatic Brain Injury and Chronic Pain: Protocol for an Open-label Pilot Trial.

BACKGROUND: Mild traumatic brain injury (mTBI) and chronic pain often co-occur and worsen rehabilitation outcomes. There is a need for improved multimodal nonpharmacologic treatments that could improve outcomes for both conditions. Yoga is a promising activity-based intervention for mTBI and chronic pain, and neuromodulation through transcranial magnetic stimulation is a promising noninvasive, nonpharmacological treatment for mTBI and chronic pain. Intermittent theta burst stimulation (iTBS) is a type of patterned, excitatory transcranial magnetic stimulation. iTBS can induce a window of neuroplasticity, making it ideally suited to boost the effects of treatments provided after it. Thus, iTBS may magnify the impacts of subsequently delivered interventions as compared to delivering those interventions alone and accordingly boost their impact on outcomes. OBJECTIVE: The aim of this study is to (1) develop a combined iTBS+yoga intervention for mTBI and chronic pain, (2) assess the intervention's feasibility and acceptability, and (3) gather preliminary clinical outcome data on quality of life, function, and pain that will guide future studies. METHODS: This is a mixed methods, pilot, open-labeled, within-subject intervention study. We will enroll 20 US military veteran participants. The combined iTBS+yoga intervention will be provided in small group settings once a week for 6 weeks. The yoga intervention will follow the LoveYourBrain yoga protocol-specifically developed for individuals with TBI. iTBS will be administered immediately prior to the LoveYourBrain yoga session. We will collect preliminary quantitative outcome data before and after the intervention related to quality of life (TBI-quality of life), function (Mayo-Portland Adaptability Index), and pain (Brief Pain Inventory) to inform larger studies. We will collect qualitative data via semistructured interviews focused on intervention acceptability after completion of the intervention. RESULTS: This study protocol was approved by Edward Hines Jr Veterans Administration Hospital Institutional Review Board (Hines IRB 1573116-4) and was prospectively registered on ClinicalTrials.gov (NCT04517604). This study includes a Food and Drug Administration Investigational Device Exemption (IDE: G200195). A 2-year research plan timeline was developed. As of March 2022, a total of 6 veterans have enrolled in the study. Data collection is ongoing and will be completed by November 2022. We expect the results of this study to be available by October 2024. CONCLUSIONS: We will be able to provide preliminary evidence of safety, feasibility, and acceptability of a novel combined iTBS and yoga intervention for mTBI and chronic pain-conditions with unmet treatment needs. TRIAL REGISTRATION: ClinicalTrials.gov NCT04517604; https://www.clinicaltrials.gov/ct2/show/NCT04517604. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): DERR1-10.2196/37836.

"Fluctuation is the norm": Rehabilitation practitioner perspectives on ambiguity and uncertainty in their work with persons in disordered states of consciousness after traumatic brain injury.

The purpose of this study is to describe the clinical lifeworld of rehabilitation practitioners who work with patients in disordered states of consciousness (DoC) after severe traumatic brain injury (TBI). We interviewed 21 practitioners using narrative interviewing methods from two specialty health systems that admit patients in DoC to inpatient rehabilitation. The overarching theme arising from the interview data is "Experiencing ambiguity and uncertainty in clinical reasoning about consciousness" when treating persons in DoC. We describe practitioners' practices of looking for consistency, making sense of ambiguous and hard to explain patient responses, and using trial and error or "tinkering" to care for patients. Due to scientific uncertainty about diagnosis and prognosis in DoC and ambiguity about interpretation of patient responses, working in the field of DoC disrupts the canonical meaning-making processes that practitioners have been trained in. Studying the lifeworld of rehabilitation practitioners through their story-making and story-telling uncovers taken-for-granted assumptions and normative structures that may exist in rehabilitation medical and scientific culture, including practitioner training. We are interested in understanding these canonical breaches in order to make visible how practitioners make meaning while treating patients.

Health Care Resource Utilization and Costs for Adults With Mild Traumatic Brain Injury With Chronic Vestibular Impairment.

OBJECTIVE: To quantify the economic burden of all-cause health care resource utilization (HCRU) among adults with and without chronic vestibular impairment (CVI) after a mild traumatic brain injury (mTBI). DESIGN: Retrospective matched cohort study. SETTING: IQVIA Integrated Data Warehouse. PARTICIPANTS: People with mTBI+CVI (n=20,441) matched on baseline age, sex, year of mTBI event, and Charlson Comorbidity Index (CCI) score to people with mTBI only (n=20,441) (N=40,882). INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: All-cause health HCRU and costs at 12 and 24 months post mTBI diagnosis. RESULTS: People with mTBI+CVI had significantly higher all-cause HCRU and costs at both time points than those with mTBI only. Multivariable regression analysis showed that, when controlling for baseline variables, costs of care were 1.5 times higher for mTBI+CVI than mTBI only. CONCLUSIONS: People who developed CVI after mTBI had greater overall HCRU and costs for up to 2 years after the injury event compared with people who did not develop CVI after controlling for age, sex, region, and CCI score. Further research on access to follow-up services and effectiveness of interventions to address CVI is warranted.

Psychometric measurement properties of the world health organization disability assessment schedule 2.0 (WHODAS) evaluated among veterans with mild traumatic brain injury and behavioral health conditions.

PURPOSE: Examine the psychometric properties of the World Health Organization Disability Assessment Schedule 2.0 among U.S. Iraq/Afghanistan Veterans with a combination of mild traumatic brain injury and behavioral health conditions using Rasch analysis. METHODS: 307 Veterans were classified as either combat control (n = 141), or one of three clinical groups: mild traumatic brain injury (n = 10), behavioral health conditions (n = 24), or both (n = 128). Data from the three clinical groups were used to establish step and item calibrations serving as anchors when including the control group. RESULTS: Measurement precision was excellent (person separation reliability = 0.93). Ordering of item calibrations formed a logical hierarchy. Test items were off-target (too easy) for the clinical groups. Principal component analysis indicated unidimensionality although 4/36 items misfit the measurement model. No meaningful differential item functioning was detected. There was a moderate effect size (Hedge's g = 1.64) between the control and clinical groups. CONCLUSIONS: The World Health Organization Disability Assessment Schedule was suitable for our study sample, distinguishing 4 levels of functional ability. Although items may be easy for some Veterans with mild traumatic brain injury and/or behavioral health conditions, the World Health Organization Disability Assessment Schedule can be used to capture disability information for those with moderate to severe disability.Implications for rehabilitationPersistent functional disability is seen in military and civilian populations with mild traumatic brain injury which often co-occurs with behavioral health conditions.A comprehensive measure of disability is needed to distinguish between levels of disability to inform clinical decisions for individual patients and to detect treatment effects between groups in research.Results of this analysis indicate the World Health Organization Disability Assessment Schedule items are sufficiently unidimensional to evaluate level of disability in the moderate and severe range among persons with mild traumatic brain injury with and without behavioral health conditions.Further examination of the psychometric properties of the World Health Organization.Disability Assessment Schedule is necessary before measurement of disability is recommended for those with less than moderate levels of disability.

miRNAs as Potential Biomarkers for Traumatic Brain Injury: Pathway From Diagnosis to Neurorehabilitation.

BACKGROUND: Biomarkers that can advance precision neurorehabilitation of the traumatic brain injury (TBI) are needed. MicroRNAs (miRNAs) have biological properties that could make them well suited for playing key roles in differential diagnoses and prognoses and informing likelihood of responsiveness to specific treatments. OBJECTIVE: To review the evidence of miRNA alterations after TBI and evaluate the state of science relative to potential neurorehabilitation applications of TBI-specific miRNAs. METHODS: This scoping review includes 57 animal and human studies evaluating miRNAs after TBI. PubMed, Scopus, and Google Scholar search engines were used. RESULTS: Gold standard analytic steps for miRNA biomarker assessment are presented. Published studies evaluating the evidence for miRNAs as potential biomarkers for TBI diagnosis, severity, natural recovery, and treatment-induced outcomes were reviewed including statistical evaluation. Growing evidence for specific miRNAs, including miR21, as TBI biomarkers is presented. CONCLUSIONS: There is evidence of differential miRNA expression in TBI in both human and animal models; however, gaps need to be filled in terms of replication using rigorous, standardized methods to isolate a consistent set of miRNA changes. Longitudinal studies in TBI are needed to understand how miRNAs could be implemented as biomarkers in clinical practice.

Customizing TMS Applications in Traumatic Brain Injury Using Neuroimaging.

Optimizing transcranial magnetic stimulation (TMS) treatments in traumatic brain injury (TBI) and co-occurring conditions may benefit from neuroimaging-based customization. PARTICIPANTS: Our total sample (N = 97) included 58 individuals with TBI (49 mild, 8 moderate, and 1 severe in a state of disordered consciousness), of which 24 had co-occurring conditions (depression in 14 and alcohol use disorder in 10). Of those without TBI, 6 individuals had alcohol use disorder and 33 were healthy controls. Of our total sample, 54 were veterans and 43 were civilians. DESIGN: Proof-of-concept study incorporating data from 5 analyses/studies that used multimodal approaches to integrate neuroimaging with TMS. MAIN MEASURES: Multimodal neuroimaging methods including structural magnetic resonance imaging (MRI), MRI-guided TMS navigation, functional MRI, diffusion MRI, and TMS-induced electric fields. Outcomes included symptom scales, neuropsychological tests, and physiological measures. RESULTS: It is feasible to use multimodal neuroimaging data to customize TMS targets and understand brain-based changes in targeted networks among people with TBI. CONCLUSIONS: TBI is an anatomically heterogeneous disorder. Preliminary evidence from the 5 studies suggests that using multimodal neuroimaging approaches to customize TMS treatment is feasible. To test whether this will lead to increased clinical efficacy, studies that integrate neuroimaging and TMS targeting data with outcomes are needed.

A Pilot Trial Examining the Merits of Combining Amantadine and Repetitive Transcranial Magnetic Stimulation as an Intervention for Persons With Disordered Consciousness After TBI.

OBJECTIVE: Report pilot findings of neurobehavioral gains and network changes observed in persons with disordered consciousness (DoC) who received repetitive transcranial magnetic stimulation (rTMS) or amantadine (AMA), and then rTMS+AMA. PARTICIPANTS: Four persons with DoC 1 to 15 years after traumatic brain injury (TBI). DESIGN: Alternate treatment-order, within-subject, baseline-controlled trial. MAIN MEASURES: For group and individual neurobehavioral analyses, predetermined thresholds, based on mixed linear-effects models and conditional minimally detectable change, were used to define meaningful neurobehavioral change for the Disorders of Consciousness Scale-25 (DOCS) total and Auditory-Language measures. Resting-state functional connectivity (rsFC) of the default mode and 6 other networks was examined. RESULTS: Meaningful gains in DOCS total measures were observed for 75% of treatment segments and auditory-language gains were observed after rTMS, which doubled when rTMS preceded rTMS+AMA. Neurobehavioral changes were reflected in rsFC for language, salience, and sensorimotor networks. Between networks interactions were modulated, globally, after all treatments. CONCLUSIONS: For persons with DoC 1 to 15 years after TBI, meaningful neurobehavioral gains were observed after provision of rTMS, AMA, and rTMS+AMA. Sequencing and combining of treatments to modulate broad-scale neural activity, via differing mechanisms, merits investigation in a future study powered to determine efficacy of this approach to enabling neurobehavioral recovery.

Safety Considerations for the Use of Transcranial Magnetic Stimulation as Treatment for Coma Recovery in People With Severe Traumatic Brain Injury.

OBJECTIVE: For persons in states of disordered consciousness (DoC) after severe traumatic brain injury (sTBI), we report cumulative findings from safety examinations, including serious adverse events (AEs) of a repetitive transcranial magnetic stimulation (rTMS) parameter protocol in 2 different studies. PARTICIPANTS: Seven persons in states of DoC after sTBI with widespread neuropathology, but no large lesions in proximity to the site of rTMS. One participant had a ventriculoperitoneal shunt with programmable valve. METHODS: Two clinical trials each providing 30 rTMS sessions to the right or left dorsolateral prefrontal cortex, involving 300 to 600 pulses over 1 or 2 sessions daily. One study provided concomitant amantadine. Safety indicators monitored related to sleep, temperature, blood pressure, skin integrity, sweating, weight loss, infections, and seizure. RESULTS: Average changes for monitored indicators were of mild severity, with 75 nonserious AEs and 1 serious AE (seizure). The participant incurring a seizure resumed rTMS while taking antieplieptics without further seizure activity. CONCLUSIONS: Considering elevated risks for this patient population and conservative patient selection, findings indicate a relatively safe profile for the specified rTMS protocols; however, potential for seizure induction must be monitored. Future research for this population can be broadened to include patients previously excluded on the basis of profiles raising safety concerns.

Neural Connectivity Changes Facilitated by Familiar Auditory Sensory Training in Disordered Consciousness: A TBI Pilot Study.

For people with disordered consciousness (DoC) after traumatic brain injury (TBI), relationships between treatment-induced changes in neural connectivity and neurobehavioral recovery have not been explored. To begin building a body of evidence regarding the unique contributions of treatments to changes in neural network connectivity relative to neurobehavioral recovery, we conducted a pilot study to identify relationships meriting additional examination in future research. To address this objective, we examined previously unpublished neural connectivity data derived from a randomized clinical trial (RCT). We leveraged these data because treatment efficacy, in the RCT, was based on a comparison of a placebo control with a specific intervention, the familiar auditory sensory training (FAST) intervention, consisting of autobiographical auditory-linguistic stimuli. We selected a subgroup of RCT participants with high-quality imaging data (FAST n = 4 and placebo n = 4) to examine treatment-related changes in brain network connectivity and how and if these changes relate to neurobehavioral recovery. To discover promising relationships among the FAST intervention, changes in neural connectivity, and neurobehavioral recovery, we examined 26 brain regions and 19 white matter tracts associated with default mode, salience, attention, and language networks, as well as three neurobehavioral measures. Of the relationships discovered, the systematic filtering process yielded evidence supporting further investigation of the relationship among the FAST intervention, connectivity of the left inferior longitudinal fasciculus, and auditory-language skills. Evidence also suggests that future mechanistic research should focus on examining the possibility that the FAST supports connectivity changes by facilitating redistribution of brain resources. For a patient population with limited treatment options, the reported findings suggest that a simple, yet targeted, passive sensory stimulation treatment may have altered functional and structural connectivity. If replicated in future research, then these findings provide the foundation for characterizing the unique contributions of the FAST intervention and could inform development of new treatment strategies. For persons with severely damaged brain networks, this report represents a first step toward advancing understanding of the unique contributions of treatments to changing brain network connectivity and how these changes relate to neurobehavioral recovery for persons with DoC after TBI. Clinical Trial Registry: NCT00557076, The Efficacy of Familiar Voice Stimulation During Coma Recovery (http://www.clinicaltrials.gov).

Self-reported Participation Restrictions Among Male and Female Veterans With Traumatic Brain Injury in Veterans Health Administration Outpatient Polytrauma Programs.

OBJECTIVES: To identify areas of most restricted self-reported participation among veterans with traumatic brain injury (TBI), explore associations among participation restriction and clinical characteristics, and examine differences in participation restrictions by sex. DESIGN: Retrospective cross-sectional design. SETTING: National VA Polytrauma System of Care outpatient settings. PARTICIPANTS: Veterans with a confirmed TBI event (N=6065). INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURE(S): Mayo-Portland Participation Index (M2PI), a 5-point Likert-type scale with 8 items. Total score was converted to standardized T score for analysis. RESULTS: The sample consisted of 5679 male and 386 female veterans with ≥1 clinically confirmed TBI events (69% white; 74% with blast exposure). The M2PI items with greatest perceived restrictions were social contact, leisure, and initiation. There were no significant differences between men and women on M2PI standardized T scores. Wilcoxon rank-sum analyses showed significant differences by sex on 4 items: leisure, residence, employment, and financial management (all P<.01). In multinomial logistic regression on each item controlling for demographics, injury characteristics, and comorbidities, female veterans had significantly greater relative risk for part-time work and unemployment on the employment item and significantly less risk for impairment on the residence and financial management item. CONCLUSIONS: There was no significant difference between men and women. Veterans on M2PI standardized T scores, which masks differences in response patterns to individual items. Clinical teams should be encouraged to discuss perceived restrictions with patients and target these areas in treatment planning. Future work is needed to investigate the psychometric properties of the M2PI by biological sex.

Relationships and Evidence-Based Theoretical Perspectives on Persisting Symptoms and Functional Impairment Among Mild Traumatic Brain Injury and Behavioral Health Conditions.

The purpose of this study is to characterize and describe the relationships between symptoms and functional impairment following mild traumatic brain injury (mTBI) and behavioral health conditions (BHCs) in order to inform evidence-based theories on why symptoms and functional impairments persist in some individuals but not others. This is a retrospective, multi-site, cross-sectional study utilizing data collected from a total of 289 Operation Iraqi Freedom/Operation Enduring Freedom Veterans who were classified into diagnostic groups using the symptom attribution and classification algorithm and the VA clinical reminder and comprehensive traumatic brain injury evaluation. The Neurobehavioral Symptom Inventory was used to assess mTBI symptom number and severity. The World Health Organization Disability Assessment Schedule 2.0 was used to assess functional impairment. Symptom profiles differed between diagnostic groups irrespective of symptom attribution method used. Veterans with both mTBI and BHCs and those with BHCs alone had consistently greater number of symptoms and more severe symptoms relative to no symptom and symptoms resolved groups. Symptom number and severity were significantly associated with functional impairment. Both symptom number and functional impairment were significantly associated with the number of mTBI exposures. Together, these results informed evidence-based theories on understanding why symptoms and functional impairment persist among some OEF/OIF Veterans.

Familiar auditory sensory training in chronic traumatic brain injury: a case study.

PURPOSE: The evaluation and treatment for patients with prolonged periods of seriously impaired consciousness following traumatic brain injury (TBI), such as a vegetative or minimally conscious state, poses considerable challenges, particularly in the chronic phases of recovery. METHOD: This blinded crossover study explored the effects of familiar auditory sensory training (FAST) compared with a sham stimulation in a patient seven years post severe TBI. Baseline data were collected over 4 weeks to account for variability in status with neurobehavioral measures, including the Disorders of Consciousness scale (DOCS), Coma Near Coma scale (CNC), and Consciousness Screening Algorithm. Pre-stimulation neurophysiological assessments were completed as well, namely Brainstem Auditory Evoked Potentials (BAEP) and Somatosensory Evoked Potentials (SSEP). RESULTS: Results revealed that a significant improvement in the DOCS neurobehavioral findings after FAST, which was not maintained during the sham. BAEP findings also improved with maintenance of these improvements following sham stimulation as evidenced by repeat testing. CONCLUSIONS: The results emphasize the importance for continued evaluation and treatment of individuals in chronic states of seriously impaired consciousness with a variety of tools. Further study of auditory stimulation as a passive treatment paradigm for this population is warranted. Implications for Rehabilitation Clinicians should be equipped with treatment options to enhance neurobehavioral improvements when traditional treatment methods fail to deliver or maintain functional behavioral changes. Routine assessment is crucial to detect subtle changes in neurobehavioral function even in chronic states of disordered consciousness and determine potential preserved cognitive abilities that may not be evident due to unreliable motor responses given motoric impairments. Familiar Auditory Stimulation Training (FAST) is an ideal passive stimulation that can be supplied by families, allied health clinicians and nursing staff of all levels.

Association Between Alcohol Craving and Health-Related Quality of Life Among Veterans With Co-occurring Conditions.

BACKGROUND: Probable alcohol use disorder (AUD), mental health disorders (MHDs), and mild traumatic brain injury (mTBI) are endemic among U.S. Veterans of the recent conflicts in Iraq and Afghanistan. Previous research demonstrates that recent Veterans with AUD and MHD both with and without mTBI (MHD ± mTBI) self-report higher alcohol craving levels relative to Veterans with AUD only. Since it is unknown if alcohol craving negatively impacts health-related quality of life (HRQOL), the purpose of this study is to identify and describe the relationship between alcohol craving and HRQOL for recent Veterans with AUD alone and those with AUD and co-occurring conditions. METHODS: This cross-sectional study included Penn Alcohol Craving Scale (PACS) and Veterans RAND 36 Item Health Survey mental and physical component score data collected among recent Veterans with AUD (N = 29, n = 27 males): 14 combat controls, 15 MHD ± mTBI. The Alcohol Use Disorder Identification Test, consumption questions determined AUD classification. That is only Veterans scoring a 4 or above for males and a 3 or above for females on the Alcohol Use Disorder Identification Test, consumption questions were included in this study. Associations between alcohol craving and HRQOL were examined using correlations and regression models. RESULTS: There was a significant negative linear relationship between PACS and mental component score (p < 0.05) that did not significantly differ between groups. There was a significant negative curvilinear relationship between PACS and physical component score with a significant group effect. DISCUSSION: Greater alcohol craving was associated with poorer mental HRQOL. Physical HRQOL was also significantly associated with alcohol craving. These relationships have important implications for clinical assessment and treatment among people with AUD. These findings suggest that alcohol craving is an important symptom of AUD for clinicians to assess and focus their treatment upon because it may negatively impact HRQOL.

Healthcare utilization following mild traumatic brain injury in female veterans.

BACKGROUND: Mild traumatic brain injury (TBI) is a significant problem for Veterans. Gender differences in mild TBI outcomes such as return-to-work, resolution of symptoms and mental health diagnoses have been reported. The purpose of the study is to characterize gender differences in VA healthcare utilization in the year following mild TBI diagnosis. METHODS: This was a retrospective database study of 12 144 Veterans diagnosed with mild TBI in fiscal year 2008 and their healthcare utilization in the following year. RESULTS: The mean age was 43.6 ± 17 and the majority were men (94.1%). Overall, women had more outpatient utilization than men with mild TBI (mean: 48 vs. 37 visits; p ≤ 0.001). Adjusted analyses indicated that women had a rate of outpatient utilization 25% higher than men (IRR = 1.25, 95% CI = 1.17-1.33). It was found that 13.6% of the difference in outpatient utilization by gender could be explained by other factors such as race, age, marital status, geographic location and illness burden. CONCLUSION: Male Veterans had less outpatient utilization than females in the year following mild TBI diagnosis. Gender and other factors only accounted for a small portion of the differences observed; therefore, gender only partially accounts for differences in healthcare utilization following mild TBI.

Diagnostic accuracy studies in mild traumatic brain injury: a systematic review and descriptive analysis of published evidence.

OBJECTIVES: To synthesize evidence and report findings from a systematic search and descriptive analysis of peer-reviewed published evidence of the accuracy of tests used for diagnosing mild traumatic brain injury (mTBI). The article also summarizes points of concurrence and divergence regarding case definitions of mTBI identified during the review. TYPE: Systematic review and descriptive analysis of published evidence. LITERATURE SURVEY: A search of PubMed, PsychInfo, and the Cochrane Library for peer-reviewed publications between 1990 and July 6, 2011, identified 1218 abstracts; 277 articles were identified for full review, and 13 articles met the criteria for evaluation. METHODOLOGY: Manuscript inclusion criteria were (1) reported sensitivity (Se) and specificity (Sp), or reported data were sufficient to compute Se and Sp; (2) >1 participant in the study; (3) at least 80% of the study cohort was ≥18 years of age; and (4) written in English. Articles describing clinical practice guidelines, opinions, theories, or clinical protocols were excluded. Seven investigators independently evaluated each article according to the Standards for Reporting of Diagnostic Accuracy (STARD) criteria. SYNTHESIS: Findings indicate that all 13 studies involved civilian noncombat populations. In 7 studies, authors examined acute mTBI, and in 4 studies, historical remote mTBI was examined. In the 13 studies, Se ranged from 13%-92% and Sp ranged from 72%-99%, but confidence in these findings is problematic because the STARD review indicates opportunities for bias in each study. CONCLUSIONS: Findings indicate that no well-defined definition or clinical diagnostic criteria exist for mTBI and that diagnostic accuracy is currently insufficient for discriminating between mTBI and co-occurring mental health conditions for acute and historic mTBI. Findings highlight the need for research examining the diagnostic accuracy for acute and historic mTBI.

An evaluation of the Veterans Affairs traumatic brain injury screening process among Operation Enduring Freedom and/or Operation Iraqi Freedom veterans.

OBJECTIVE: To describe the early results of the U.S. Department of Veterans Affairs (VA) screening program for traumatic brain injury (TBI) and to identify patient and facility characteristics associated with receiving a TBI screen and results of the screening. DESIGN: National retrospective cohort study. SETTING: VA Medical facilities. PATIENTS: A total of 170,681 Operation Enduring Freedom and/or Operation Iraqi Freedom (OEF/OIF) Veterans who sought care at VA medical facilities from April 2007 to September 30, 2008. METHODS: Data were abstracted from VA administrative and operational databases, including patient demographics, facility characteristics, and outcomes. MAIN OUTCOME MEASUREMENTS: The main outcomes were receipt of and results of the TBI screen. RESULTS: The majority of veterans eligible received the TBI screen (91.6%). Screening rates varied by patient and facility characteristics. In all, 25% of screened veterans had probable TBI exposure, in which the majority of the exposures were blasts (85.0%). The rate of a positive TBI screen was 20.5% for the screened cohort. Male gender, service in the army, multiple deployments, and mental health diagnoses in the previous year were associated with a positive screen. CONCLUSIONS: TBI screening rates are high in VA; concomitant mental health diagnoses were highly prevalent in individuals with positive TBI screens. These data indicate that there will be a significant need for long-term health care services for veterans with TBI symptomatology.

Prevalence and treatment of headaches in veterans with mild traumatic brain injury.

OBJECTIVES: To report the prevalence and characteristics of headaches in veterans with mild traumatic brain injury (TBI) and to describe most common treatment strategies after neurological evaluation. METHODS: We conducted a retrospective cohort study. The setting was a United States Veterans Healthcare Administration Polytrauma Network Site. The study participants consisted of 246 veterans with confirmed diagnosis of mild TBI. The main outcome measures were: Self-reported head pain occurring 30 days prior to initial mild TBI screening; headache severity measured by the Neurobehavioral Symptom Inventory; headache characteristics; and treatment prescribed by neurologists. RESULTS: The majority (74%) of veterans with a confirmed diagnosis of mild TBI (N=246), due largely to blast exposure, reported headaches in the 30 days preceding the initial mild TBI evaluation. Thirty-three percent of these veterans (N=81) were referred to neurology for persistent headaches. Of the 56 veterans attending the neurology evaluation, 45% were diagnosed with migraine headaches and 20% with chronic daily headaches. The most commonly used abortive agents were triptans (68%) and the most common preventive medications were anticonvulsants (55%) and tricyclics (40%). CONCLUSION: There was an increased prevalence of headaches in veterans with mild TBI. Most of the TBI veterans in our study group were exposed to blast injury and findings indicate that the nature of head trauma may be contributing to headaches. Findings highlight the need for developing effective headache prevention and treatment strategies for all persons with mild TBI and in particular for veterans with blast-related mild TBI.