Indiana University-Purdue University Indianapolis (IUPUI) / Between 3.2 and 5.3 million U.S. civilians live with traumatic brain injury (TBI)-related disabilities. Although the post-acute phase of TBI has been recognized as both a discrete disease process and risk factor for chronic conditions, TBI is not recognized as a chronic disease. TBI epidemiology draws upon untimely, incomplete, cross-sectional, administrative datasets. The adoption of electronic health records (EHR) may supplement traditional datasets for public health surveillance and research. Methods Indiana constructed a state-wide clinical TBI registry from longitudinal (2004-2018) EHRs. This dissertation includes three distinct studies to enhance, evaluate, and apply the registry: 1) development and evaluation of a natural language processing algorithm for identification of TBI severity within free-text notes; 2) evaluation and comparison of the performance of the ICD-9-CM and ICD-10-CM surveillance definitions; and 3) estimating the effect of mild TBI (mTBI) on the risk of post-acute chronic conditions compared to individuals without mTBI. Results Automated extraction of Glasgow Coma Scale from clinical notes was feasible and demonstrated balanced recall and precision (F-scores) for classification of mild (99.8%), moderate (100%), and severe (99.9%) TBI. We observed poor sensitivity for ICD-10-CM TBI surveillance compared to ICD-9-CM (0.212 and 0.601, respectively), resulting in potentially 5-fold underreporting. ICD-10-CM was not statistically equivalent to ICD-9-CM for sensitivity (𝑑𝑑𝑑𝑑̂=0.389, 95% CI [0.388,0.405]) or positive predictive value (𝑑𝑑𝑑𝑑̂=-0.353, 95% CI [-0.362,-0.344]). Compared to a matched cohort, individuals with mTBI were more likely to be diagnosed with mental health, substance use, neurological, cardiovascular, and endocrine conditions. Conclusion ICD-9-CM and ICD-10-CM surveillance definitions were not equivalent, and the transition resulted in a underreporting incidence for mTBI. This has direct implications on existing and future TBI registries and the Report to Congress on Traumatic Brain Injury in the United States. The supplementation of state-based trauma registries with structured and unstructured EHR data is effective for studying TBI outcomes. Our findings support the classification of TBI as a chronic disease by funding bodies, which may improve public funding to replace legacy systems to improve standardization, timeliness, and completeness of the epidemiology and post-acute outcomes of TBI.

The aim of this research was to produce a reliable finite element model of a helmet, that could be used to simulate approval tests as well as impacts to investigate the safety offered. A 2D and 3D mesh was generated from the CAD file of an Easton Synergy 380 with HyperWorks, and then checked referring to standard parameter values. A few specimens cut from the liner were tested with the Instron Electropuls E3000 (Instron, High Wycombe, Great Britain) machine to determine Young’s modulus, Poisson’s ratio and the density of the EPP. The numerical model was characterised with appropriate materials with Ls-PrePost, such as ABS for the shell, EPP for the liner and steel for the impact anvil. The foam was implemented both with the *063_CRUSHABLE_FOAM and the *126_MODIFIED_HONEYCOMB card, in two different configurations. The helmet model was coupled with a finite element model of a HIII head form and three impact scenarios were set up. Backward, lateral and pitched impact were simulated and results were compared with those obtained from the experimental tests carried on at the MIPS. The two configurations were tested in all the three scenarios. The correlation between numerical and experimental results was evaluated by analysing the linear and rotational acceleration, and the rotational velocity, recorded by the accelerometer positioned inside the HIII headform. The parameters used were the Pearson correlation coefficient, the peak linear acceleration score, the shape of the curves, the time occurrence of peaks and the percentage of the difference between them. The first configuration showed good correlation scores (>85%) for the backward and lateral impact, for the rotational velocity and acceleration, while lower values were recorded for the pitched impact simulation. Lower values (70.88% and 77.76%) were obtained for the peak linear acceleration score, which stress the need for modifications of the contact definition in Ls-PrePost or a more detailed material testing. Worse results were recorded for the second configuration, but the smaller computational time required suggests that more attempts should be done in this direction.

OBJECTIVE: Gunshot wounds to the head (GSWH) are devastating injuries with a grim prognosis. Several prognostic scores have been created to estimate mortality and functional outcome, including the so-called Baylor score, an uncomplicated scoring method based on bullet trajectory, patient age, and neurological status on admission. This study aimed to validate the Baylor score within a temporally, institutionally, and geographically distinct patient population. METHODS: Data were obtained from the trauma registry at a level I trauma center in the southeastern US. Patients with a GSWH in which dural penetration occurred were identified from data collected between January 1, 2009, and June 30, 2019. Patient demographics, medical history, bullet trajectory, intent of GSWH (e.g., suicide), admission vital signs, Glasgow Coma Scale score, pupillary response, laboratory studies, and imaging reports were collected. The Baylor score was calculated directly by using its clinical components. The ability of the Baylor score to predict mortality and good functional outcome (Glasgow Outcome Scale score 4 or 5) was assessed using the receiver operating characteristic curve and the area under the curve (AUC) as a measure of performance. RESULTS: A total of 297 patients met inclusion criteria (mean age 38.0 [SD 15.7] years, 73.4% White, 85.2% male). A total of 205 (69.0%) patients died, whereas 69 (23.2%) patients had good functional outcome. Overall, the Baylor score showed excellent discrimination of mortality (AUC = 0.88) and good functional outcome (AUC = 0.90). Baylor scores of 3-5 underestimated mortality. Baylor scores of 0, 1, and 2 underestimated good functional outcome. CONCLUSIONS: The Baylor score is an accurate and easy-to-use prognostic scoring tool that demonstrated relatively stable performance in a distinct cohort between 2009 and 2019. In the current era of trauma management, providers may continue to use the score at the point of admission to guide family counseling and to direct investment of healthcare resources.

Persons with traumatic brain injuries (TBI) who have engaged in problematic or illegal sexual behavior present with complex assessment and intervention needs yet remain understudied within the empirical literature. In the current exploratory analysis, important differences in adaptive and clinical functioning, adverse childhood experiences, and criminal offense history are examined in 25 persons with previous brain injury, 118 persons with intellectual disability but no known TBI, and 103 persons with no history of brain injury or intellectual disability, all of whom have engaged in problematic sexual behavior and who were residing in secure forensic inpatient care. Group differences were examined using comparisons of means and chi-squares. Results highlight important differences in education and employment experiences, diagnostic presentation, exposure to childhood maltreatment, and justice system involvement and characteristics of their sexual offense victims. Associations with prior literature and future research directions are discussed.

This study examines the background and qualifications of plaintiff and defense experts using the H-Index score as quantification of expert background and qualifications. The goal is to better understand the similarities and differences among the professionals offering paid expert witness testimony in mild traumatic brain injury (mTBI) civil litigation. In this quantitative study, descriptive statistics include the mean and standard deviation scores for the data to support examining measures of central tendency and variance, respectively. The study includes the use of logistic regression and the Wilcoxon signed-rank test, and their statistical assumptions were tested to determine whether they would be used or if it was more appropriate to use a non-parametric test. The study included two research questions: How do the qualifications of plaintiff and defense expert witnesses in mild traumatic brain injury civil litigation compare? and to what extent does a higher h-index correlate with a favorable litigation outcome in a mild traumatic brain injury case? The findings for the hypothesis tests associated with the research questions led to the acceptance of the null hypothesis in each test. There was a lack of asymptotic significance in Hypothesis 1 and a lack of significance in Hypothesis 2. The findings from these tests shall support the discussion of the implications of this research and the direction of future research.

Veterans of Operation Enduring Freedom, Operation Iraqi Freedom, and Operation New Dawn are presenting for treatment with high rates of combat-related posttraumatic stress disorder (PTSD) and traumatic brain injury (TBI), spurring a need for clinical research on optimal treatment strategies. While exposure therapy has long been supported as an efficacious treatment for combat-related PTSD, some clinicians are hesitant to utilize this treatment for veterans with TBI history due to presumed cognitive deficits that may preclude successful engagement. The purpose of this study was to compare exposure therapy process variables in veterans with PTSD only and veterans with PTSD+TBI. Results suggest that individuals with PTSD+TBI engage successfully in exposure therapy, and do so no differently than individuals with PTSD only. Additional analyses indicated that regardless of TBI status, more severe PTSD was related to longer sessions, more sessions, and slower extinction rate during imaginal exposure. Finally, in a subset of participants, self-report of executive dysfunction did not impact exposure therapy process variables. Overall, findings indicate that exposure therapy should be the first-line treatment for combat-related PTSD regardless of presence of TBI history.

Att drabbas av traumatisk hjärnskada (Traumatic Brain Injury; TBI) innebär att hjärnan utsättas för ett yttre våld som kan orsaka kortvariga samt långvariga funktionsnedsättningar. Det kan medföra livsförsändningar både för den drabbade och för de närstående. Syftet med denna litteraturstudie var att beskriva upplevelsen av att vara närstående till en person med traumatisk hjärnskada. Studien utfördes i form av en litteraturstudie med kvalitativ innehållsanalys som analyserades med manifest ansats där människors upplevelse och erfarenheter var i fokus. I studien inkluderades 13 vetenskapliga artiklar. Under analysprocessen av valda artiklar identifierades sex slutkategorier; Ta ansvar och ge upp sina egna behov, Få förändrade och nya roller, Brist på information från hälso-och sjukvården, Vara psykiskt belastad, känsla av ensamhet och isolering; Förlust av relationer. Resultatet visade att närstående upplevde olika svårigheter relaterade till att leva med en person med traumatisk hjärnskada. Att vara närstående till en person med traumatisk hjärnskada kan skapa ekonomiska, sociala, psykiska, känslomässiga och sexuella konsekvenser vilket medför stora förändringar i sociala roller och relationer. Sjuksköterskor behöver kunskap om hur det är att vara närstående till personer med traumatisk hjärnskada samt ha en förståelse för deras upplevelse för att kunna bemöta dem på ett adekvat sätt. Sjuksköterskans kunskap och förståelse kan förbättra närståendes upplevelse av sjukvården samt att de får stöd i sin situation.

Within the past few decades brain injury, or traumatic brain injury (TBI), has gained widespread attention. Early focus was on more severe forms of TBI; severity typically measured using the Glasgow Coma Scale. In more recent years, however, mild traumatic brain injury (mTBI), most notably concussions, has gained increasing interest due to the high frequency of concussions suffered in athletes of all levels and, recently, in military personnel due to blast injuries. Studies being performed have focused not only on ways to help minimize the incidence of concussion as well as treating concussive symptoms, but also on detecting concussions. Many concussions go unreported due to inadequate knowledge of concussive symptoms amongst the general population. Because many concussions go unnoticed and hence unreported the individual who has sustained a concussion is at risk for a more serious injury in the future. One such injury is Second Impact Syndrome (SIS). Second Impact Syndrome is essentially a synergistic event where the sum of two seemingly mild concussions combine to create an event that is potentially fatal. The findings during the autopsy are that there is insignificant damage to the brain to cause death. The damage that occurs, however, is on a molecular level causing a strain on the metabolic processes of the brain called dysautoregulation. Without an understanding of the changes that have occurred on a molecular level in SIS the assignment of cause and manner of death is difficult for the medical examiner. Currently, in order to diagnose SIS, a thorough scene investigation, along with the documentation of a previous head injury is needed. Without a full understanding of SIS and the pathophysiology changes that take place a medical examiner (ME) could misclassify the cause and manner of death in a death due to SIS. In the future, eliminating the prerequisite of identification and documentation of previous head injuries in order to diagnose SIS is needed. This paper evaluates the literature on the current knowledge of TBI and concussions in an attempt to create a protocol on how a medical examiner should approach a case where autopsy findings are unremarkable.

Youth football players ages 8-12 may incur hundreds of repeated head impacts (RHI) each season. Evidence suggests concussive brain injury during childhood may disrupt normal developmental processes resulting in long-term impairments. However, little research has investigated the long-term effects of incurring RHI during critical periods of neurodevelopment. Rapid myelination and cerebral blood flow rates, peaks in regional cortical thickness and volumes of specific structures, refinement of regional connectivity, and other neurodevelopmental changes occurring in the brain from ages 10-12 could create a window of vulnerability to RHI. The objective of this research was to determine the relationship between exposure to RHI prior to age 12, during a critical period of neurodevelopment, and later-life brain structure and function. Former National Football League (NFL) players ages 40-65 were divided into two groups based on their age of first exposure (AFE) to RHI through tackle football: AFE <12 and AFE ≥12. In the first study, we observed significantly lower scores on objective tests of executive functioning, memory, and estimated verbal IQ in those who began playing football prior to age 12 compared to those who began playing at age 12 or older. Next, we used diffusion tensor imaging (DTI) to examine the structural integrity of the corpus callosum (CC) and observed that the AFE <12 group had significantly lower fractional anisotropy (FA) as well as a greater decline in FA with age in anterior CC regions than the AFE ≥12 group. Lastly, we used advanced DTI tractography techniques to examine seven CC regions. Significant differences between AFE groups in associations between CC diffusion measures and cognition, mood, and behavior were found. The results of this research suggest that incurring RHI through tackle football during a critical neurodevelopmental period prior to age 12 may result in later-life structural and functional consequences, including cognitive, mood, and behavioral impairments; alterations in white matter structure; and greater vulnerability of white matter to the normal aging process. If replicated with longitudinal designs, larger samples, and athletes whose highest level of play was youth, high school, or college, these findings may have implications for safety recommendations for youth sports.

Clinical Researchers recently identified NFL players and US military veterans as high-risk populations for sustaining repetitive Traumatic Brain Injury (TBI) and developing the neurodegenerative disease Chronic Traumatic Encephalopathy (CTE). American culture celebrates military veterans as national heroes, and NFL players as popular athletes and social icons. Both subcultures are constructed around hyper-masculine ideals embedded in tenants of violence and aggression, suffer repeated TBIs due to this nature, and are ultimately at high-risk for developing CTE. The TBI/CTE phenomenon also affects family members who assume care-taking responsibilities for these first two populations as their loved one’s symptoms persist. The purpose of this research is to understand the TBI/CTE experiences of NFL players, military veterans, and their caretakers, and how all three populations intersect with mediatization and the social and medical legitimation of TBI/CTE in America. Using narratives from all three populations, I explore how power dynamics within the NFL and US military have intersected with modern media outlets and functioned to socio-medically legitimize a sick role for those who suffer from persistent symptoms of TBI and CTE.