Computerised tomography indices of raised intracranial pressure and traumatic brain injury severity in a New Zealand sample

After traumatic brain injury (TBI) complex cellular and biochemical processes occur¹ including changes in blood flow and oxygenation of the brain; cerebral swelling; and raised intracranial pressure (ICP).² This can dramatically worsen the damage³ and contributes to mortality

Attention deficits after incident stroke in the acute period: Frequency across types of attention and relationships to patient characteristics and functional outcomes

Background: Attention deficits are common post stroke and result in poorer functional outcomes. This study examined the frequency of attention deficits after incident stroke and their correlates. Method: Attention of 94 stroke survivors was assessed using the Bells test, Trails Making Test A/B, 2.4- and 2.0-second trials of the Paced Auditory Serial Addition Test (PASAT), and Integrated Auditory Visual Continuous Performance Test (IVA-CPT) within 3 weeks post stroke. Wider functioning was assessed using the Medical Short Form-36 (SF-36) Physical and Mental Component Summary scores (PCS and MCS), London Handicap Scale, Modified Rankin Scale, General Health Questionnaire-28, and Cognitive Failures Questionnaire (CFQ). Results: Most participants were impaired or very impaired on the IVA-CPT (z scores > 3 SDs below normative mean) but not other attention measures. Functional independence and cognitive screening test (Mini-Mental State Examination) performance were significantly related to IVA-CPT, Trails A/B, and Bells tests but not PASAT. Better performance across the Bells test was related to better SF-36 PCS, whereas Trails A and the PASAT were related to SF-36 MCS. Better CFQ naming was related to Trails B, whereas worse CFQ memory was related to better PASAT performance. Conclusion: Attention deficits are common post stroke, though frequency varies widely across the forms of attention assessed, with tests of neglect and speeded attention tasks being linked to quality of life. This variability of performance and linking to wider outcomes suggests the need for comprehensive assessment of attention and that attention is a viable target for rehabilitative efforts

Population-based cohort study of the impacts of mild traumatic brain injury in adults four years post-injury

There is increasing evidence that some people can experience persistent symptoms for up to a year following mild TBI. However, few longitudinal studies of mild TBI exist and the longerterm impact remains unclear. The purpose of this study is to determine if there are long-term effects of mild traumatic brain injury (TBI) four-years later. Adults (aged 16 years) identified as part of a TBI incidence study who experienced a mild-TBI four-years ago (N = 232) were compared to age-sex matched controls (N = 232). Sociodemographic variables, prior TBI and symptoms were assessed at the time of injury. Four years post-injury participants completed the Rivermead Post-Concussion Symptom Questionnaire, Hospital Anxiety and Depression Scale, Pittsburgh Sleep Quality Index and the Participation Assessment with Recombined Tools. Analysis of covariance was used to compare differences between TBI cases four years post-injury and controls, controlling for prior TBI and depression. A multiple regression model was used to identify the predictors of increased symptoms and reduced participation. The mild-TBI sample experienced significantly increased self-reported cognitive symptoms (F = 19.90, p = <0.01) four years post-injury than controls. There were no differences between the groups for somatic (F = 0.02, p = 0.89) or emotional symptoms (F = 0.31, p = 0.58). Additionally, the mild-TBI group reported significantly poorer community participation across all three domains: productivity (F = 199.07, p = <0.00), social relations (F = 13.93, p = <0.00) and getting out and about (F = 364.69, p = <0.00) compared to controls. A regression model accounting for 41% of the variance in cognitive symptoms in TBI cases revealed a history of TBI, receiving acute medical attention and baseline cognitive symptoms, sleep quality, anxiety and depression were predictive of outcome. The results indicate that whilst somatic and emotional symptoms resolve over time, cognitive symptoms can become persistent and that mild TBI can impact longer-term community participation. Early intervention is needed to reduce the longer-term impact of cognitive symptoms and facilitate participation

Trajectories in health recovery in the 12 months following a mild traumatic brain injury in children: Findings from the BIONIC Study

Introduction: There is growing consensus that adverse child outcomes may be evident in the early recovery phase following mild traumatic brain injury (TBI). However, controversy remains around the nature of children's longer-term recovery. Aim: To examine child cognitive, behavioural and quality-of-life outcomes over 12 months following mild injury, and to identify prognostic factors associated with outcomes. Methods: A prospective sample of 222 children (aged 2-15 years at injury) with mild TBI was assessed using a cognitive testing battery and parent-report questionnaires at ≤ 14 days, 1, 6 and/or 12-months post-injury. RESULTS Parents reported significant improvements in their child's behavioural adjustment between baseline and 6 months (P = 0.003), with further improvements at 12 months following inju ry (P = 0.001). Cognitive recovery and quality-of-life improvements were more gradual with minimal changes in the first month (P > 0.05), but significant improvements by 12-months post-injury (P = 0.03, P = 0.02, respectively). Time since injury, male gender, living rurally and parent anxiety were associated with extent of recovery beyond the acute period. CONCLUSIONS Children's recovery from mild TBI continues beyond the initial 6 months following injury. Health-care providers need to be vigilant about the varying trajectories in children's recovery from TBI. On-going monitoring of children following injury will enable timely and proactive responses to persistent difficulties, with a view to minimising longer-term adverse consequences

Changes over time in family members of adults with mild traumatic brain injury

Objective: The impact of traumatic brain injury (TBI) extends beyond the person who was injured. Family caregivers of adults with moderate to severe TBI frequently report increased burden, stress and depression. Few studies have examined the well-being of family members in the mild TBI population despite the latter representing up to 95% of all TBIs. Methods: Five areas of well-being were examined in 99 family members (including parents, partners, siblings, other relatives, adult children, friends or neighbours) of adults (aged ≥16 years) with mild TBI. At 6- and 12-month post-injury, family members completed the Bakas Caregiver Outcomes Scale, Short Form-36 Health Survey, EQ-5D-3L, Hospital Anxiety and Depression Scale and the Pittsburgh Sleep Quality Index. Outcomes and change over time and associated factors were examined. Results: At 6 months, group mean scores for health-related quality of life for mental and physical components and overall health status were similar to the New Zealand (NZ) population. Mean scores for sleep, anxiety and depression were below clinically significant thresholds. From 6 to 12 months, there were significant improvements in Bakas Caregiver Outcomes Scale scores by 2.61 (95% confidence interval: 0.72–4.49), health-related quality of life (mental component) and EQ-5D-3L overall health (P = 0.01). Minimally clinically important differences were observed in overall health, anxiety, health-related quality of life and depression at 12 months. Female family members reported significant improvements in physical health over time, and more positive life changes were reported by those caring for males with TBI. Conclusions: The findings suggest diminished burden over time for family members of adults with mild TBI

Parent and teacher-reported child outcomes seven years after mild traumatic brain Injury: A nested case control study

Background: Increasing evidence suggests potential lifetime effects following mild traumatic brain injury (TBI) in childhood. Few studies have examined medium-term outcomes among hospitalized and non-hospitalized samples. Study aims were to describe children's behavioral and emotional adjustment, executive function (EF), quality of life, and participation at 7-years following mild TBI using parents' and teachers' reports. Methods: Nested case control study of 86 children (68% male, mean age at assessment = 11.27 years; range 7–17 years) who sustained a mild TBI 7-years previously, identified from a prospective, population-based study. They were compared to 69 children free from TBI (61% male, mean age at assessment = 11.12 years; range 5–17 years). In addition to parent-reported socio-demographic details, parents (mild TBI n = 86, non-TBI n = 69) completed age-appropriate standardized questionnaires about children's health-related quality of life, behavioral and emotional adjustment, EF, and social participation. Parents own mood was assessed using the Hospital Anxiety and Depression Scale. Teachers (mild TBI n = 53, non-TBI n = 42) completed questionnaires about children's behavioral and emotional adjustment, and EF. Results: Parent reports showed median group-level scores for cases were statistically significantly greater than controls for emotional symptoms, conduct problems, hyperactivity/inattention, total behavioral difficulties, inhibitory control, shifting, planning/organizing, and Global Executive Composite (total) EF difficulties (p-values 0.001–0.029). Parent reports of child quality of life and social participation were similar, as were teacher reports of child behavioral and emotional adjustment, and EF (p > 0.05). When examining clinical cut-offs, compared to controls, cases had a higher risk of parent-reported total EF difficulties (odds ratio = 3.00) and, to a lesser extent, total behavior problems (odds ratio = 2.51). Conclusions: As a group, children with a history of mild TBI may be at elevated risk for clinically significant everyday EF difficulties in the medium-term compared to non-TBI controls, as judged by their parents. Further multi-informant longitudinal research is required, following larger samples. Aspects requiring particular attention include pre-injury characteristics, such as sleep disturbances and comorbidities (e.g., headaches), that may act as potential confounders influencing the association between mild TBI and child behavioral problems

Reducing recurrent stroke: Methodology of the motivational interviewing in stroke (MIST) randomized clinical trial

Rationale Recurrent stroke is prevalent in both developed and developing countries, contributing significantly to disability and death. Recurrent stroke rates can be reduced by adequate risk factor management. However, adherence to prescribed medications and lifestyle changes recommended by physicians at discharge after stroke is poor, leading to a large number of preventable recurrent strokes. Using behavior change methods such as Motivational Interviewing early after stroke occurrence has the potential to prevent recurrent stroke. Aims and/or hypothesis The overall aim of the study is to determine the effectiveness of motivational interviewing in improving adherence to medication and lifestyle changes recommended by treating physicians at and after hospital discharge in stroke patients 12 months poststroke to reduce risk factors for recurrent stroke. Design Recruitment of 430 first-ever stroke participants will occur in the Auckland and Waikato regions. Randomization will be to intervention or usual care groups. Participants randomized to intervention will receive four motivational interviews and five follow-up assessments over 12 months. Nonintervention participants will be assessed at the same time points. Study outcomes Primary outcome measures are changes in systolic blood pressure and low-density lipoprotein levels 12 months poststroke. Secondary outcomes include self-reported adherence and barriers to prescribed medications, new cardiovascular events (including stroke), changes in quality of life, and mood. Discussion The results of the motivational interviewing in stroke trial will add to our understanding of whether motivational interviewing may be potentially beneficial in the management of stroke and other diseases where similar lifestyle factors or medication adherence are relevant

Usability and feasibility of PreventS-MD webapp for stroke prevention

Background: Most strokes and cardiovascular diseases (CVDs) are potentially preventable if their risk factors are identified and well controlled. Digital platforms, such as the PreventS-MD webapp (PreventS-MD) may aid health care professionals (HCPs) in assessing and managing risk factors and promoting lifestyle changes for their patients.Methods: This is a mixed methods cross-sectional 2-phase survey using a largely positivist (quantitative and qualitative) framework. During phase 1, a prototype of PreventS-MD was tested internationally by 59 of 69 consenting HCPs of different backgrounds, age, sex, working experience and specialities using hypothetical data. Collected comments/suggestions from the study HCPs in phase 1 were reviewed and implemented. In phase 2, a near-final version of PreventS-MD was developed and tested by 58 of 72 consenting HCPs using both hypothetical and real patient (n=10) data. Qualitative semi-structured interviews with real patients (n=10) were conducted, and 1-month adherence to the preventative recommendations was assessed by self-reporting. The four System Usability Scale (SUS) groups of scores (0-50 unacceptable; 51-68 poor, 68-80.3 good; >80.3 excellent) were used to determine usability of PreventS-MD.Findings: 99 HCPs from 27 countries (45% from low- to middle-income countries) participated in the study, out of whom 10 HCPs were involved in the development of PreventS before the study, and therefore were not involved in the survey. Of the remaining 89 HCPs 69 consented to the first phase of the survey, out of whom 59 completed the first phase of the survey (response rate 86%) and 58 HCPs completed the second phase of the survey (response rate 84%). The SUS scores supported good usability of the prototype (mean score=80.2; 95% CI [77.0-84.0]) and excellent usability of the final version of PreventS-MD (mean score=81.7; 95%CI [79.1-84.3]) in the field. Scores were not affected by the age, sex, working experience or speciality of the HCPs. One month follow-up of the patients confirmed the high level of satisfaction/acceptability of PreventS-MD and (100%) adherence to the recommendations. Interpretation: The PreventS-MD webapp has a high level of usability, feasibility and satisfaction by HCPs and individuals at risk of stroke/CVD. Individuals at risk of stroke/CVD demonstrated a high level of confidence and motivation in following and adhering to preventative recommendations generated by PreventS-MD

Global and national Burden of diseases and injuries among children and adolescents between 1990 and 2013

Importance The literature focuses on mortality among children younger than 5 years. Comparable information on nonfatal health outcomes among these children and the fatal and nonfatal burden of diseases and injuries among older children and adolescents is scarce. Objective To determine levels and trends in the fatal and nonfatal burden of diseases and injuries among younger children (aged <5 years), older children (aged 5-9 years), and adolescents (aged 10-19 years) between 1990 and 2013 in 188 countries from the Global Burden of Disease (GBD) 2013 study. Evidence Review Data from vital registration, verbal autopsy studies, maternal and child death surveillance, and other sources covering 14 244 site-years (ie, years of cause of death data by geography) from 1980 through 2013 were used to estimate cause-specific mortality. Data from 35 620 epidemiological sources were used to estimate the prevalence of the diseases and sequelae in the GBD 2013 study. Cause-specific mortality for most causes was estimated using the Cause of Death Ensemble Model strategy. For some infectious diseases (eg, HIV infection/AIDS, measles, hepatitis B) where the disease process is complex or the cause of death data were insufficient or unavailable, we used natural history models. For most nonfatal health outcomes, DisMod-MR 2.0, a Bayesian metaregression tool, was used to meta-analyze the epidemiological data to generate prevalence estimates. Findings Of the 7.7 (95% uncertainty interval [UI], 7.4-8.1) million deaths among children and adolescents globally in 2013, 6.28 million occurred among younger children, 0.48 million among older children, and 0.97 million among adolescents. In 2013, the leading causes of death were lower respiratory tract infections among younger children (905 059 deaths; 95% UI, 810 304-998 125), diarrheal diseases among older children (38 325 deaths; 95% UI, 30 365-47 678), and road injuries among adolescents (115 186 deaths; 95% UI, 105 185-124 870). Iron deficiency anemia was the leading cause of years lived with disability among children and adolescents, affecting 619 (95% UI, 618-621) million in 2013. Large between-country variations exist in mortality from leading causes among children and adolescents. Countries with rapid declines in all-cause mortality between 1990 and 2013 also experienced large declines in most leading causes of death, whereas countries with the slowest declines had stagnant or increasing trends in the leading causes of death. In 2013, Nigeria had a 12% global share of deaths from lower respiratory tract infections and a 38% global share of deaths from malaria. India had 33% of the world’s deaths from neonatal encephalopathy. Half of the world’s diarrheal deaths among children and adolescents occurred in just 5 countries: India, Democratic Republic of the Congo, Pakistan, Nigeria, and Ethiopia. Conclusions and Relevance Understanding the levels and trends of the leading causes of death and disability among children and adolescents is critical to guide investment and inform policies. Monitoring these trends over time is also key to understanding where interventions are having an impact. Proven interventions exist to prevent or treat the leading causes of unnecessary death and disability among children and adolescents. The findings presented here show that these are underused and give guidance to policy makers in countries where more attention is needed

The burden of unintentional drowning : global, regional and national estimates of mortality from the Global Burden of Disease 2017 Study

Background Drowning is a leading cause of injury-related mortality globally. Unintentional drowning (International Classification of Diseases (ICD) 10 codes W65-74 and ICD9 E910) is one of the 30 mutually exclusive and collectively exhaustive causes of injury-related mortality in the Global Burden of Disease (GBD) study. This study's objective is to describe unintentional drowning using GBD estimates from 1990 to 2017. Methods Unintentional drowning from GBD 2017 was estimated for cause-specific mortality and years of life lost (YLLs), age, sex, country, region, Socio-demographic Index (SDI) quintile, and trends from 1990 to 2017. GBD 2017 used standard GBD methods for estimating mortality from drowning. Results Globally, unintentional drowning mortality decreased by 44.5% between 1990 and 2017, from 531 956 (uncertainty interval (UI): 484 107 to 572 854) to 295 210 (284 493 to 306 187) deaths. Global age-standardised mortality rates decreased 57.4%, from 9.3 (8.5 to 10.0) in 1990 to 4.0 (3.8 to 4.1) per 100 000 per annum in 2017. Unintentional drowning-associated mortality was generally higher in children, males and in low-SDI to middle-SDI countries. China, India, Pakistan and Bangladesh accounted for 51.2% of all drowning deaths in 2017. Oceania was the region with the highest rate of age-standardised YLLs in 2017, with 45 434 (40 850 to 50 539) YLLs per 100 000 across both sexes. Conclusions There has been a decline in global drowning rates. This study shows that the decline was not consistent across countries. The results reinforce the need for continued and improved policy, prevention and research efforts, with a focus on low- and middle-income countries.Peer reviewe