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- Title
Association Between 5-Year Clinical Outcome in Patients With Nonmedically Evacuated Mild Blast Traumatic Brain Injury and Clinical Measures Collected Within 7 Days Postinjury in Combat.
- Authors
Mac Donald, Christine L.; Barber, Jason; Patterson, Jana; Johnson, Ann M.; Dikmen, Sureyya; Fann, Jesse R.; Temkin, Nancy
- Abstract
Key Points: Question: What clinical measures collected acutely in combat are associated with 5-year outcome in patients with concussive blast injury? Findings: In this longitudinal cohort study, nonmedically evacuated blast concussion patients had significant and sustained symptoms of neurobehavioral impairment, mental health and global disability, whereas cognitive changes were unremarkable compared with combat-deployed nonconcussed controls. Assessments collected in theater were associated with multiple domains of outcome. Meaning: Nonmedically evacuated patients with concussive blast injury, considered the mildest of the mild combat casualties fared poorly 5 years later compared with combat-deployed controls. This cohort study characterizes 5-year outcome in nonmedically evacuated blast concussion patients compared with combat-deployed controls to evaluate what clinical measures collected acutely in theater are associated with 5-year outcomes. Importance: Although previous work has examined clinical outcomes in combat-deployed veterans, questions remain regarding how symptoms evolve or resolve following mild blast traumatic brain injury (TBI) treated in theater and their association with long-term outcomes. Objective: To characterize 5-year outcome in patients with nonmedically evacuated blast concussion compared with combat-deployed controls and understand what clinical measures collected acutely in theater are associated with 5-year outcome. Design, Setting, and Participants: A prospective, longitudinal cohort study including 45 service members with mild blast TBI within 7 days of injury (mean 4 days) and 45 combat deployed nonconcussed controls was carried out. Enrollment occurred in Afghanistan at the point of injury with evaluation of 5-year outcome in the United States. The enrollment occurred from March to September 2012 with 5-year follow up completed from April 2017 to May 2018. Data analysis was completed from June to July 2018. Exposures: Concussive blast TBI. All patients were treated in theater, and none required medical evacuation. Main Outcomes and Measures: Clinical measures collected in theater included measures for concussion symptoms, posttraumatic stress disorder (PTSD) symptoms, depression symptoms, balance performance, combat exposure intensity, cognitive performance, and demographics. Five-year outcome evaluation included measures for global disability, neurobehavioral impairment, PTSD symptoms, depression symptoms, and 10 domains of cognitive function. Forward selection multivariate regression was used to determine predictors of 5-year outcome for global disability, neurobehavior impairment, PTSD, and cognitive function. Results: Nonmedically evacuated patients with concussive blast injury (n = 45; 44 men, mean [SD] age, 31 [5] years) fared poorly at 5-year follow-up compared with combat-deployed controls (n = 45; 35 men; mean [SD] age, 34 [7] years) on global disability, neurobehavioral impairment, and psychiatric symptoms, whereas cognitive changes were unremarkable. Acute predictors of 5-year outcome consistently identified TBI diagnosis with contribution from acute concussion and mental health symptoms and select measures of cognitive performance depending on the model for 5-year global disability (area under the curve following bootstrap validation [AUCBV] = 0.79), neurobehavioral impairment (correlation following bootstrap validation [RBV] = 0.60), PTSD severity (RBV = 0.36), or cognitive performance (RBV = 0.34). Conclusions and Relevance: Service members with concussive blast injuries fared poorly at 5-year outcome. The results support a more focused acute screening of mental health following TBI diagnosis as strong indicators of poor long-term outcome. This extends prior work examining outcome in patients with concussive blast injury to the larger nonmedically evacuated population.
- Subjects
AFGHANISTAN; UNITED States; AMERICAN veterans; BRAIN concussion; BRAIN injuries; COGNITION disorders; MENTAL depression; EMERGENCIES; CIVILIAN evacuation; FISHER exact test; LONGITUDINAL method; MENTAL illness; NEUROLOGIC manifestations of general diseases; HEALTH outcome assessment; POST-traumatic stress disorder; PSYCHOLOGICAL tests; PSYCHOMETRICS; QUALITY of life; QUESTIONNAIRES; REGRESSION analysis; THERAPEUTIC complications; TIME; MULTIPLE regression analysis; BLAST injuries; RECEIVER operating characteristic curves; DESCRIPTIVE statistics; ODDS ratio; MANN Whitney U Test
- Publication
JAMA Network Open, 2019, Vol 2, Issue 1, pe186676
- ISSN
2574-3805
- Publication type
Article
- DOI
10.1001/jamanetworkopen.2018.6676