Jess F. Kraus

A systematic review of brain injury epidemiology in Europe

SummaryBackground. The world’s literature on traumatic brain injury (TBI) grows annually including new reports on epidemiologic findings from many regions. With the wide variety of reports emphasizing various factors it is useful to compile these findings, hence the objective of this report. Thus, we describe epidemiological factors from European studies largely published in the last 20 years.Method. The Medline was searched for TBI related articles from about 1980 to 2003 including terms such as “epidemiology”, “head injury”, “brain injury” and others. From the research reports identified, we checked references for additional relevant reports and from those reports we abstracted data on TBI incidence, severity, external cause, gender, mortality, prevalence, cost and related factors.Results. Twenty three European reports met inclusion criteria and included findings from national studies from Denmark, Sweden, Finland, Portugal, Germany, and from regions within Norway, Sweden, Italy, Switzerland, Spain, Denmark, Ireland, the U.K. and France. An aggregate hospitalized plus fatal TBI incidence rate of about 235 per 100,000 was derived. Prevalence rate data were not reported from any European country. An average mortality rate of about 15 per 100,000 and case fatality rate of about 11 per 100 were derived. The TBI severity ratio of hospitalized patients was about 22:1.5:1 for mild vs. moderate vs. severe cases, respectively. The percentages of TBI from external causes varied considerably and several reports reported an association of alcohol use with TBI. Outcome or disability findings were mixed and inconsistent.Interpretation. It was difficult to reach a consensus on all epidemiological findings across the 23 published European studies because of critical differences in methods employed across the reports. We highly recommend the development of research guidelines to standardize definitional, case finding, and data reporting parameters to help establish a more precise description and hence utility of the epidemiology of TBI in Europe.

Incidence, risk factors and prevention of mild traumatic brain injury: Results of the WHO Collaborating Centre Task Force on Mild Traumatic Brain Injury

OBJECTIVE We undertook a best-evidence synthesis on the incidence, risk factors and prevention of mild traumatic brain injury. METHODS Medline, Cinahl, PsycINFO and Embase were searched for relevant articles. After screening 38,806 abstracts, we critically reviewed 169 studies on incidence, risk and prevention, and accepted 121 (72%). RESULTS The accepted articles show that 70-90% of all treated brain injuries are mild, and the incidence of hospital-treated patients with mild traumatic brain injury is about 100-300/100,000 population. However, much mild traumatic brain injury is not treated at hospitals, and the true population-based rate is probably above 600/100,000. Mild traumatic brain injury is more common in males and in teenagers and young adults. Falls and motor-vehicle collisions are common causes. CONCLUSION Strong evidence supports helmet use to prevent mild traumatic brain injury in motorcyclists and bicyclists. The mild traumatic brain injury literature is of varying quality, and the studies are very heterogeneous. Nevertheless, there is evidence that mild traumatic brain injury is an important public health problem, but we need more high-quality research into this area.

Methodological issues and research recommendations for mild traumatic brain injury: the WHO Collaborating Centre Task Force on Mild Traumatic Brain Injury.

The WHO Collaborating Centre for Neurotrauma Task Force on Mild Traumatic Brain Injury performed a comprehensive search and critical review of the literature published between 1980 and 2002 to assemble the best evidence on the epidemiology, diagnosis, prognosis and treatment of mild traumatic brain injury. Of 743 relevant studies, 313 were accepted on scientific merit and comprise our best-evidence synthesis. The current literature on mild traumatic brain injury is of variable quality and we report the most common methodological flaws. We make recommendations for avoiding the shortcomings evident in much of the current literature and identify topic areas in urgent need of further research. This includes the need for large, well-designed studies to support evidence-based guidelines for emergency room triage of children with mild traumatic brain injury and to explore more fully the issue of prognosis after mild traumatic brain injury in the elderly population. We also advocate use of standard criteria for defining mild traumatic brain injury and propose a definition.

Risk factors for injury to women from domestic violence

BACKGROUND Domestic violence is the most common cause of nonfatal injury to women in the United States. To identify risk factors for such injuries, we examined the socioeconomic and behavioral characteristics of women who were victims of domestic violence and the men who injured them. METHODS We conducted a case-control study at eight large, university-affiliated emergency departments. The 256 intentionally injured women had acute injuries resulting from a physical assault by a male partner. The 659 controls were women treated for other conditions in the emergency department. Information was collected with a standardized questionnaire; no information was obtained directly from the male partners. RESULTS The 256 intentionally injured women had a total of 434 contusions and abrasions, 89 lacerations, and 41 fractures and dislocations. In a multivariate analysis, the characteristics of the partners that were most closely associated with an increased risk of inflicting injury as a result of domestic violence were alcohol abuse (adjusted relative risk, 3.6; 95 percent confidence interval, 2.2 to 5.9); drug use (adjusted relative risk, 3.5; 95 percent confidence interval, 2.0 to 6.4); intermittent employment (adjusted relative risk, 3.1; 95 percent confidence interval, 1.1 to 8.8); recent unemployment (adjusted relative risk, 2.7; 95 percent confidence interval, 1.2 to 6.5); having less than a high-school-graduates education (adjusted relative risk, 2.5; 95 percent confidence interval, 1.4 to 4.4); and being a former husband, estranged husband, or former boyfriend (adjusted relative risk, 3.5; 95 percent confidence interval, 1.5 to 8.3). CONCLUSIONS Women at greatest risk for injury from domestic violence include those with male partners who abuse alcohol or use drugs, are unemployed or intermittently employed, have less than a high-school-graduates education, and are former husbands, estranged husbands, or former boyfriends of the women.

Mild traumatic brain injury in the United States, 1998--2000.

Primary objective: To determine the incidence and epidemiology of emergency department (ED)-attended mild traumatic brain injury (mTBI) in the US. Research design: Secondary analysis of ED visits for mTBI in the National Hospital Ambulatory Medical Care Survey for 1998–2000. Methods and procedures: MTBI defined by International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM) codes for ‘skull fracture’, ‘concussion’, ‘intracranial injury of unspecified nature’ and ‘head injury, unspecified’. Main outcome and results: The average incidence of mTBI was 503.1/100 000, with peaks among males (590/100 000), American Indians/Alaska Natives (1,026/100 000) and those <5 years of age (1,115.2/100 000). MTBI incidence was highest in the Midwest region (578.4/10 000) and in non-urban areas (530.9/100 000) of the US. Bicycles and sports accounted for 26.4% of mTBI in the 5–14 age group. Conclusions: The national burden of mTBI is significant and the incidence higher than that reported by others. Possible explanations are discussed. Bicycle and sports-related injuries are an important and highly preventable cause of mTBI underscoring the need to promote prevention programmes on a national level.

EPIDEMIOLOGIC ASPECTS OF BRAIN INJURY

Approximately 2 million head injuries occur each year in the United States, producing a brain injury rate of 175 to 200 per 100,000 population and causing as many as 56,000 deaths per year. The economic and emotional toll of this public health burden is staggering. By identifying risk factors, perhaps effective legislation and environmental and educational intervention strategies can be developed to prevent brain injury.

The epidemiology of mild, uncomplicated brain injury.

Mild brain injury accounts for a substantial proportion of all persons admitted to a hospital for brain trauma, yet the amount of information on the epidemiology of this problem is quite sparse. Data on mild brain injuries for San Diego County residents injured in 1981 were analyzed for incidence, external cause, prehospital factors, diagnoses, alcohol use, and in-hospital treatment costs. More than 80% of all San Diego County residents hospitalized for an acute brain injury had a mild uncomplicated brain injury: a rate of 130.8 per 100,000 per year. Three quarters of these had an ER Glasgow Coma Scale of 15. Rates are twice as high for males compared to females, with peak occurrence for males at ages 15-19 years. More than 40% of mild brain injuries are caused by motor-vehicle-related events. The most common diagnosis was concussion (80%) or other intracranial injury (14%). Median length of hospital stay was 2-3 days and depended on brain injury diagnosis or Glasgow Coma Scale. Although less than 30% of those aged 15 years and older were blood tested for alcohol, two thirds of those tested had a level of 100 mg% or higher. In-hospital treatment costs for concussion or other mild intracranial injury for San Diego County residents exceeded six million dollars in 1981.

A review of risk factors and patterns of motorcycle injuries

Per vehicle mile traveled, motorcycle riders have a 34-fold higher risk of death in a crash than people driving other types of motor vehicles. While lower-extremity injuries most commonly occur in all motorcycle crashes, head injuries are most frequent in fatal crashes. Helmets and helmet use laws have been shown to be effective in reducing head injuries and deaths from motorcycle crashes. Alcohol is the major contributing factor to fatal crashes. Enforcement of legal limits on the blood alcohol concentration is effective in reducing motorcycle deaths, while some alcohol-related interventions such as a minimal legal drinking age, increased alcohol excise taxes, and responsible beverage service specifically for motorcycle riders have not been examined. Other modifiable protective or risk factors comprise inexperience and driver training, conspicuity and daytime headlight laws, motorcycle licensure and ownership, riding speed, and risk-taking behaviors. Features of motorcycle use and potentially effective prevention programs for motorcycle crash injuries in developing countries are discussed. Finally, recommendations for future motorcycle-injury research are made.

Effect of Italy’s motorcycle helmet law on traumatic brain injuries

Objectives: To evaluate the impact of a revised Italian motorcycle-moped-scooter helmet law on crash brain injuries. Design: A pre-post law evaluation of helmet use and traumatic brain injury (TBI) occurrence from 1999 to 2001. Setting: Romagna region, northeastern Italy, with a 2000 resident population of 983 534 persons. Participants: Motorcycle-moped rider survey for helmet use compliance and all residents in the region admitted to the Division of Neurosurgery of the Maurizio Bufalini Hospital in Cesena, Italy for TBI. Outcome measures: Helmet use compliance and change in TBI admissions and type(s) of brain lesions. Results: Helmet use increased from an average of less than 20% to over 96%. A comparison of TBI incidence in the Romagna region shows that there was no significant variation before and after introduction of the revised helmet law, except for TBI admissions for motorcycle-moped crashes where a 66% decrease was observed. In the same area TBI admissions by age group showed that motorcycle mopeds riders aged 14–60 years sustained significantly fewer TBIs. The rate of TBI admissions to neurosurgery decreased by over 31% and epidural hematomas almost completely disappeared in crash injured moped riders. Conclusions: The revised Italian mandatory helmet law, with police enforcement, is an effective measure for TBI prevention at all ages.

Blood alcohol tests, prevalence of involvement, and outcomes following brain injury

We collected data on all residents of San Diego County, California who were hospitalized for or died from a brain injury in 1981. The objectives were to assess the frequency of blood alcohol concentration (BAC) testing and the associations of BAC prevalence with the external cause of the brain injury and case outcome. We found that high BAC levels were most frequent among brain-injured subjects between the ages of 25 and 44 and among those subjects involved in motor vehicle crashes and assaults. Contrary to expectations, injury severity and hospital mortality were inversely related to BAC level, controlling for other predictors. We believe that these inverse associations might be due to differential rates of BAC testing by severity. Among brain-injured survivors with more severe injuries, however, we found that BAC level was positively associated with the prevalence of physician-diagnosed neurological impairment at discharge and with the length of hospitalization.