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ObjectiveTo compare the perspectives of caregivers of children with autism receiving care at the Neurobehavior Healthy Outcomes Medical Excellence (HOME) Program, an interdisciplinary clinic that provides primary care and behavioral/mental health services for patients with autism and other developmental disabilities, with those responding to the 2016 National Survey of Children's Health (NSCH). We focused on ratings related to shared decision-making, care coordination, family-centered care, and care within a medical home.MethodsWe administered a subset of items from the 2016 NSCH to caregivers of children with autism enrolled in HOME and compared responses with the same items from a nationally representative group of caregivers of children with autism who completed the 2016 NSCH. We compared the proportions that reported receiving shared decision-making, care coordination, family-centered care, care within a medical home, and unmet needs among the 2 study groups using Poisson regression, controlling for age, sex, race/ethnicity, payor, autism severity, and intellectual disability (ID).ResultsCompared with the NSCH cohort (n = 1151), children enrolled in HOME (n = 129) were older, more often female, had severe autism, and had co-occurring ID. Caregivers perceived that children receiving care within HOME more often received family-centered, coordinated care within a medical home compared with a national sample of children with autism. HOME enrollees also reported increased access to behavioral treatments and adult transition services with less financial burden compared with the national sample.ConclusionAn interdisciplinary clinic model may best serve children with autism, especially those with higher severity symptoms and co-occurring conditions.

BackgroundPredicting neurological recovery after spinal cord injury (SCI) is challenging. Using topological data analysis, we have previously shown that mean arterial pressure (MAP) during SCI surgery predicts long-term functional recovery in rodent models, motivating the present multicenter study in patients.MethodsIntra-operative monitoring records and neurological outcome data were extracted (n = 118 patients). We built a similarity network of patients from a low-dimensional space embedded using a non-linear algorithm, Isomap, and ensured topological extraction using persistent homology metrics. Confirmatory analysis was conducted through regression methods.ResultsNetwork analysis suggested that time outside of an optimum MAP range (hypotension or hypertension) during surgery was associated with lower likelihood of neurological recovery at hospital discharge. Logistic and LASSO (least absolute shrinkage and selection operator) regression confirmed these findings, revealing an optimal MAP range of 76-[104-117] mmHg associated with neurological recovery.ConclusionsWe show that deviation from this optimal MAP range during SCI surgery predicts lower probability of neurological recovery and suggest new targets for therapeutic intervention.FundingNIH/NINDS: R01NS088475 (ARF); R01NS122888 (ARF); UH3NS106899 (ARF); Department of Veterans Affairs: 1I01RX002245 (ARF), I01RX002787 (ARF); Wings for Life Foundation (ATE, ARF); Craig H. Neilsen Foundation (ARF); and DOD: SC150198 (MSB); SC190233 (MSB).

A considerable subset of mild traumatic brain injury (mTBI) patients fail to return to baseline functional status at or beyond 3 months postinjury. Identifying at-risk patients for poor outcome in the emergency department (ED) may improve surveillance strategies and referral to care. Subjects with mTBI (Glasgow Coma Scale 13-15) and negative ED initial head CT < 24 h of injury, completing 3- or 6-month functional outcome (Glasgow Outcome Scale-Extended; GOSE), were extracted from the prospective, multicenter Transforming Research and Clinical Knowledge in Traumatic Brain Injury (TRACK-TBI) Pilot study. Outcomes were dichotomized to full recovery (GOSE = 8) vs. functional deficits (GOSE < 8). Univariate predictors with p < 0.10 were considered for multivariable regression. Adjusted odds ratios (AOR) were reported for outcome predictors. Significance was assessed at p < 0.05. Subjects who completed GOSE at 3- and 6-month were 211 (GOSE < 8: 60%) and 185 (GOSE < 8: 65%). Risk factors for 6-month GOSE < 8 included less education (AOR = 0.85 per-year increase, 95% CI: (0.74-0.98)), prior psychiatric history (AOR = 3.75 (1.73-8.12)), Asian/minority race (American Indian/Alaskan/Hawaiian/Pacific Islander) (AOR = 23.99 (2.93-196.84)), and Hispanic ethnicity (AOR = 3.48 (1.29-9.37)). Risk factors for 3-month GOSE < 8 were similar with the addition of injury by assault predicting poorer outcome (AOR = 3.53 (1.17-10.63)). In mTBI patients seen in urban trauma center EDs with negative CT, education, injury by assault, Asian/minority race, and prior psychiatric history emerged as risk factors for prolonged disability.

Introduction: Risk factors for young adults with mTBI are not well understood. Improved understanding of age and sex as risk factors for impaired six-month outcomes in young adults is needed. Methods: Young adult mTBI subjects aged 18-39 years (18-29y; 30-39y) with six-month outcomes were extracted from the Transforming Research and Clinical Knowledge in Traumatic Brain Injury Pilot (TRACK-TBI Pilot) study. Multivariable regressions were performed for outcomes with age, sex, and the interaction factor age-group*sex as variables of interest, controlling for demographic and injury variables. Mean-differences (B) and 95% CIs are reported. Results: One hundred mTBI subjects (18-29y, 70%; 30-39y, 30%; male, 71%; female, 29%) met inclusion criteria. On multivariable analysis, age-group*sex was associated with six-month post-traumatic stress disorder (PTSD; PTSD Checklist-Civilian version); compared with female 30-39y, female 18-29y (B= -19.55 [-26.54, -4.45]), male 18-29y (B= -19.70 [-30.07, -9.33]), and male 30-39y (B= -15.49 [-26.54, -4.45]) were associated with decreased PTSD symptomatology. Female sex was associated with decreased six-month functional outcome (Glasgow Outcome Scale-Extended (GOSE): B= -0.6 [1.0, -0.1]). Comparatively, 30-39y scored higher on six-month nonverbal processing speed (Wechsler Adult Intelligence Scale-Processing Speed Index (WAIS-PSI); B= 11.88, 95% CI [1.66, 22.09]). Conclusions: Following mTBI, young adults aged 18-29y and 30-39y may have different risks for impairment. Sex may interact with age for PTSD symptomatology, with females 30-39y at highest risk. These results may be attributable to cortical maturation, biological response, social modifiers, and/or differential self-report. Confirmation in larger samples is needed; however, prevention and rehabilitation/counseling strategies after mTBI should likely be tailored for age and sex.

Introduction: Over 70% of traumatic brain injuries (TBI) are classified as mild (mTBI), which present heterogeneously. Associations between pre-injury comorbidities and outcomes are not well-understood, and understanding their status as risk factors may improve mTBI management and prognostication. Methods: mTBI subjects (GCS 13-15) from TRACK-TBI Pilot completing 3- and 6-month functional [Glasgow Outcome Scale-Extended (GOSE)] and post-concussive outcomes [Acute Concussion Evaluation (ACE) physical/cognitive/sleep/emotional subdomains] were extracted. Pre-injury comorbidities >10% incidence were included in regressions for functional disability (GOSE ≤ 6) and post-concussive symptoms by subdomain. Odds ratios (OR) and mean differences (B) were reported. Significance was assessed at p < 0.0083 (Bonferroni correction). Results: In 260 subjects sustaining blunt mTBI, mean age was 44.0-years and 70.4% were male. Baseline comorbidities >10% incidence included psychiatric-30.0%, cardiac (hypertension)-23.8%, cardiac (structural/valvular/ischemic)-20.4%, gastrointestinal-15.8%, pulmonary-15.0%, and headache/migraine-11.5%. At 3- and 6-months separately, 30.8% had GOSE ≤ 6. At 3-months, psychiatric (GOSE ≤ 6: OR = 2.75, 95% CI [1.44-5.27]; ACE-physical: B = 1.06 [0.38-1.73]; ACE-cognitive: B = 0.72 [0.26-1.17]; ACE-sleep: B = 0.46 [0.17-0.75]; ACE-emotional: B = 0.64 [0.25-1.03]), headache/migraine (GOSE ≤ 6: OR = 4.10 [1.67-10.07]; ACE-sleep: B = 0.57 [0.15-1.00]; ACE-emotional: B = 0.92 [0.35-1.49]), and gastrointestinal history (ACE-physical: B = 1.25 [0.41-2.10]) were multivariable predictors of worse outcomes. At 6-months, psychiatric (GOSE ≤ 6: OR = 2.57 [1.38-4.77]; ACE-physical: B = 1.38 [0.68-2.09]; ACE-cognitive: B = 0.74 [0.28-1.20]; ACE-sleep: B = 0.51 [0.20-0.83]; ACE-emotional: B = 0.93 [0.53-1.33]), and headache/migraine history (ACE-physical: B = 1.81 [0.79-2.84]) predicted worse outcomes. Conclusions: Pre-injury psychiatric and pre-injury headache/migraine symptoms are risk factors for worse functional and post-concussive outcomes at 3- and 6-months post-mTBI. mTBI patients presenting to acute care should be evaluated for psychiatric and headache/migraine history, with lower thresholds for providing TBI education/resources, surveillance, and follow-up/referrals. Clinical Trial Registration: www.ClinicalTrials.gov, identifier NCT01565551.

The annual incidence of mild traumatic brain injury (MTBI) is 3.8 million in the USA with 10⁻15% experiencing persistent morbidity beyond one year. Chronic traumatic encephalopathy (CTE), a neurodegenerative disease characterized by accumulation of hyperphosphorylated tau, can occur with repetitive MTBI. Risk factors for CTE are challenging to identify because injury mechanisms of MTBI are heterogeneous, clinical manifestations and management vary, and CTE is a postmortem diagnosis, making prospective studies difficult. There is growing interest in the genetic influence on head trauma and development of CTE. Apolipoprotein epsilon 4 (APOE-ε4) associates with many neurologic diseases, and consensus on the ε4 allele as a risk factor is lacking. This review investigates the influence of APOE-ε4 on MTBI and CTE. A comprehensive PubMed literature search (1966 to 12 June 2018) identified 24 unique reports on the topic (19 MTBI studies: 8 athletic, 5 military, 6 population-based; 5 CTE studies: 4 athletic and military, 1 leucotomy group). APOE-ε4 genotype is found to associate with outcomes in 4/8 athletic reports, 3/5 military reports, and 5/6 population-based reports following MTBI. Evidence on the association between APOE-ε4 and CTE from case series is equivocal. Refining modalities to aid CTE diagnosis in larger samples is needed in MTBI.

The prevalence of neuropsychiatric disorders following traumatic brain injury (TBI) is 20%-50%, and disorders of mood and cognition may remain even after recovery of neurologic function is achieved. Selective serotonin reuptake inhibitors (SSRI) block the reuptake of serotonin in presynaptic cells to lead to increased serotonergic activity in the synaptic cleft, constituting first-line treatment for a variety of neurocognitive and neuropsychiatric disorders. This review investigates the utility of SSRIs in treating post-TBI disorders. In total, 37 unique reports were consolidated from the Cochrane Central Register and PubMed (eight randomized-controlled trials (RCTs), nine open-label studies, 11 case reports, nine review articles). SSRIs are associated with improvement of depressive but not cognitive symptoms. Pooled analysis using the Hamilton Depression Rating Scale demonstrate a significant mean decrease of depression severity following sertraline compared to placebo-a result supported by several other RCTs with similar endpoints. Evidence from smaller studies demonstrates mood improvement following SSRI administration with absent or negative effects on cognitive and functional recovery. Notably, studies on SSRI treatment effects for post-traumatic stress disorder after TBI remain absent, and this represents an important direction of future research. Furthermore, placebo-controlled studies with extended follow-up periods and concurrent biomarker, neuroimaging and behavioral data are necessary to delineate the attributable pharmacological effects of SSRIs in the TBI population.

IntroductionThe Glasgow Coma Scale (GCS) score is the primary method of assessing consciousness after traumatic brain injury (TBI), and the clinical standard for classifying TBI severity. There is scant literature discerning the influence of circadian rhythms or emergency department (ED) arrival hour on this important clinical tool.MethodsRetrospective cohort analysis of adult patients suffering blunt TBI using the National Sample Program of the National Trauma Data Bank, years 2003-2006. ED arrival GCS score was characterized by midday (10 a.m.-4 p.m.) and midnight (12 a.m.-6 a.m.) cohorts (N=24548). Proportions and standard errors are reported for descriptive data. Multivariable regressions using odds ratios (OR), mean differences (B), and their associated 95% confidence intervals [CI] were performed to assess associations between ED arrival hour and GCS score. Statistical significance was assessed at p

BACKGROUND: Preinjury employment status may contribute to disparity, injury risk, and recovery patterns following mild traumatic brain injury (MTBI). OBJECTIVE: To characterize associations between preinjury unemployment, prior comorbidities, and outcomes following MTBI. METHODS: MTBI patients from TRACK-TBI Pilot with complete six-month outcomes were extracted. Preinjury unemployment, comorbidities, injury factors, and intracranial pathology were considered. Multivariable regression was performed for employment and outcomes, correcting for demographic and injury factors. Mean-differences (B) and 95% CIs are reported. Statistical significance was assessed at p < 0.05. RESULTS: 162 MTBI patients were aged 39.8±15.4-years and 24.6% -unemployed. Unemployed patients demonstrated increased psychiatric comorbidities (45.0% -vs.– 23.8%; p = 0.010), drug use (52.5% -vs.– 21.3%; p < 0.001), smoking (62.5% -vs.– 27.0%; p < 0.001), prior TBI (78.4% -vs.– 55.0%; p = 0.012), and lower education (15.0% -vs.– 45.1% college degree; p = 0.003). On multivariable analysis, unemployment associated with decreased six-month functional outcome (Glasgow Outcome Scale-Extended: B = – 0.50, 95% CI [– 0.88, – 0.11]), increased psychiatric disturbance (Brief Symptom Inventory-18: B = 6.22 [2.33, 10.10]), postconcussional symptoms (Rivermead Questionnaire: B = 4.91 [0.38, 9.44]), and post-traumatic stress disorder (PTSD Checklist-Civilian: B = 5.99 [0.76, 11.22]). No differences were observed for cognitive measures or satisfaction with life. CONCLUSIONS: Unemployed patients are at risk for preinjury psychosocial comorbidities, poorer six-month functional recovery and increased psychiatric/postconcussional/PTSD symptoms. Resource allocation and return precautions should be implemented to mitigate and/or prevent the decline of at-risk patients. [ABSTRACT FROM AUTHOR]

Objective: Interhospital transfers for status epilepticus (SE) are common, and some are avoidable and likely lower yield. The use of interhospital transfer may differ in emergency department (ED) and inpatient settings, which contend with differing clinical resources and financial incentives. However, transfer from these two settings is understudied, leaving gaps in our ability to improve the hospital experience, cost, and triage for this neurologic emergency. We aimed to describe interhospital transfer for SE and examine the relationship between the site of transfer and hospital length of stay., Methods: We performed a cross-sectional study of adult patients with SE who underwent interhospital transfer using data from the State Emergency Department Databases and State Inpatient Databases of Florida (2016-2019) and New York (2018-2019). The primary outcome was discharge after undergoing transfer. Secondary outcomes were discharge within 1 day, discharge after 30 days, receipt of electroencephalography (EEG), and discharge disposition., Results: There were 10 461 encounters for SE. Of 1790 ED encounters without admission to the same hospital, 324 (18.1%) resulted in transfer. Of 8671 hospitalizations, 629 (7.3%) resulted in transfer. Patients transferred from the ED were younger, more likely were White, more likely were in a metro area, and had fewer medical comorbidities than patients transferred from the inpatient setting. The median time to discharge was 5 days (interquartile range [IQR] = 2.0-9.0) after ED transfer and 10 days (IQR = 4.0-20.0) after inpatient transfer. There were 58 (17.9%) patients who were discharged within 1 day after undergoing transfer from an ED. ED transfers had higher rates of discharge at 30 days and higher likelihood of undergoing EEG at the receiving hospital and being discharged home., Significance: A high proportion of patients with SE are discharged shortly after undergoing interhospital transfer, particularly those transferred from the ED. Understanding reasons for transfer is a crucial next step in triaging limited inpatient epilepsy resources and reducing costs associated with interhospital transfer., (© 2025 International League Against Epilepsy.)

Purpose: Recent data suggest great variability in costs for surgical hospitalization for spinal surgery. However, the magnitude of expenditures attributable to complications is unknown. The purpose of this study is to describe cost of care associated with surgical and medical complications after cervical spine surgery., Materials and Methods: A retrospective cohort study utilizing the National Inpatient Sample years 2002-2014 was conducted. A weighted sample of 901,508 adults undergoing elective cervical fusion for degenerative indications was extracted using diagnostic and procedure codes. Twelve categories of major complications were identified, and patient/hospital variables were evaluated as predictors of the overall reimbursed cost using multivariate regression. Mean differences (B) and 95% confidence intervals were reported., Results: The mean age was 52.2 ± 11.4 years, with 5.2% of patients experiencing a complication. Mean overall increase in inflation-adjusted cost associated with complication was $16,435 ± 10,358, varying significantly by type of complication, surgical approach, and number of levels fused. The most common complications and their attributed costs were dysphagia (1.6%, B = $2624 [2476-2771], P < 0.001), pulmonary complications (1.0%, B = $9334 [9110-9558], P < 0.001), and device-related complications (0.9%, B = $3125 [2927-3324], P < 0.001). The costliest complications were infection (0.1%, B = $25359 [24723-25994], P < 0.001), thromboembolism (0.1%, B = $17480 [16808-18153], P < 0.001), and neurological complications (0.2%, B = $10098 [9629-10567], P < 0.001)., Conclusions: Although complications are rare after elective cervical fusion, they are associated with dramatically increase costs of care as high as $25,359 in the setting of postoperative infection. Improved understanding of the economic magnitude of complications may help guide efforts in reducing health care spending and improving perioperative care., Competing Interests: There are no conflicts of interest.

Introduction: Odontoid fractures (OF) are the most frequent cervical spine fracture type in the elderly, often following low-velocity falls. The rise in life expectancies has led to an increase in octogenarians suffering OF, for which the optimal treatment remains undetermined., Evidence Acquisition: A comprehensive search was conducted (National Library of Medicine MEDLINE, Cochrane Central Register of Controlled Trials) for all articles through 03/2016. Articles were included if the study population evaluated treatment modalities in OF patients aged ≥80-years. Outcomes assessed were mortality, complications, osseous union, and fracture stability. Pooled odds ratios (OR) and 95% confidence intervals (CI) are reported., Evidence Synthesis: Across 22 case series/retrospective studies, attributable mortality for surgery was 5.4% (8/149) vs. 10.1% (10/99) for nonsurgery (P=0.159). Surgery patients suffered higher complications rates (38.9%, 58/149; vs. 24.5%, 26/106); OR 1.96 ([1.13-3.40], P=0.016). Osseous union was better achieved with surgery (68.5%, 37/54; vs. 43.2%, 16/37); OR 2.86 ([1.20-6.80]; P=0.016). Fracture stability was better achieved with surgery (86.0%, 49/57; vs. 63.6%, 28/44); OR 3.50 ([1.33-9.21], P=0.009)., Conclusions: In general, octogenarians undergoing surgery for OF showed higher fusion and stability rates compared to nonsurgery, which may be due in part to surgical selection criteria, surgeon preference and patient comorbidities. Higher complications were observed for surgery patients, while no differences were observed for mortality. Prospective trials are greatly needed to identify the optional treatment modality and predictors of clinical outcome in octogenarians suffering OF.