National Trauma Research Institute

Melbourne, Australia

National Trauma Research Institute

Melbourne, Australia
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Rosenfeld J.V.,Monash University | Rosenfeld J.V.,The Alfred Hospital | Rosenfeld J.V.,National Trauma Research Institute | McFarlane A.C.,University of Adelaide | And 6 more authors.
The Lancet Neurology | Year: 2013

A bomb blast may cause the full severity range of traumatic brain injury (TBI), from mild concussion to severe, penetrating injury. The pathophysiology of blast-related TBI is distinctive, with injury magnitude dependent on several factors, including blast energy and distance from the blast epicentre. The prevalence of blast-related mild TBI in modern war zones has varied widely, but detection is optimised by battlefield assessment of concussion and follow-up screening of all personnel with potential concussive events. There is substantial overlap between post-concussive syndrome and post-traumatic stress disorder, and blast-related mild TBI seems to increase the risk of post-traumatic stress disorder. Post-concussive syndrome, post-traumatic stress disorder, and chronic pain are a clinical triad in this patient group. Persistent impairment after blast-related mild TBI might be largely attributable to psychological factors, although a causative link between repeated mild TBIs caused by blasts and chronic traumatic encephalopathy has not been established. The application of advanced neuroimaging and the identification of specific molecular biomarkers in serum for diagnosis and prognosis are rapidly advancing, and might help to further categorise these injuries. © 2013 Elsevier Ltd.


Gabbe B.J.,Monash University | Gabbe B.J.,National Trauma Research Institute | Harrison J.E.,Flinders University | Lyons R.A.,University of Swansea | Jolley D.,Monash University
PLoS ONE | Year: 2011

Background: Injury is a leading cause of the global burden of disease (GBD). Estimates of non-fatal injury burden have been limited by a paucity of empirical outcomes data. This study aimed to (i) establish the 12-month disability associated with each GBD 2010 injury health state, and (ii) compare approaches to modelling the impact of multiple injury health states on disability as measured by the Glasgow Outcome Scale - Extended (GOS-E). Methods: 12-month functional outcomes for 11,337 survivors to hospital discharge were drawn from the Victorian State Trauma Registry and the Victorian Orthopaedic Trauma Outcomes Registry. ICD-10 diagnosis codes were mapped to the GBD 2010 injury health states. Cases with a GOS-E score >6 were defined as "recovered." A split dataset approach was used. Cases were randomly assigned to development or test datasets. Probability of recovery for each health state was calculated using the development dataset. Three logistic regression models were evaluated: a) additive, multivariable; b) "worst injury;" and c) multiplicative. Models were adjusted for age and comorbidity and investigated for discrimination and calibration. Findings: A single injury health state was recorded for 46% of cases (1-16 health states per case). The additive (C-statistic 0.70, 95% CI: 0.69, 0.71) and "worst injury" (C-statistic 0.70; 95% CI: 0.68, 0.71) models demonstrated higher discrimination than the multiplicative (C-statistic 0.68; 95% CI: 0.67, 0.70) model. The additive and "worst injury" models demonstrated acceptable calibration. Conclusions: The majority of patients survived with persisting disability at 12-months, highlighting the importance of improving estimates of non-fatal injury burden. Additive and "worst" injury models performed similarly. GBD 2010 injury states were moderately predictive of recovery 1-year post-injury. Further evaluation using additional measures of health status and functioning and comparison with the GBD 2010 disability weights will be needed to optimise injury states for future GBD studies. © 2011 Gabbe et al.


Mitra B.,Alfred Hospital | Mitra B.,Monash University | Mitra B.,National Trauma Research Institute | Fitzgerald M.,National Trauma Research Institute | And 2 more authors.
Injury | Year: 2014

Introduction and aims: The use of intravenous oxygen carriers (packed red blood cells (PRBC), whole blood and synthetic haemoglobins (HBOCs) for selected pre-hospital trauma resuscitation cases has been reported, despite a lack of validated clinical indications. The aim of this study was to retrospectively identify a sub-group of adult major trauma patients most likely to benefit from pre-hospital oxygen carrier administration and determine the predictive relationship between pre-hospital shock index (SI) [pulse rate/systolic blood pressure] and haemorrhagic shock, blood transfusion and mortality. Methods: A retrospective review of adult major trauma patients recorded in The Alfred Trauma Registry was conducted. Patients were included if they received at least 1 L of pre-hospital crystalloid and spent over 30 min in transit. The association of shock index and transfusion was determined. Patients were further sub-grouped by mode of transport to determine the population of trauma patients who could be included into prospective studies of intravenous oxygen carriers. Results: There were 1149 patients included of whom 311 (21.9%) received an acute blood transfusion. The SI correlated well with transfusion practice. A SI ≥ 1.0, calculated after at least 1 L of crystalloid transfusion, identified patients with a high specificity (93.5%; 95% CI: 91.8-94.8) for receiving a blood transfusion within 4 h of hospital arrival. While patients transported by helicopter had higher injury severity and blood transfusion requirement, there were no difference in physiological variables and outcomes when compared to patients transported by road car. Conclusions: A shock index ≥ 1.0 is an easily calculated variable that may identify patients for inclusion into trials for pre-hospital oxygen carriers. Shocked patients have high mortality rates whether transported by road car or by helicopter. The efficacy of pre-hospital intravenous oxygen carriers should be trialled using a shock index ≥ 1.0 despite fluid resuscitation as the clinical trigger for administration. © 2013 Elsevier Ltd. All rights reserved.


Downing M.G.,Monash University | Downing M.G.,Monash Epworth Rehabilitation Research Center | Stolwyk R.,Monash University | Ponsford J.L.,Monash University | And 2 more authors.
Journal of Head Trauma Rehabilitation | Year: 2013

Background: Previous research has suggested that sexuality is compromised following traumatic brain injury (TBI), but there has been limited comparison with healthy samples. Objectives: The aim of the current study was to compare sexuality in individuals with TBI with that in healthy controls matched for age and gender. In doing this, the current study aimed to characterize those individuals who reported a decrease in sexuality relative to those reporting an increase according to certain demographic and injury variables. Method: A total of 865 participants with predominantly moderate to severe TBI and 142 controls completed the Brain Injury Questionnaire of Sexuality (BIQS), the Hospital Anxiety and Depression Scale, and the Rosenberg Self-Esteem Scale on one occasion. Results: The results indicated that there was a significant difference between participants with TBI and controls on all the BIQS subscales as well as the total score. Age, depression, anxiety, and self-esteem levels significantly differentiated participants with TBI who reported decreased sexuality from those who reported increased sexuality. Participants with TBI attributed sexual changes to various causes - most commonly, fatigue, low confidence, pain, decreased mobility, and feeling unattractive. Conclusions: Further research examining the factors contributing to sexual changes is warranted. Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins.


Bragge P.,National Trauma Research Institute | Gruen R.L.,National Trauma Research Institute | Chau M.,National Trauma Research Institute | Forbes A.,Monash University | Taylor H.R.,University of Melbourne
Archives of Ophthalmology | Year: 2011

Objectives: To examine how mydriasis and the medical qualifications of photographers who take retinal photographs influence the accuracy of screening for diabetic retinopathy (DR). Methods: Our meta-analysis included studies that measured the sensitivity and specificity of tests designed to detect any DR, sight-threatening DR, or macular edema. Using random-effects logistic regression, we examined the effect of variations in mydriatic status and in medical qualifications of photographers on sensitivity and specificity. Results: Only the category of "any DR" had sufficient consistency in definition, number of studies (n=20), and number of assessments (n=40) for meta-analysis. Variations in mydriatic status did not significantly influence sensitivity (odds ratio [OR], 0.89; 95% confidence interval [CI], 0.56-1.41; P=.61) or specificity (OR, 0.94; 95% CI, 0.57-1.54; P=.80). Variations in medical qualifications of photographers did not significantly influence sensitivity (OR, 1.25; 95% CI, 0.31-5.12; P=.75). Specificity of detection of any DR was significantly higher for screening methods that use a photographer with specialist medical or eye qualifications (OR, 3.86; 95% CI, 1.78-8.37; P=.001). Conclusion: Outreach screening is an effective alternative to on-site specialist examination. It has potential to increase screening coverage of high-risk patients with DR in remote and resource-poor settings without the risk of missing DR and the opportunity to prevent vision loss. Our analysis was confined to the presence or absence of DR. Future studies should use consistent DR classification schemes to facilitate further analysis. © 2011 American Medical Association. All rights reserved.


Dahm J.,Monash University | Wong D.,Monash University | Ponsford J.,Monash University | Ponsford J.,Epworth Hospital | Ponsford J.,National Trauma Research Institute
Journal of Affective Disorders | Year: 2013

Background: Anxiety and depression following traumatic brain injury (TBI) are associated with poorer outcomes. A brief self-report questionnaire would assist in identifying those at risk, however validity of such measures is complicated by confounding symptoms of the injury. This study investigated the validity of the Depression Anxiety Stress Scales (DASS) and Hospital Anxiety and Depression Scale (HADS), in screening for clinical diagnoses of anxiety and mood disorders following TBL Methods: One hundred and twenty-three participants with mild to severe TBI were interviewed using the SCID (Axis I) and completed the DASS and HADS. Results: The DASS, DASS2I and HADS scales demonstrated validity compared with SCID diagnoses of anxiety and mood disorders as measured by Area Under ROC Curve, sensitivity and specificity. Validity of the DASS depression scale benefited from items reflecting symptoms of devaluation of life, self- deprecation, and hopelessness that are not present on the HADS. Validity of the HADS anxiety scale benefited from items reflecting symptoms of tension and worry that are measured separately for the DASS on the stress scale. Limitations: Participants were predominantly drawn from a rehabilitation centre which may limit the extent to which results can be generalized. Scores for the DASS2I were derived from the DASS rather than being administered separately. Conclusions: The DASS, DASS2I and HADS demonstrated validity as screening measures of anxiety and mood disorders in this TBI sample. The findings support use of these self-report questionnaires for individuals with TBI to identify those who should be referred for clinical diagnostic follow-up. © 2013 Elsevier B.V. All rights reserved.


Ponsford J.,Monash University | Ponsford J.,Epworth Hospital | Ponsford J.,National Trauma Research Institute | Schonberger M.,Monash University | Schonberger M.,Epworth Hospital
Journal of the International Neuropsychological Society | Year: 2010

Previous studies have documented poor family functioning, anxiety, and depression in relatives of individuals with traumatic brain injury (TBI). However, few studies have examined family functioning over extended periods after injury. The present study aimed to investigate family functioning and relatives emotional state 2 and 5 years following TBI, predictive factors, and their interrelationships. Participants were individuals with TBI and their relatives, with 301 seen at 2 years and 266 at 5 years post-injury. Measures included a Structured Outcome Questionnaire, Family Assessment Device (FAD), Hospital Anxiety and Depression Scale, and the Craig Handicap Assessment and Reporting Technique. Results showed that while the group did not differ greatly in family functioning from a normative group, a significant proportion showed unhealthy functioning across most FAD subscales. Both TBI participants and their relatives showed elevated rates of anxiety and depression. There was little difference between family functioning or relatives anxiety or depression levels at 2 and 5 years post-injury. Path analysis indicated that neurobehavioral changes in the injured individual have an impact on family functioning and distress in relatives even at 5 years post-injury. These findings indicate the need for long-term support of families with a brain-injured member. Copyright © 2010 The International Neuropsychological Society.


Schonberger M.,Monash University | Schonberger M.,Epworth Hospital | Ponsford J.,Monash University | Ponsford J.,Epworth Hospital | Ponsford J.,National Trauma Research Institute
Psychiatry Research | Year: 2010

There is a lack of validated scales for screening for anxiety and depression in individuals with traumatic brain injury (TBI). The purpose of this study was to examine the factor structure of the Hospital Anxiety and Depression Scale (HADS) in individuals with TBI. A total of 294 individuals with TBI (72.1% male; mean age 37.1. years, S.D. 17.5, median post-traumatic amnesia (PTA) duration 17. days) completed the HADS 1 year post-injury. A series of confirmatory factor analyses was conducted to examine the fit of a one-, two- and three-factor solution, with and without controlling for item wording effects (Multi-Trait Multi-Method approach). The one-, two- or three-factor model fit the data only when controlling for negative item wording. The results are in support of the validity of the original anxiety and depression subscales of the HADS and demonstrate the importance of evaluating item wording effects when examining the factor structure of a questionnaire. The results would also justify the use of the HADS as a single scale of emotional distress. However, even though the three-factor solution fit the data, alternative scales should be used if the purpose of the assessment is to measure stress symptoms separately from anxiety and depression. © 2009 Elsevier Ltd.


Whelan-Goodinson R.,Monash University | Ponsford J.L.,Monash University | Ponsford J.L.,National Trauma Research Institute | Schonberger M.,Monash University | Johnston L.,Epworth Hospital
Journal of Head Trauma Rehabilitation | Year: 2010

Objective: To investigate predictors of posttraumatic brain injury psychiatric disorders. Design: Retrospective, cross-sectional design with stratified random sampling of groups of patients on average 1 to 5 years postinjury. DSM-based diagnostic interviews of both traumatic brain injury (TBI) participant and informant. Participants: One hundred community-based participants, aged 19-74 years, with traumatic brain injury sustained 0.05-5.5 years previously. Setting: Community-based patients previously treated at a rehabilitation hospital. Main Measure: The Structured Clinical Interview for DSM-IV diagnosis. Results: A psychiatric history was a high-risk factor for having the same disorder postinjury. However, the majority of cases of depression and anxiety were novel, suggesting that significant factors other than pre-TBI psychiatric status contribute to post-TBI psychiatric outcome. Female gender, lower education, and pain were also associated with postinjury depression and unemployment and older age with anxiety. Conclusion: Findings suggest that long-term screening and support are important for individuals with TBI, regardless of preinjury psychiatric status. © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins.


Frugier T.,National Trauma Research Institute | Conquest A.,National Trauma Research Institute | McLean C.,Alfred Hospital | Currie P.,Monash University | And 2 more authors.
Journal of Neuropathology and Experimental Neurology | Year: 2012

Glial scars that consist predominantly of reactive astrocytes create a major barrier to neuronal regeneration after traumatic brain injury (TBI). In experimental TBI, Eph receptors and their ephrin ligands are upregulated on reactive astrocytes at injury sites and inhibit axonal regeneration, but very little is known about Eph receptors in the human brain after TBI. A better understanding of the functions of glial cells and their interactions with inflammatory cells and injured axons will allow the development of treatment strategies that may promote regeneration. We analyzed EphA4 expression and activation in postmortem brain tissue from 19 patients who died after acute closed head injury and had evidence of diffuse axonal injury and 8 controls. We also examined downstream pathways that are mediated by EphA4 in human astrocyte cell cultures. Our results indicate that, after TBI in humans, EphA4 expression is upregulated and is associated with reactive astrocytes. The expression was increased shortly after the injury and remained activated for several days. EphA4 activation induced under inflammatory conditions in vitro was inhibited using unclustered EphA4 ligand. These results suggest that blocking EphA4 activation may represent a therapeutic approach for TBI and other types of brain injuries in humans. Copyright © 2012 by the American Association of Neuropathologists, Inc.

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