5Mittler-MaticaRoxana_OnTraumatic Romanian Neurosurgery (2015) XXIX (XXII) 1: 43 - 50 43 On traumatic brain injury epidemiological data collected from a county hospital in Romania and an estimation of psychiatric consequences thereof Roxana Mittler-Matica PhD Student in Medicine, University of Oradea, Romania Neurosurgery Resident, Neurochirurgische Klinik, Städtisches Klinikum Braunschweig, Germany Abstract: Introduction: Many aspects justify the increasing attention upon TBI and post TBI sequels. Material and Methods: The paper resumes statistics on traumatic brain injury (TBI) from a Romanian country district, collected throughout five years. Statistics in the literature that demonstrated the link between TBI and psychiatric disorders are extrapolated. Results: TBI is considered to be a risk factor for psychiatric disorders. As consequence, estimation of some post TBI psychiatric sequels is computed aiming to emphasize the need for psychiatric support and treatment in more organized multidisciplinary neuro-trauma management teams. Conclusions: TBI is considered to be a risk factor for psychiatric disorders which are a major cause of post TBI disability. The size of these psychiatric sequels in accordance with the existing literature can be approximated in a given population. TBI epidemiology analysis reveals hazardous impact on the overall health condition of patients. Key words: psychiatric sequels, aetiology. Introduction Traumatic brain injury (TBI) has been identified and established as a real public health problem. It is shown that approximately 6.6% results in death in the case of TBI patients, of which 91.4% less than 7 days after TBI. [1] A percentage of 3.5% to 4% of TBI cases of all patients who have survived a TBI, are followed by permanent disability with socio-economic impact, most of these cases involving psychiatric disabilities. [2] Corroborating recent data, it is found that every two minutes one EU citizen dies of an injury and annually approximately one million EU people remain permanently disabled due to an injury, [3] most of which are TBI. In the geographical area targeted by our paper (i.e. Bihor county, Romania), it was determined a ratio of 1/5 of the incidence of severe TBI versus moderate TBI, for 44 Mittler-Matica TBI epidemiological data collected from a county hospital in Romania hospitalized patients, and 1/22 of the moderate TBI versus uncomplicated TBI. [6] It is known that a psychiatric sequel post TBI can occur even after a longer period of time. [4] Establishing a causal relationship between psychiatric disorders and TBI is especially important for understanding the pathophysiology of such possible sequels, in order to treat these diseases. Also, it contributes to understand the pathogenesis and define the causality of mental suffering in general. If the psychiatric disorders highlight the causes of psychiatric morbidity, this should alert physicians to consider the TBI- psychiatric sequel causality and to try to prevent such consequences. Such a finding regarding causality would be more important in the case of legal disputes concerning the consequences of TBI compared to simple situations when an individual presents only post TBI motor difficulties. Frequently reported, psychiatric disorders after TBI are greater than on general population and prospective follow-up studies have found that the most common post TBI psychiatric disorders are depression and anxiety, although the causality association remains unclear. [5] The occurrence of generalized anxiety disorder was associated with post TBI greater physical and emotional problems, with negative impact on the active role in social life and general health. Numerous definitions and measures were used to assess "successful outcome" of TBI treatment, including return to work or social functional recovery.[4; 5] The result of the treatment is multi-dimensional and complex and cannot be comprehensively understood by a single score achieved on certain scales (such as the Glasgow outcome scale). Causality of psychiatric sequel after TBI is not fully elucidated. Approaches to explaining the causality could account on the high incidence of somatic sequels after TBI. In order to improve the outcome after TBI, it is important to have an overview of epidemiological data on TBI and their psychiatric impact. The analysis of locally adapted epidemiological data provides the opportunity to form a more realistic idea of the size of the studied pathology and guides the clinician in the decision making for treatments. Therefore an epidemiological analysis of TBI, in a given district and correlation with data from the literature on the psychiatric consequences of post TBI, both provide an overview of the pathological phenomenon in question. Material and Methods This paper presents the analyze of TBI cases in the Bihor county, Romania, reported in the city of Oradea, at Emergency Regional Hospital, for 5 years along. It consists of a retrospective study on demographic and clinical data. It was followed parameters like TBI etiology, patient age, health status at discharge... All patients treated in the neuro- surgery department of this county hospital, on which a chart of the patient was drawn, were included in statistics. Data processing method involved coding information in a database and then processed in Excel management database (for each year a file was filled in, and the years submitted for analysis are 2005, 2006, 2007, 2008 and 2009). Romanian Neurosurgery (2015) XXIX (XXII) 1: 43 - 50 45 Results Various diagrams are presented below by means of which we intend to highlight the evolution of TBI casuistry, reported at Emergency Regional Hospital, Bihor County, and various characteristics of their prevalence and incidence. The total number of TBI cases varied over the five years, [6] see Table 1. The number of patients, diagnosed with TBI, reported in rural versus urban area is balanced, Table 1. Analysis by gender, shown in Table 2, highlights the following observation: women represent a smaller percentage of cases, compared with men. TABLE 1 Patients diagnosed with TBI, reported in rural versus urban residential area Year 2005 2006 2007 2008 2009 All patients 608 603 628 640 597 Rural 261 250 269 322 306 Urban 347 353 359 318 291 TABLE 2 Number of patients by gender, admitted to the neurosurgery department of the county hospital, diagnosed with TBI Year 2005 2006 2007 2008 2009 All patients 608 603 628 640 597 Men 405 397 432 456 412 Women 203 206 196 184 185 Computing the association of TBI with multiple trauma (since it complicate the treatment and may be marks of more important lesions), for 2005, the percentage is 4.23% from TBI total cases, for 2006 the percentage is 3.98%, for 2007 the percentage is 15.29%, for 2008 the percentage is 5.78% and for 2009 it is 1.84%. The number of post TBI deaths is relatively small, so per each year the percentages of TBI fatal cases were as follows: 2.96%; 2.82%; 3.98%; 4.36%; 4.52%. The distribution of cases by the TBI in relation with age was determined for the age groups, according to the following data, as shown in Table 3. The etiology of TBI has a diversified distribution, as shown in Table 4. The association with alcoholism is of interest because of the increased susceptibility regarding those patients to be victims of accidents and incidents with cerebral adverse consequences. The percentage of those patients with alcoholism is about 7%, for the five years studied. The alcoholism is a risk factor for TBI (p=0.1) and the evolution of patient after TBI treatment is not favorable (p=0.05). Analyzing the patients’ post TBI health condition at discharge from hospital, we find several patients with post traumatic deficits, especially neuro-motor deficit, see table 5 below. The favorable development is conventionally defined as an intact neurological status. 46 Mittler-Matica TBI epidemiological data collected from a county hospital in Romania TABLE 3 Distribution of TBI cases by age groups year: 2005 2006 2007 2008 2009 aged < 1 year 0 1 0 4 3 aged 1 to 4 3 5 10 14 18 aged 5 to 14 old 36 39 27 32 30 aged15 to 18 62 63 48 54 38 aged 18 to 24 59 54 45 45 31 aged 25 to 34 83 76 92 73 76 aged 35 to 54 81 69 94 82 66 aged 45 to 54 86 87 94 105 92 aged 55 to 64 82 80 99 79 87 aged 65 to 74 55 62 67 84 83 aged 75 to 84 52 59 41 54 61 aged > 85 9 8 11 14 12 all patients 608 603 628 640 597 TABLE 4 Etiology of TBI, for whole time analyzed (%) Aetiology 2005 2006 2007 2008 2009 accidentally hitting with a blunt object 7.50% 7.30% 11.20% 8.80% 7.03% traffic accidents 9.10% 8.60% 12.60% 6.70% 16.42% fall from same level 53% 60% 43.60% 61.60% 39.87% fall from height 12.40% 8.50% 5.40% 4.10% 0.84% aggression 11.60% 9.30% 12.90% 9.20% 10.55% unspecified 5.40% 5.30% 8.30% 5.90% 20.26% fall from bike 0.50% 0.70% 3% 2.80% 2.68% horse kick 0.50% 0.30% 0.30% 0.20% 0.00% fall from tram 0.00% 0.00% 0.50% 0.00% 0.00% fall from motorcycle 0.00% 0.00% 1.40% 0.00% 0.00% sports accident 0.00% 0.00% 0.00% 0.20% 1.51% accident at work 0.00% 0.00% 0.00% 0.50% 0.84% Romanian Neurosurgery (2015) XXIX (XXII) 1: 43 - 50 47 TABLE 5 Patients post TBI health status at discharge from hospital, concerning patients with TBI (%) Patients health status 2005 2006 2007 2008 2009 improved 2.06% 1.91% 1.84% 6.41% 87.60% slow progressive 84.39% 85.03% 82.03% 84.84% 4.36% favorable development 7.63% 7.48% 7.22% 4.06% 1.84% surgical intervention healed 0.93% 0.32% 3.84% 1.09% 1.51% transferred to another hospital 0.52% 0.64% 0.61% 0.47% 0.50% discharged on request 3.92% 3.98% 3.84% 2.81% 3.85% deficit neuro-motor 0.55% 0.64% 0.61% 0.31% 0.34% TABLE 6 Number of deaths per year (during 2005-2009) Year Number of severe TBI Number of deaths Deaths in total patients with severe TBI (%) Total number patients with TBI Deaths in total patients with TBI (%) 2005 98 18 18.37% 608 2.96% 2006 95 17 17.89% 603 2.82% 2007 83 25 30.12% 628 3.98% 2008 74 26 35.14% 640 4.36% 2009 63 27 42.86% 597 4.52% Discussions Traumatic brain TBI is a significant cause of hospitalizations and remains a major cause of death, especially in the case of young people. The highest number of patients with TBI is included in this age group, i.e. aged 15 to 24 years old, see Fig.1, (per each year of the five years study time span, i.e. 2005-2009). The number of deaths in patients who have had TBI is shown in Table 6. The probability of survival after severe TBI, considering the first 7 days (the majority of deaths occurred in this period) is represented in the Figure 2 below, considering Kaplan- Meier method, (after one day 94.18% of patients survive having severe TBI, 89.35% after two days, after three days the rate of survival was 84.99%, and 81.84% after another day). The mortality graph, after severe TBI, is represented in Figure 3 below (after the first day 5.82% of the patients with severe TBI deceased, 10.65% deceased after two days, with a daily death rate increase as follows: 15.01%; 18.16%; 20.82%; 23.24%; 25.42%; 27.36%). The percentage of total number of deaths, recorded after the first seven days from a severe TBI, was 7.08%. A TBI case may have devastating consequences. [7- 10] 48 Mittler-Matica TBI epidemiological data collected from a county hospital in Romania Figure 1 - TBI cases number of patients aged 15 to 24 years old (days) Figure 2 - Graph of survival after severe TBI (Kaplan-Meier curve) (days) Figure 3 - Graph on mortality after severe TBI (Kaplan-Meier curve) Most post TBI disability involves psychiatric disorders. For example about 70% of cases were followed by a post TBI depression. Among post TBI psychiatric disorders, one could list the following ones (see Table 7 below): major depression in more than 14% of TBI cases; bipolar disorder in more than 2% (and up to 17%) of the TBI cases; generalized anxiety disorder in more than 3% (and up to 28%) of the TBI cases; panic disorder in more than 4% of the TBI cases; phobic disorders in more than 1% TBI cases; obsessive-compulsive disorder in more than 2% TBI cases; post-traumatic stress disorder (PTSD) in more than 3% TBI cases; substance abuse or dependency in more than 5% of patients who have suffered a TBI, and schizophrenia in about 1% of TBI cases. [4, 10] It is shown [10] that the headaches occur in more than 25% (up to 90%) of TBI cases; dizziness or vertigo, as the second incidence of sequel after TBI, has been reported to occur in more than 24% (up to 78%) of TBI cases; sleep disorders or drowsiness in up to 73% of TBI cases, compared with 32% in the general population. Tiredness was reported in up to 73% of patients who have suffered a TBI, [10] with negative implications for social integration, activities, productivity and quality of life. Considering the number of patients with post TBI psychiatric sequels or other post TBI health problems, and based on this epidemiological data of the patients from Bihor county treated in the Emergency Regional Hospital, the expected number of patients presenting post TBI psychiatric sequels was estimated, see Table 7 below. 113 107 93 97 69 608 603 628 640 597 0 100 200 300 400 500 600 700 1 2 3 4 5 Romanian Neurosurgery (2015) XXIX (XXII) 1: 43 - 50 49 TABLE 7 Estimates on the number of patients with possible post TBI psychiatric sequels or other post TBI health problems, based on the literature Name of post TBI disorder Specified percentage value Estimated number of possible patients post TBI sleep disorders and sleepiness 41% 1011 post TBI tiredness 73% 1,801 post TBI migraine (headaches) 25% 617 post TB vertigo I 24% 592 post TBI depression 70% 1,827 post TBI major depression 14% 345 post TBI bipolar disorder 2% 49 post TBI generalized anxiety disorder 3% 74 post TBI panic disorder 4% 98 post TBI phobic disorders 1% 24 post TBI obsessive-compulsive 2% 49 post TBI PTSD (Post Traumatic Stress Disorder) 3% 74 post TBI substance dependence 5% 123 post TBI schizophrenia 1% 24 The estimated total number of TBI psychiatric sequel or other post TBI health problems is more than 6700 new cases. In various studies, [3; 7] the causality (though less explicit in pathophysiological mechanisms) between TBI and some psychiatric disorders was proved. The neuro psychiatric consequences of TBI are numerous in terms of life quality impact or results at workplace e.g. return to job when compared to others disorders; therefore the prevention, rapid detection and effective treatment are highly recommended. [7; 8] At the moment, there is no standard psychiatric management algorithm for acute and sub-acute TBI. So far, this study aimed to emphasize the importance of psychiatric component in the treatment of traumatic brain injury (TBI). Correspondence Roxana Mittler-Matica e-mail: roxana.mittler-matica@live.de References 1. BHR Pharma, Traumatic Brain Injury Fact Sheet. BHR Pharma, A Besisa Healtcare Company, May, 2012. 2. Bryant R, et all, The psychiatric sequelae of Traumatic Injury. Am. Journal Psychiatry, 2010 , 167:312-3. 3. EuroSafe, Summary of injury statistics for the year 2008-2010. European Association for Injury Prevention and Safety Promotion (EuroSafe), Injuri in the EU. 2012, Rijswijkstraat 2, 1059 GK Amsterdam, The Netherlands, ISBN: 978-90-6788-464-8. 50 Mittler-Matica TBI epidemiological data collected from a county hospital in Romania 4. Hall EC, Lund E, Brown D, Murdock KR, Gettings L, Scalea TM, Stein DM, How are you really feeling? A prospective evaluation of cognitive function following trauma. J. Trauma Acute Care Surg., 2014, Mar; 76(3):859-64; discussion 864-5. doi: 10.1097/TA.0000000000000148. 5. http://www.cdc.gov/ncipc/pub- res/tbi_congress/01_executive_summary.htm 6. Matica Roxana, Actualităţi ȋn traumatismele cranio cerebrale. Lucrare de licenţă, Universitatea din Oradea, 2010, Romania. 7. Sansonetti D, Hoffmann T, Cognitive assessment across the continuum of care: the importance of occupational performance-based assessment for individuals post-stroke and traumatic brain injury. Aust. Occup. Ther. J., Oct; 60(5):334-42. doi: 10.1111/1440- 1630.12069. Epub. 2013, Sep. 1. 8. Schwarzbold M, 2008, Psychiatric Disorders and Traumatic Brain Injury. Neuropsychiatric Disease and Treatment, 4 (4) 797-816. 9. Sommer JB, Norup A, Poulsen I, Mogensen J, Cognitive activity limitations one year post-trauma in patients admited to sub-acute rehabilitation after severe traumatic brain injury. Rehabil. Med., 2013, 45: 778–784. 10. Whelan-Goodison R, Ponsford J, Schonberger M, Association between Psychiatric States Following traumatic brain injury and outcome. Journal Rehabil. Med., 2008, 40:850-85.