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Intimate Partner Violence and Traumatic Brain Injury: A Public Health Issue

Monahan K. J Neurol Neuromed (2018) 3(3): 3-6
Journal of Neurology & Neuromedicine
Mini Review Open Access
Journal of Neurology & Neuromedicine
Page 3 of 6
Intimate Partner Violence and Traumatic Brain Injury: A Public Health
Kathleen Monahan
School of Social Welfare, Stony Brook University, 10 Bobilin Lane, Rocky Point, NY 11778, USA
Article Info
Article Notes
Received: April 20, 2018
Accepted: June 25, 2018
Director of the Family Violence Education and Research Center
School of Social Welfare, Stony Brook University, 10 Bobilin
Lane, Rocky Point, NY 11778, USA
Telephone: (631) 444-3152
© 2018 Monahan K. This article is distributed under the terms of
the Creative Commons Attribution 4.0 International License
Inmate Partner Violence (IPV) remains at epidemic proporons in the United
States. Traumac Brain Injury (TBI) as an outcome of IPV is now being invesgated by
researchers, parcularly long-term sequelae. This review addresses underreporng
and lack of treatment, and the physical and psychological impact for vicms of IPV
who have received a TBI. Recent research has begun to invesgate professional
sports players who experience repeated concussions and their at-risk status for
Chronic Traumac Encephalopathy (CTE). Women who are in abusive relaonships
for long periods of me may also incur repeated blows to the head. Researching
the at-risk status for CTE is a much needed line of inquiry for this underserved
Intimate Partner Violence (IPV) remains at epidemic proportion
in the United States with over 1 in 3 women experiencing, “…sexual
violence, physical violence, and/or stalking victimization by an intimate
partner during her lifetime”1. The National Intimate Partner and Sexual
Violence Survey (NISVS) as well as other research indicates that one in
four women in the United States experienced severe violence during
her lifetime1-4
         
        
        
players but has been largely overlooked in the female population.
          
         
warranted. Women may spend decades in an abusive relationship where
head injury frequently occurs but is not typically diagnosed or treated.
  
         
       
         
physical violence directed toward a current or former intimate partner.”1
or being shot1. IPV creates long-term health and disability issues for its
victims1-4 
between 2.3 billion and 7.0 billion dollars1,5. Workplace productivity and
absenteeism may also be affected by current and/or past IPV6.
             
the normal function of the brain” as a result from an external force to
the head7
Monahan K. J Neurol Neuromed (2018) 3(3): 3-6 Journal of Neurology & Neuromedicine
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United States77-8
and when factoring in the lack of reporting and/or lack of
treatment, the incidence may be substantially higher7-8.
 
across disciplines as well as individual providers, making
 
interchangeably9. Practitioners may also look at symptom
to guide diagnosis10
assessment and referral for treatment may not occur.
        
      
usually directed at the woman’s face or head creating
   11-17. Mechanic, et
al.18, examined moderate-to-severe injuries among help-
seeking women who experienced IPV and nearly half
reported repeated blows to the head. While women may
seek medical intervention for their injuries and may go
on to leave the abusive relationship, others may not,
        
duration of the relationship18
   
affect psychological and physical outcome as well as social
and familial adjustment.
Identication and Underreporting
Universal Screening of IPV which includes attention
to head injury should occur in all health-care settings3,16.
Additionally, standardized guidelines to identify IPV and
However, this lack of uniformity across the variety of
  
       
immediate medical assistance present complex issues for
the practitioner. Appearing in the medical practitioner’s
       
        
84% of one sample experienced severe injuries, yet only
21% sought medical attention immediately following the
assault despite clinical symptoms15. The patient may not
associate current neurological symptoms with previous
      
current treatment.
Medical attention is not sought for a variety of reasons:
      
costs, lack of insurance, transportation issues, and shame,
resulting in under-reporting and lack of treatment19. When
women do seek treatment, they often attribute the assault
as “a fall down the stairs” thus intervention and safety
issues are not addressed, nor is the injury recorded as an
assault, particularly IPV20,21.
An exploratory study conducted in 1999 of domestic
violence shelter residents14 assessed the incidence of head
done to further this research until recently. Many domestic
violence shelters are only beginning to include questions
        
       
Injury Alliance of Iowa developed a project, along with 10
        
provide them with resources. Of the 148 female individuals
who were screened in 2012, 88 or 60% positively endorsed
 22         
variety of IPV populations,3, 12, 14,23 yet this information has
       
shelter intervention policy14-16. Anecdotal accounts from
shelter residents describe IPV assaults in which their head
was smashed into the dashboard of the car, hit with a closed
14, 16.
Short and long-term sequelae
       
anxiety to constant fear, hypervigilance, confusion,
      
       
present, yet practitioners often confuse the overlapping
   24-25. While comorbidity
        
symptomatology may be overlooked or underestimated.
Additionally, neuropsychiatric symptoms may be attributed
by the healthcare provider and the patient as, “sequelae of
the traumatic experience of IPV, menopause or aging and
do not suspect a connection to head trauma/s sustained in
the past”20.
Long-term outcomes for this population may result
in debilitating impairments. Goldin states, “The most
     
        
reported by women survivors of IPV”16  
26-27. There may also be sex-
      
premenopausal women28.
Monahan K. J Neurol Neuromed (2018) 3(3): 3-6 Journal of Neurology & Neuromedicine
Page 5 of 6
Chronic Traumatic Encephalopathy (CTE)
      
       
       
particularly as they age. However, little is known regarding
     
      
29-30. Individuals in this cohort have been diagnosed
Roberts, et al., described an elderly woman admitted
to the hospital with multiple injuries.31 She suffered years
of physical abuse by her husband and exhibited physical
      
Post-mortem evaluation revealed brain pathology
that, “have only been reported in dementia pugilistica,
      
factor in this case”31   
investigation is whether women who are in long-term,
      
      
       
dialogue regarding brain donation from women who have
      
violence shelter staff and victims highlights this issue.
      
        3,16. It
is reasonable to assume that neurologists are treating
IPV victims without direct knowledge of their trauma
history and therefore not associating symptoms with
sought treatment for head injuries, nor associated their
confusion, and memory loss, by a patient or a family
member, a thorough history of head injuries that include
IPV victimization, should be conducted. It is imperative
that information regarding IPV be gathered without the
batterer present or with a trusted family member. Asking
for this information in front of the batterer will not only
provide false information (the victim will, in all likelihood
– not answer truthfully) but will put the patient at further
risk for violence. It is also important to note that IPV does
not decline with age, so assuming that an older adult’s
abuse is in the past would be erroneous32.
Intake forms that query for IPV as well as previous
head injury create the atmosphere that the healthcare
          
list of local resources should be posted in the examination
       
the county domestic violence shelter, how to contact a
     
       
practices and safety for the IPV population.
Attention to the short and long-term issues of post-
      
safety issues are the primary concern along with the
cessation of IPV. Long-term issues may include attention to
     
      
over from situation to situation. These issues may best be
treated by an interprofessional health care team that can
address neurological, physical, and mental health issues as
well as rehabilitation needs.
Research needs to address the scope of IPV and
         
population to address disability needs. Additionally,
sex and gender equity in research is often overlooked in
    
and the primary rationale for the development of the
SAGER guidelines33      
of various risk factors and the treatment guidelines for
        
male patients”28      
  inquiry and will assist patients
in the process of recovery, adjustment and well-being. The
also needs extensive inquiry.
Purposeful injury to the brain deprives a victim of
individuality and the right to live an independent and
autonomous life. IPV is considered a public health issue yet
it continues to remain at epidemic proportions. Universal
      
serve to identify this public health issue and provide
much-needed secondary prevention. Professional schools
dealing with the health of the public should highlight the
IPV and post-IPV neurological issues. Research should also
We now understand how physical and psychological
traumas, including neglect, affect psychosocial adjustment
and, most importantly, the architecture of the brain.
However, the issues of brain health, brain diseases and
disability emanating from IPV have not been included in
     
        
further research and assist health-care professions to
understand the long-term neurological consequences of
violence toward women in the United States.
Monahan K. J Neurol Neuromed (2018) 3(3): 3-6 Journal of Neurology & Neuromedicine
Page 6 of 6
for her thoughtful review of this manuscript
1.      
Sexual Violence Survey (NISVS): 2010-2012 State Report. Atlanta, GA:
2.           
     
Retrieved from. 2015.
3.         
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31.            
drunk wife. Lancet
32. 
adults: Analysis using data from the National Elder Mistreatment
Study. J. of Interpersonal Vio. 32(3): 311-330.
33.              
Research: Rationale for the SAGER guidelines and recommended use.
Research Integrity and Peer Review
... 12,15,22,29 Research shows that IPV survivors with comorbid TBI and PTSD may describe their health needs as physical and psychological distress. 30,31 Nevertheless, we did not explicitly ask participants if they were traumatized or experiencing any symptoms of PTSD. Shelter-seeking women who have sustained one or more IPV head injuries and screen positive for probable TBI have been traumatized, whether or not they meet clinical diagnostic criteria for PTSD. ...
... Common behavioral symptoms of PTSD, such as avoidance and ambivalence, can be missed, yet, may help explain the rate of anxiety and depression in women with IPV head injuries and poor health outcomes in women with untreated TBI. 15,[31][32][33][34][35] The lifetime rate of exposure to IPV, including sexual violence, physical violence, and stalking, for non-Hispanic black women is estimated to be *45.1%, the rates of primary care and psychological treatment for IVP are much lower. 36 Black women can be less likely to seek or report health care for distressing daily symptoms or IPV-related despair 37 if they are uncertain about the interaction or their care-seeking requires successfully navigating systemic health care barriers and supremacy bias. ...
Background: Unmet health needs of women with head injuries sustained by intimate partner violence (IPV) include risk of traumatic brain injury (TBI). The purpose of this evaluation was to explore the potential effectiveness of TBI screening as a health promotion strategy for shelter-seeking women with IPV head injuries. We wanted to learn if shelter-seeking women, willing to disclose IPV, would accept TBI screening if offered. Methods: An extended version of the HELPS TBI screening tool and survey of daily symptoms and health needs were used to screen new residents of an urban shelter for women. Results: The participants (N = 18) primarily were educated black women with one or more self-reported IPV-related head injury. Most participants (77.8%) had positive TBI screens for probable brain injury. The majority (88.8%) lived with one or more daily symptoms they did not have before sustaining a IPV head injury. The symptoms reported most frequently were depression (88.9%), anxiety (77.8%), and headache (66.7%). All participants had one or more unmet health need. Although most (77.8%) needed to see a primary care provider, mental health care was the most important health need identified. Conclusions: TBI screening could be considered an effective health promotion strategy for IPV survivors if screening facilitates treatment for positive screens and other unmet health needs. Further research is needed to properly assess this.
... The consequences and signs of aggression in the victim vary according to factors such as gender, age, physical constitution and pre-existing pathologies that might influence the consequences of such abuse events [17][18][19][20][21][22][23]. is also common in victims of intimate partner violence. These symptoms can lead the victim to attempt or consummate suicide, as a result of the abuse they were subjected [28,33,34]. ...
... According to the World Health Organization, female victims might also suffer consequences at a reproductive level, with the data pointing out that those who experience intimate partner violence are 1.5 times more likely to develop sexually transmitted diseases and, in some regions of the world, HIV, when compared to women who have never experienced this type of violence[7,24- 26]. Recent studies show high rates of occurrence of brain injuries and traumatic brain injuries, as well as the possibility of spinal injuries[19,22,[27][28][29][30][31][32]. The psychological damages usually occur in the form of post-concussive syndrome (PCL), depression, anxiety, dizziness, insomnia, nightmares, apathy, irritability, fatigue, headaches and memory loss. ...
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“Gender inequality” and “gender-based violence” are paradigms that one hope would be extinct by the 21st Century, two cultural concepts that our society tries to disguise as dated, but that still exist in the form of intimate partner violence (IPV) in developed countries. In this literature review, we will describe IPV as a serious public health issue with high occurrence rates across the world, which requires an urgent implementation of protection and prevention measures. The extensive study of contents resulting from a search with the terms “intimate partner violence”, “domestic violence”, “prevention”, “violence against women”, “abuse”, “IPV” and “crime” allowed us to gather information on preventive measures and integrate updated statistics of the World Health Organization (WHO) and of the Portuguese Association for Victim Support (APAV). The measures of protection and prevention of this type of crimes demand a change of moral and legal behaviours around the globe, as well as the implementation of algorithms of functional performance that can be applied by health professionals at patient-directed services. In this literature review, we will present the “RESPECT”, “AVDR” and “HELP” algorithms. Keywords: “Intimate partner violence”, “domestic violence”, “prevention”, “violence against women”, “abuse”, “crime”, “IPV”, “AVDR”, “RESPECT”, “HELP”.
... The victim may experience substantial fear and shame in relation to reporting their situation and injuries, and may not be forthcoming about the etiology or extent of their symptoms. A victim's financial position may also prevent them from seeking medical care in jurisdictions that do not offer subsidised medical treatment (Monahan, 2018). The behavior of the perpetrator of violence may also prevent a victim from coming forward or seeking medical care. ...
... At present, there are no universal guidelines for healthcare professionals who screen for DV and TBI (Monahan, 2018), though it has been suggested that any clinician who suspects their patient may be subject to DV should attempt to speak with the woman alone in a sensitive manner and in a way in which confidentiality is ensured, the problem is acknowledged and resources and referrals are offered (American Academy of Pediatrics, 1998). An excellent lay resource detailing the encountered issues for those living with TBI can be found at: ...
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Traumatic brain injury (TBI) resulting from episodes of domestic violence (DV) is a serious yet greatly underreported issue. Head injuries arising in these circumstances are often concussive or sub-concussive in nature, and are unlikely to be isolated incidents, with victims frequently suffering repetitive TBIs over time. Although men may also be victims of DV, women and children are most at risk of DV via intimate partners and parents, respectively. Due to the complexities of these interpersonal relationships, victims of DV are not always able to receive appropriate clinical diagnoses, care or follow-up after TBI. TBI arising from DV is also likely to occur in a complex milieu of fear, anxiety and depression, the physical and psychological consequences of which may worsen or perpetuate the pathology of TBI. This review examines the complexities of TBI arising from DV from several perspectives, with focus on three pertinent and interrelated topics: 1) pathobiology and complications of single and repetitive TBI, encompassing direct neural consequences, inflammation and hormonal changes; 2) behavioral, cognitive and psychosocial consequences of TBI; and 3) contributing factors to TBI and complications, including strategies to increase clinician recognition of TBI in DV patients, and programs and policies in place in Australia and abroad to decrease rates of offending.
... There is also some research to suggest that childhood victims of family violence have higher rates of intimate partner violence, 32 which is a common cause of TBI in adulthood. 33 Biological and social responses to physical abuse as a child may differ from other childhood adversities, explaining why alcohol use mediates the relationship between some, but not all, ACEs and TBI. 34 Our results highlight the importance of preventing excessive alcohol consumption, particularly binge drinking, given its strong association between TBI and multiple adverse outcomes. ...
Objective Adverse childhood experiences (ACEs) are associated with increased risk of sustaining a traumatic brain injury (TBI). Alcohol use may play an important role in this relationship. This study examines whether binge drinking mediates the relationship between four ACEs and TBIs sustained in adulthood. Methods Using the National Longitudinal Survey of Youth, 1979 cohort, we conducted longitudinal mediation analyses (n=6317). Interviews occurred annually from 1979 to 1994 and biennially until 2016. We evaluated the direct and indirect effects of individual ACEs (ie, experiencing physical violence, low parental warmth, familial alcoholism and familial mental illness; reported retrospectively) and a cumulative ACEs score on mean level of binge drinking (calculated across waves) and having a TBI in adulthood. To establish temporality, we included binge drinking that was measured at age 18 or older and before any reported TBI. Results Cumulative ACEs, familial alcoholism and physical abuse exposure were significantly associated with having a TBI through binge drinking, although this only explained a small part of the association between ACEs and TBI. Other ACEs were not significantly associated with binge drinking or TBI. Conclusion The results indicate that while ACEs and adult TBI risk were significantly associated, lifetime binge drinking explains only a small part of the association. Future research could examine alternative social, biological and behavioural mechanisms along the pathway between ACEs and TBI. Determining this mechanism will allow public health practitioners to design and implement effective TBI prevention programmes for those at higher risk of injury due to ACE exposure.
... The effects of these changes are complex, and they're associated with alterations in the mitochondrial oxidative metabolism that are a consequence of asphyxia, and can trigger a brain dysfunction and cell lesions. On the other hand, the synaptic dysfunction caused by the depolarization of the membrane and the deficit in the energy metabolism can lead to neuronal death [46][47][48][49][50][51][52][53][54]. ...
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The victims of intimate partner violence are subjected to emotional, physical and/or sexual abuse. The physical abuse often includes episodes of mechanical asphyxia and its most frequent mechanisms: throttling and strangulation. Non-fatal asphyxia situations have signs, symptoms and short-term or long-term consequences whose severity varies according to the intensity, duration and number of episodes. The extensive study of bibliographic contents available at the PubMed platform, which resulted from a search with the terms “intimate partner violence”, “domestic violence”, “strangulation”, “brain injury”, “PTSD”, “non-fatal lesions”, “asphyxia”, “forensic”, “neck compression”, “fatal lesions”, “prevention”, “violence against women” and “crime”, as well as the study of the books “Forensic Pathology”, “Medicolegal Investigation of Death”, “Medicina legal y toxicologia” and “Odontologia legal & antropologia forense” allowed to gather the most recent information on asphyxia in an intimate partner violence context. The typical signs of mechanical asphyxia are abrasions and contusions on the neck, which may or may not be visible, and the most common symptoms are neck pain, swallowing difficulties and sore throat. Among the several consequences, there is the possibility of developing brain injuries that might work to signal a non-fatal intimate partner violence situation or that lead to the victim’s death. The occurrence of asphyxia increases the victim’s likelihood of being murdered in the context of that intimate relationship. Given the severity of this public health issue, it becomes imperative to identify the victims of asphyxia in order to ensure the provision of healthcare and the application of measures of protection and prevention that are adequate to victims and survivors. Keywords: Intimate Partner Violence; Domestic Violence; Asphyxia; Strangulation; Brain Injury; PTSD; Choking; Forensic; Neck Compression; Violence Against Women
... Additionally, it is well known that offenders often have a history of being subjected to domestic violence, 41 and there have been calls for routine screening for interpersonal violence and head injury in all healthcare settings. 42 The high risk of consequent disability deserves widespread attention, including in criminal justice and nonhealthcare community settings. Workers with women subjected to abuse should be trained to screen for SHI and include it in formulation for intervention and support. ...
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Background The prevalence of head injury is estimated to be as high as 55% in women in prison and might be a risk factor for violent offending, but evidence is equivocal. The extent of persisting disability is unknown, making decisions about service needs difficult. The UN recognises vulnerabilities in women in prison, but does not include head injury. This study aimed to investigate relationships among head injury, comorbidities, disability, and offending in women in prison. Methods In this cross-sectional study, women were recruited between Feb 2, 2018, and Sept 30, 2019, from four prisons across Scotland, UK: Her Majesty's Prison (HMP) Cornton Vale, Her Majesty's Young Offenders Institute Polmont, HMP Edinburgh, and HMP Greenock (detaining approximately 355 individuals at the time of recruitment). Women were included if they were aged older than 16 years, fluent in English, able to participate in face-to-face assessment and provide informed consent, and did not have a severe acute disorder of cognition or communication. Head injury, cognition, disability, mental health, and history of abuse and problematic substance use were assessed by interview. History of head injury was assessed with the Ohio State University Traumatic Brain Injury Identification method and disability was assessed with the Glasgow Outcome at Discharge Scale. Comparisons were made between women with and without a history of significant head injury. Findings We recruited 109 (31%) of the 355 women in these prisons. The sample was demographically representative of the approximately 400 individuals in women's prisons in Scotland. Significant head injury (SHI) was found in 85 (78%) of 109 women, of whom 34 (40%) had associated disability. Repeat head injury was reported in 71 (84%) of the 85 women with SHI and, in most cases, this resulted from domestic abuse that had occurred over many years. Women with a history of SHI were significantly more likely to have a history of violent offences than those without a history of SHI (66 [79%] of 85 women in the SHI group vs 13 [54%] of 24 women in the no-SHI group had committed a violent offence; odds ratio [OR] 3·1, 95% CI 1·2–8·1). This effect remained significant after adjusting for current factors (3·1, 1·1–9·0), including comorbidities associated with post-traumatic stress disorder, and was no longer statistically significant after adjusting for historical factors (3·3, 1·0–10·9), such as abuse as a child or adult. Women with SHI had spent longer in prison than women without SHI after adjustment for current (rate ratio 3·4, 1·3–8·4) or historical (3·5, 1·3–9·2) risk factors. Interpretation It is recognised that women in prison are vulnerable because of histories of abuse and problematic substance use; however, history of SHI needs to be included when developing criminal justice policy, interventions to reduce mental health morbidity, and assessment and management of risk of violent offending. Funding The Scottish Government.
... If a TBI or strangulation with alteration in consciousness has occurred within the last 72-96 hours women should be referred to the emergency department or medical professional where a post-concussion and/or strangulation protocol can be administered to ensure there has not been a moderate to severe TBI, or either a carotid dissection or imminent stroke from strangulation, both of which need immediate treatment (Smock & Sturgeon, 2017). In the context of IPV-related TBI, education about the impacts of brain injuries and strangulation should be discussed as part of safety planning including strategies for protecting one's head from perpetrators (e.g., holding arms in an x-shape above her face and head during an assault; Monahan, 2018). Validation of women's experiences and messaging that it is not her fault are critical; victim blaming or minimization of abuse discourages women from seeking help and works to perpetuate her situation (Ivany et al., 2018). ...
Awareness of the highly detrimental and long-term sequelae of brain injuries, and in particular repetitive mild traumatic brain injuries (mTBIs/concussions), has been rapidly growing. Specifically, there has been significant focus on repetitive mTBIs in male athletes and military personnel. Unfortunately, what is likely the largest group of repetitive mTBI sufferers, namely women who experience intimate partner violence (IPV), has received scant attention. Women experiencing IPV sustain both repetitive mTBIs at a high rate and also strangulation-related anoxic/hypoxic brain injuries. Due to biological, psychosocial and trauma-related differences between these women and the (mostly) men who have been studied to date, we cannot generalize what is learned from these studies to women suffering from IPV-related TBIs. Here we summarize some research aimed at understanding the occurrence and sequelae of IPV-related TBIs among various samples (i.e., women in shelters or primary care, from the community, veterans). These data show that IPV-related TBIs are highly prevalent, and associated with a range of negative cognitive and psychological outcomes as well as structural and functional brain connectivity. These associations could not be accounted for by potential confounds (e.g., abuse severity, psychiatric symptoms), making it clear that these negative health outcomes were not merely artifacts of being in an abusive relationship. We highlight gaps in research and provide recommendations for clinical practice. We present ideas for future research to elucidate the mechanisms underlying the associations noted above, in hopes of providing new insights into the links between TBIs and health risks in women who have experienced IPV.
The overwhelming scope and range of negative impacts of IPV are well-documented. Research underscores that IPV victims/survivors most often experience multiple forms of abuse. Mental health professionals are uniquely positioned through their close and confidential relationship with clients to promote a woman's physical and mental health safety. This chapter reviews the prevalence of IPV in general and clinical populations, describes the forms of abuse, and focuses on critical components of clinical care when working with IPV victim/survivors.
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IMPORTANCE Players of American football may be at increased risk of long-term neurological conditions, particularly chronic traumatic encephalopathy (CTE). OBJECTIVE To determine the neuropathological and clinical features of deceased football players with CTE. DESIGN, SETTING, AND PARTICIPANTS Case series of 202 football players whose brains were donated for research. Neuropathological evaluations and retrospective telephone clinical assessments (including head trauma history) with informants were performed blinded. Online questionnaires ascertained athletic and military history. EXPOSURES Participation in American football at any level of play. MAIN OUTCOMES AND MEASURES Neuropathological diagnoses of neurodegenerative diseases, including CTE, based on defined diagnostic criteria; CTE neuropathological severity (stages I to IV or dichotomized into mild [stages I and II] and severe [stages III and IV]); informant-reported athletic history and, for players who died in 2014 or later, clinical presentation, including behavior, mood, and cognitive symptoms and dementia. RESULTS Among 202 deceased former football players (median age at death, 66 years [interquartile range, 47-76 years]), CTE was neuropathologically diagnosed in 177 players (87%; median age at death, 67 years [interquartile range, 52-77 years]; mean years of football participation, 15.1 [SD, 5.2]), including 0 of 2 pre–high school, 3 of 14 high school (21%), 48 of 53 college (91%), 9 of 14 semiprofessional (64%), 7 of 8 Canadian Football League (88%), and 110 of 111 National Football League (99%) players. Neuropathological severity of CTE was distributed across the highest level of play, with all 3 former high school players having mild pathology and the majority of former college (27 [56%]), semiprofessional (5 [56%]), and professional (101 [86%]) players having severe pathology. Among 27 participants with mild CTE pathology, 26 (96%) had behavioral or mood symptoms or both, 23 (85%) had cognitive symptoms, and 9 (33%) had signs of dementia. Among 84 participants with severe CTE pathology, 75 (89%) had behavioral or mood symptoms or both, 80 (95%) had cognitive symptoms, and 71 (85%) had signs of dementia. CONCLUSIONS AND RELEVANCE In a convenience sample of deceased football players who donated their brains for research, a high proportion had neuropathological evidence of CTE, suggesting that CTE may be related to prior participation in football.
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Background:: Sex and gender differences are often overlooked in research design, study implementation and scientific reporting, as well as in general science communication. This oversight limits the generalizability of research findings and their applicability to clinical practice, in particular for women but also for men. This article describes the rationale for an international set of guidelines to encourage a more systematic approach to the reporting of sex and gender in research across disciplines. Methods:: A panel of 13 experts representing nine countries developed the guidelines through a series of teleconferences, conference presentations and a 2-day workshop. An internet survey of 716 journal editors, scientists and other members of the international publishing community was conducted as well as a literature search on sex and gender policies in scientific publishing. Results:: The Sex and Gender Equity in Research (SAGER) guidelines are a comprehensive procedure for reporting of sex and gender information in study design, data analyses, results and interpretation of findings. Conclusions:: The SAGER guidelines are designed primarily to guide authors in preparing their manuscripts, but they are also useful for editors, as gatekeepers of science, to integrate assessment of sex and gender into all manuscripts as an integral part of the editorial process.
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Background: Intimate partner violence (IPV) is the most frequent type of violence against women. We compared clinical and radiological IPV characteristics to stranger assault (SA). Methods: We retrospectively identified 123 women with IPV from court reports and matched them to 124 SA. Clinical and radiological characteristics were evaluated by testing their sensitivity, specificity, positive and negative predictive value for IPV, and the strength of their association with IPV. Results: IPV women referred with more delay to the emergency department (ED), had more ED accesses, and showed more mismatch between reports to the triage and disclosures to the ED physician. They also displayed more head, neck, and face injuries, and new-plus-old fractures. Conclusion: The identification of specific features may help ED physicians to suspect IPV.
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The term “repetitive head impacts” (RHI) refers to the cumulative exposure to concussive and subconcussive events. Although RHI are believed to increase risk for later-life neurological consequences (including chronic traumatic encephalopathy), quantitative analysis of this relationship has not yet been examined because of the lack of validated tools to quantify lifetime RHI exposure. The objectives of this study were: 1) to develop a metric to quantify cumulative RHI exposure from football, which we term the “cumulative head impact index” (CHII); 2) to use the CHII to examine the association between RHI exposure and long-term clinical outcomes; and 3) to evaluate its predictive properties relative to other exposure metrics (i.e., duration of play, age of first exposure, concussion history). Participants included 93 former high school and collegiate football players who completed objective cognitive and self-reported behavioral/mood tests as part of a larger ongoing longitudinal study. Using established cutoff scores, we transformed continuous outcomes into dichotomous variables (normal vs. impaired). The CHII was computed for each participant and derived from a combination of self-reported athletic history (i.e., number of seasons, position[s], levels played), and impact frequencies reported in helmet accelerometer studies. A bivariate probit, instrumental variable model revealed a threshold dose-response relationship between the CHII and risk for later-life cognitive impairment (p < 0.0001), self-reported executive dysfunction (p < 0.0001), depression (p < 0.0001), apathy (p = 0.0161), and behavioral dysregulation (p < 0.0001). Ultimately, the CHII demonstrated greater predictive validity than other individual exposure metrics.
Traumatic brain injury (TBI) is a common chronically debilitating consequence of intimate-partner violence (IPV). Diagnosis and effective treatment are precluded by poor detection and lack of uniform practice guidelines for TBI screening in IPV. Although there are several TBI-screening tools commonly used in clinical and research practices, their applicability to this unique and vulnerable population is unclear. In this review paper, we propose a theoretically based framework for screening for history of TBI in women exposed to IPV and apply it to investigate the applicability of TBI-screening instruments. The framework was developed by examining existing guidelines for working with IPV survivors and applied to evaluate the content of nine currently available TBI screening instruments to determine the extent to which each offers (1) events that can lead to TBI in an IPV situation; (2) safe (without increasing the risk of retaliation) endorsement of an event; and (3) ease of administration. Our evaluation of the currently available TBI-screening tools determined that no instrument met the proposed framework standards and only 2 (Brain Injury Screening Questionnaire and Ohio State University TBI Identification Method) came close, requiring only minor adjustments to meet the postulated criteria. We make specific content and interview-based recommendations for revising TBI screening instruments to minimize the weaknesses of currently available screening tools among women exposed to IPV and the knowledge gaps about TBI in this context. The proposed framework and recommendations are intended to guide future work in this area to enhance the capacity of TBI screening tools to safely detect TBI in this population. Level of Evidence V
Women who receive traumatic brain injuries (TBI) from intimate partner violence (IPV) are gaining attention; however, research studies are lacking in this area. A review of literature conducted on TBI from IPV found prevalence of 60% to 92% of abused women obtaining a TBI directly correlated with IPV. Adverse overlapping health outcomes are associated with both TBI and IPV. Genetic predisposition and epigenetic changes can occur after TBI and add increased vulnerability to receiving and inflicting a TBI. Health care providers and community health workers need awareness of the link between IPV/TBI to provide appropriate treatment and improve the health of women and families.