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Krch D, Lequerica AH, Arango-Lasprilla JC, Corrigan JD. Neurobehavioral Symptoms in Spanish-Speaking Individuals With Subconcussive Injuries. J Head Trauma Rehabil 2024:00001199-990000000-00127. [PMID: 38456793 DOI: 10.1097/htr.0000000000000939] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/09/2024]
Abstract
OBJECTIVE To examine whether exposure to high-risk events causing injury to the head or neck has an effect on neurobehavioral symptoms in the absence of an alteration of consciousness in Spanish-speakers. SETTING Web-based survey. PARTICIPANTS Seven hundred forty-eight individuals from Spain and Latin America, aged 18 to 65 years, with 10 years or more of education. Thirty-nine participants failed quality checks and were excluded. Seven hundred nine participants were included in the analyses. DESIGN Cross-sectional study. Subconcussive exposure was defined as endorsing exposure to one or more high-risk scenarios in the absence of any alteration of consciousness. Three injury groups were derived: No Head Injury, Subconcussive Exposure, and traumatic brain injury (TBI). The Subconcussive Exposure group was further divided into Single and Multiple Exposures. Two analyses were conducted: the effect of lifetime exposure to injury (No Head Injury, Subconcussive Exposure, TBI) on neurobehavioral symptoms; the effect of Subconcussive Exposure Frequency (No Head Injury, Single Exposure, Multiple Exposures) on neurobehavioral symptoms. MAIN MEASURES Spanish Ohio State University Traumatic Brain Injury Identification Method Self-Administered-Brief (OSU TBI-ID SAB); Neurobehavioral Symptom Inventory (NSI). RESULTS There was a significant effect for Injury group on the NSI partial eta-squared (ηp2 = 0.053) and a significant effect of Exposure Frequency group on the NSI (ηp2 = 0.40). Individuals with subconcussive exposures reported significantly more neurobehavioral symptoms than those with no history of head injury and significantly less symptoms than those with TBI. Individuals with multiple subconcussive exposures reported significantly more neurobehavioral symptoms than those with single and no exposure. CONCLUSION This research expands the utility of the OSU-TBI-ID SAB as a lifetime TBI history assessment tool to one capable of evaluating subconcussive exposure dosing effects in Spanish-speakers. Such an index may facilitate establishment of subconcussive exposure prevalence rates worldwide, leading to improved understanding of the chronic effects of high-risk exposures.
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Affiliation(s)
- Denise Krch
- Author Affiliations: Center for Traumatic Brain Injury Research, Kessler Foundation, East Hanover, and Department of Physical Medicine and Rehabilitation, Rutgers, New Jersey Medical School, Newark, New Jersey (Drs Krch and Lequerica); Department of Psychology, Virginia Commonwealth University, Richmond, Virginia (Dr Arango-Lasprilla); and Department of Physical Medicine and Rehabilitation, The Ohio State University, Columbus, Ohio (Dr Corrigan)
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Abbas Q, Zeeshan A, Jawwad M, Moazzam M, Yousafzai M. BIG score and its comparison with different scoring systems for mortality prediction in children with severe traumatic brain injury admitted in pediatric intensive care unit. J Pediatr Neurosci 2023. [DOI: 10.4103/jpn.jpn_16_22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023] Open
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3
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Juengst SB, Perrin PB, Klyce DW, O’Neil-Pirozzi TM, Herrera S, Wright B, Lengenfelder J, Lercher K, Callender L, Arango-Lasprilla JC. Caregiver Characteristics of Adults with Acute Traumatic Brain Injury in the United States and Latin America. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:5717. [PMID: 35565112 PMCID: PMC9102876 DOI: 10.3390/ijerph19095717] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 03/31/2022] [Revised: 04/29/2022] [Accepted: 05/05/2022] [Indexed: 12/04/2022]
Abstract
Objectives: To compare characteristics of caregivers of adults with acute traumatic brain injury (TBI) in the U.S. and Latin America (Mexico and Colombia). Design: Secondary data analysis of two cohorts. Cohort 1: English-speaking caregivers of adults with TBI in the U.S. (n = 80). Cohort 2: Spanish-speaking caregivers of adults with TBI in Mexico or Colombia (n = 109). Results: Similarities between the U.S. and Latin American caregiver groups, respectively, were: predominantly women (81.3%, 81.7%, respectively); spouses/domestic partners (45%, 31.2%); and motor vehicle accident (41.5%, 48.6%) followed by fall etiologies (40%, 21.1%). Differences between U.S. and Latin American caregivers were: age (49.5 years, 41.5 years, p < 0.001); employment status ((Χ52 = 59.63, p < 0.001), full-time employment (63.7%, 25.7%), homemaker (2.5%, 31.2%), and retired (17.5%, 1.8%)); violence-related etiology (2.5%, 15.6%); and severity of depressive symptoms (M = 7.9, SD = 5.8; M = 5.8, SD = 5.7; p = 0.014). Conclusions: TBI caregivers in the U.S. were older and employed full-time or retired more often than those in Latin America. Violence-related etiology was nearly five times more common in Latin America, raising concerns for potential implications of post-traumatic stress and family adjustment after injury. Although both groups likely could use mental health support, this was particularly true of the U.S. cohort, maybe due to differential demographics, mechanisms of injury, or family and community support.
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Affiliation(s)
- Shannon B. Juengst
- Department of Physical Medicine & Rehabilitation, University of Texas Southwestern Medical Center, Dallas, TX 75390, USA; (S.H.); (B.W.)
- TIRR Memorial Hermann Brain Injury Research Center, Houston, TX 77030, USA
- Department of Physical Medicine & Rehabilitation, UT Health Sciences Center at Houston, Houston, TX 77030, USA
| | - Paul B. Perrin
- Department of Psychology, Virginia Commonwealth University, Richmond, VA 23284, USA;
- Department of Physical Medicine and Rehabilitation, Virginia Commonwealth University, Richmond, VA 23284, USA
- Central Virginia Veterans Affairs Health Care System, Richmond, VA 23249, USA;
| | - Daniel W. Klyce
- Central Virginia Veterans Affairs Health Care System, Richmond, VA 23249, USA;
- Virginia Commonwealth University Health System, Richmond, VA 23284, USA
- Sheltering Arms Institute, Richmond, VA 23233, USA
| | - Therese M. O’Neil-Pirozzi
- Department of Physical Medicine and Rehabilitation, Spaulding Rehabilitation Hospital, Boston, MA 02129, USA;
- Department of Communication Sciences and Disorders, Northeastern University, Boston, MA 02115, USA
| | - Susan Herrera
- Department of Physical Medicine & Rehabilitation, University of Texas Southwestern Medical Center, Dallas, TX 75390, USA; (S.H.); (B.W.)
| | - Brittany Wright
- Department of Physical Medicine & Rehabilitation, University of Texas Southwestern Medical Center, Dallas, TX 75390, USA; (S.H.); (B.W.)
| | - Jean Lengenfelder
- Department of Physical Medicine & Rehabilitation, Rutgers-New Jersey Medical School, Newark, NJ 07101, USA;
- Kessler Foundation, East Hanover, NJ 07936, USA
| | - Kirk Lercher
- Department of Physical Medicine & Rehabilitation, JFK Johnson Rehabilitation Institute, Hackensack Meridian Health, Edison, NJ 08820, USA;
| | - Librada Callender
- Baylor Scott & White Institute for Rehabilitation, Dallas, TX 75246, USA;
| | - Juan Carlos Arango-Lasprilla
- BioCruces Bizkaia Health Research Institute, 48903 Barakaldo, Spain;
- IKERBASQUE, Basque Foundation for Science, 48009 Bilbao, Spain
- Department of Cell Biology and Histology, University of the Basque Country, 48940 Leioa, Spain
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Pugh M, Perrin PB, Arango-Lasprilla JC. Predicting caregiver burden over the first 4 months after acute traumatic brain injury in Latin America: a multi-country study. Brain Inj 2021; 35:769-777. [PMID: 33822684 DOI: 10.1080/02699052.2021.1907861] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
Background: Traumatic brain injury (TBI) rates and outcomes are worse in Latin American countries relative to high-income countries. This study examined whether cognitive dysfunction, depressive mood, and poor social and emotional self-regulation in individuals with an acute TBI in Latin America predict longitudinal trajectories of caregiver burden during the first 4 months post-discharge.Method: A sample of 109 caregivers of individuals with a new TBI from Colombia and Mexico completed the observer European Brain Injury Questionnaire before hospital discharge and the Zarit Burden Inventory at the same time and again at 2 and 4 months after discharge. A hierarchical linear model (HLM) was used to assess whether cognitive dysfunction, depressive mood, and poor social and emotional self-regulation at hospital discharge predicted longitudinal trajectories of caregiver burden.Results: Results suggested that burden trajectories decreased over time and men reported higher burden than women. Additionally, results showed that poor patient social and emotional self-regulation predicted higher burden trajectories.Conclusions: Men and caregivers providing care for those experiencing poor social and emotional self-regulation may be at risk for burden. Culturally sensitive interventions focusing on social functioning of individuals with TBI and gender-informed caregiver interventions aimed at burden should be implemented in Latin America.
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Affiliation(s)
- Mickeal Pugh
- Department of Psychology, Virginia Commonwealth University, Richmond, USA
| | - Paul B Perrin
- Department of Psychology, Virginia Commonwealth University, Richmond, USA.,Department of Physical Medicine and Rehabilitation, Virginia Commonweath University, Richmond, USA
| | - Juan Carlos Arango-Lasprilla
- BioCruces Bizkaia Health Research Institute, Cruces University Hospital Barakaldo, Barakaldo, Spain.,IKERBASQUE, Basque Foundation for Science, Bilbao, Spain.,Department of Cell Biology and Histology, University of the Basque Country (UPV/EHU), Bilbao, Spain
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Ohayagha C, Perrin PB, Cariello AN, Arango-Lasprilla JC. Is Helping Really Helping? Health-Related Quality of Life after TBI Predicting Caregiver Depression Symptom Trajectories in Latin America. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2021; 18:ijerph18031247. [PMID: 33573228 PMCID: PMC7908361 DOI: 10.3390/ijerph18031247] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/21/2020] [Revised: 01/20/2021] [Accepted: 01/21/2021] [Indexed: 12/23/2022]
Abstract
Previous research connecting health-related quality of life (HRQoL) in people with traumatic brain injury (TBI) and caregiver mental health has primarily been conducted cross-sectionally in the U.S. and Western Europe. This study, therefore, examined how HRQoL in individuals immediately after their TBI predicts longitudinal caregiver depression symptom trajectories in Latin America. A sample of 109 patients with an acute TBI and 109 caregivers (total n = 218) was recruited from three hospitals in Mexico City, Mexico, and in Cali and Neiva, Colombia. TBI patients reported their HRQoL while they were still in hospital, and caregivers reported their depression symptoms at the same time and at 2 and 4 months later. Hierarchal linear models (HLM) found that caregiver depression symptom scores decreased over time, and lower patient mental health and pain-related quality of life at baseline (higher pain) predicted higher overall caregiver depression symptom trajectories across the three time points. These findings suggest that in Latin America, there is an identifiable relationship between psychological and pain-related symptoms after TBI and caregiver depression symptom outcomes. The results highlight the importance of early detection of caregiver mental health needs based in part upon patient HRQoL and a culturally informed approach to rehabilitation services for Latin American TBI caregivers.
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Affiliation(s)
- Chimdindu Ohayagha
- Department of Psychology, Virginia Commonwealth University, Richmond, VA 23284, USA; (C.O.); (P.B.P.); (A.N.C.)
| | - Paul B. Perrin
- Department of Psychology, Virginia Commonwealth University, Richmond, VA 23284, USA; (C.O.); (P.B.P.); (A.N.C.)
| | - Annahir N. Cariello
- Department of Psychology, Virginia Commonwealth University, Richmond, VA 23284, USA; (C.O.); (P.B.P.); (A.N.C.)
| | - Juan Carlos Arango-Lasprilla
- BioCruces Bizkaia Health Research Institute, 40903 Barakaldo, Spain
- IKERBASQUE, Basque Foundation for Science, 48009 Bilbao, Spain
- Department of Cell Biology and Histology, University of the Basque Country (UPV/EHU), 48940 Leioa, Spain
- Correspondence:
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Silva GS, Maldonado NJ, Mejia-Mantilla JH, Ortega-Gutierrez S, Claassen J, Varelas P, Suarez JI. Neuroemergencies in South America: How to Fill in the Gaps? Neurocrit Care 2020; 31:573-582. [PMID: 31342447 DOI: 10.1007/s12028-019-00775-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
South America is a subcontinent with 393 million inhabitants with widely distinct countries and diverse ethnicities, cultures, political and societal organizations. The epidemiological transition that accompanied the technological and demographic evolution is happening in South America and leading to a rise in the incidence of neurodegenerative and cardiovascular diseases that now coexist with the still high burden of infectious diseases. South America is also quite heterogeneous regarding the existence of systems of care for the various neurological emergencies, with some countries having well-organized systems for some diseases, while others have no plan of action for the care of patients with acute neurological symptoms. In this article, we discuss the existing systems of care in different countries of South America for the treatment of neurological emergencies, mainly stroke, status epilepticus, and traumatic brain injury. We also will address existing gaps between the current systems and recommendations from the literature to improve the management of such emergencies, as well as strategies on how to solve these disparities.
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Affiliation(s)
- Gisele Sampaio Silva
- Department of Neurology and Neurosurgery, Federal University of São Paulo (UNIFESP) and Albert Einstein Hospital, Albert Einstein Street, 627, Suite 218, São Paulo, SP, 05652-900, Brazil.
| | | | | | | | | | | | - Jose I Suarez
- Neurosciences Critical Care, Departments of Anesthesiology and Critical Care Medicine, Neurology, and Neurosurgery, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
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Cariello AN, Perrin PB, Agudelo YR, Olivera Plaza SL, Quijano-Martínez MC, Trujillo MA, Arango-Lasprilla JC. Predictors of longitudinal depression trajectories after traumatic brain injury in Latin America: A multi-site study. NeuroRehabilitation 2020; 46:205-212. [PMID: 32083603 DOI: 10.3233/nre-192972] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND Latin America has exceptionally high rates of traumatic brain injury (TBI), but very little research has been conducted on longitudinal TBI outcomes in this global region. OBJECTIVE This study examined whether cognitive dysfunction and social disadaptation in individuals with TBI in Latin America at hospital discharge predict longitudinal trajectories of depression at baseline, 2 months, and 4 months. METHODS A sample of 109 people with a new TBI was recruited from three hospitals: Mexico City, Mexico, Cali, Colombia and Neiva, Colombia. Participants completed measures of cognitive dysfunction and social disadaptation before hospital discharge and measures of depression at baseline, 2 months, and 4 months. RESULTS Results suggested that depression scores were found to decrease over time in a quadratic (or U-shaped) fashion, and more significant cognitive dysfunction at hospital discharge was associated with higher longitudinal depression trajectories. Social disadaptation did not exert a unique effect on depression trajectories after controlling for cognitive dysfunction. Depression trajectories changed differentially over time as a function of baseline cognitive dysfunction, such that for those with high cognitive impairment, depression scores started high and then dropped to a moderated range and plateaued, but for individuals with low cognitive dysfunction, depression scores started lower and decreased linearly but moderately. CONCLUSIONS The results suggest a strong need for neuropsychological assessments and evidence-based cognitive rehabilitation strategies to be implemented immediately after TBI in Latin America, which could exert salubrious effects on depression trajectories over time.
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Affiliation(s)
| | | | - Yaneth Rodriguez Agudelo
- Department of Neuropsychology, National Institute of Neurology and Neurosurgery, Mexico City, Mexico
| | | | | | | | - Juan Carlos Arango-Lasprilla
- BioCruces Bizkaia Health Research Institute, Cruces University Hospital Barakaldo, Barakaldo, Spain.,IKERBASQUE, Basque Foundation for Science, Bilbao, Spain.,Department of Cell Biology and Histology, University of the Basque Country (UPV/EHU), Leioa, Spain
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Wongchareon K, Thompson HJ, Mitchell PH, Barber J, Temkin N. IMPACT and CRASH prognostic models for traumatic brain injury: external validation in a South-American cohort. Inj Prev 2020; 26:546-554. [PMID: 31959626 DOI: 10.1136/injuryprev-2019-043466] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2019] [Revised: 11/22/2019] [Accepted: 11/25/2019] [Indexed: 02/02/2023]
Abstract
OBJECTIVE To develop a robust prognostic model, the more diverse the settings in which the system is tested and found to be accurate, the more likely it will be generalisable to untested settings. This study aimed to externally validate the International Mission for Prognosis and Clinical Trials in Traumatic Brain Injury (IMPACT) and Corticosteroid Randomization after Significant Head Injury (CRASH) models for low-income and middle-income countries using a dataset of patients with severe traumatic brain injury (TBI) from the Benchmark Evidence from South American Trials: Treatment of Intracranial Pressure study and a simultaneously conducted observational study. METHOD A total of 550 patients with severe TBI were enrolled in the study, and 466 of those were included in the analysis. Patient admission characteristics were extracted to predict unfavourable outcome (Glasgow Outcome Scale: GOS<3) and mortality (GOS 1) at 14 days or 6 months. RESULTS There were 48% of the participants who had unfavourable outcome at 6 months and these included 38% who had died. The area under the receiver operating characteristic curve (AUC) values were 0.683-0.775 and 0.640-0.731 for the IMPACT and CRASH models respectively. The IMPACT CT model had the highest AUC for predicting unfavourable outcomes, and the IMPACT Lab model had the best discrimination for predicting 6-month mortality. The discrimination for both the IMPACT and CRASH models improved with increasing complexity of the models. Calibration revealed that there were disagreement between observed and predicted outcomes in the IMPACT and CRASH models. CONCLUSION The overall performance of all IMPACT and CRASH models was adequate when used to predict outcomes in the dataset. However, some disagreement in calibration suggests the necessity for updating prognostic models to maintain currency and generalisability.
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Affiliation(s)
- Kwankaew Wongchareon
- Adult and Gerontology Nursing, Naresuan University Faculty of Nursing, Phitsanulok, Thailand
| | - Hilaire J Thompson
- Biobehavioral Nursing and Health Informatics, University of Washington, Seattle, Washington, USA
| | - Pamela H Mitchell
- Biobehavioral Nursing and Health Informatics, University of Washington, Seattle, Washington, USA
| | - Jason Barber
- Neurosurgery, University of Washington, Seattle, Washington, USA
| | - Nancy Temkin
- Neurosurgery, University of Washington, Seattle, Washington, USA
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Melatonin as a Therapy for Traumatic Brain Injury: A Review of Published Evidence. Int J Mol Sci 2018; 19:ijms19051539. [PMID: 29786658 PMCID: PMC5983792 DOI: 10.3390/ijms19051539] [Citation(s) in RCA: 33] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2018] [Revised: 05/04/2018] [Accepted: 05/07/2018] [Indexed: 12/15/2022] Open
Abstract
Melatonin (MEL) is a hormone that is produced in the brain and is known to bind to MEL-specific receptors on neuronal membranes in several brain regions. MEL’s documented neuroprotective properties, low toxicity, and ability to cross the blood-brain-barrier have led to its evaluation for patients with traumatic brain injury (TBI), a condition for which there are currently no Food and Drug Administration (FDA)-approved therapies. The purpose of this manuscript is to summarize the evidence surrounding the use of melatonin after TBI, as well as identify existing gaps and future directions. To address this aim, a search of the literature was conducted using Pubmed, Google Scholar, and the Cochrane Database. In total, 239 unique articles were screened, and the 22 preclinical studies that met the a priori inclusion/exclusion criteria were summarized, including the study aims, sample (size, groups, species, strain, sex, age/weight), TBI model, therapeutic details (preparation, dose, route, duration), key findings, and conclusions. The evidence from these 22 studies was analyzed to draw comparisons across studies, identify remaining gaps, and suggest future directions. Taken together, the published evidence suggests that MEL has neuroprotective properties via a number of mechanisms with few toxic effects reported. Notably, available evidence is largely based on data from adult male rats and, to a lesser extent, mice. Few studies collected data beyond a few days of the initial injury, necessitating additional longer-term studies. Other future directions include diversification of samples to include female animals, pediatric and geriatric animals, and transgenic strains.
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Alarcon JD, Rubiano AM, Okonkwo DO, Alarcón J, Martinez‐Zapata MJ, Urrútia G, Bonfill Cosp X. Elevation of the head during intensive care management in people with severe traumatic brain injury. Cochrane Database Syst Rev 2017; 12:CD009986. [PMID: 29283434 PMCID: PMC6486002 DOI: 10.1002/14651858.cd009986.pub2] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
BACKGROUND Traumatic brain injury (TBI) is a major public health problem and a fundamental cause of morbidity and mortality worldwide. The burden of TBI disproportionately affects low- and middle-income countries. Intracranial hypertension is the most frequent cause of death and disability in brain-injured people. Special interventions in the intensive care unit are required to minimise factors contributing to secondary brain injury after trauma. Therapeutic positioning of the head (different degrees of head-of-bed elevation (HBE)) has been proposed as a low cost and simple way of preventing secondary brain injury in these people. The aim of this review is to evaluate the evidence related to the clinical effects of different backrest positions of the head on important clinical outcomes or, if unavailable, relevant surrogate outcomes. OBJECTIVES To assess the clinical and physiological effects of HBE during intensive care management in people with severe TBI. SEARCH METHODS We searched the following electronic databases from their inception up to March 2017: Cochrane Injuries' Specialised Register, CENTRAL, MEDLINE, Embase, three other databases and two clinical trials registers. The Cochrane Injuries' Information Specialist ran the searches. SELECTION CRITERIA We selected all randomised controlled trials (RCTs) involving people with TBI who underwent different HBE or backrest positions. Studies may have had a parallel or cross-over design. We included adults and children over two years of age with severe TBI (Glasgow Coma Scale (GCS) less than 9). We excluded studies performed in children of less than two years of age because of their unfused skulls. We included any therapeutic HBE including supine (flat) or different degrees of head elevation with or without knee gatch or reverse Trendelenburg applied during the acute management of the TBI. DATA COLLECTION AND ANALYSIS Two review authors independently checked all titles and abstracts, excluding references that clearly didn't meet all selection criteria, and extracted data from selected studies on to a data extraction form specifically designed for this review. There were no cases of multiple reporting. Each review author independently evaluated risk of bias through assessing sequence generation, allocation concealment, blinding, incomplete outcome data, selective outcome reporting, and other sources of bias. MAIN RESULTS We included three small studies with a cross-over design, involving a total of 20 participants (11 adults and 9 children), in this review. Our primary outcome was mortality, and there was one death by the time of follow-up 28 days after hospital admission. The trials did not measure the clinical secondary outcomes of quality of life, GCS, and disability. The included studies provided information only for the secondary outcomes intracranial pressure (ICP), cerebral perfusion pressure (CPP), and adverse effects.We were unable to pool the results as the data were either presented in different formats or no numerical data were provided. We included narrative interpretations of the available data.The overall risk of bias of the studies was unclear due to poor reporting of the methods. There was marked inconsistency across studies for the outcome of ICP and small sample sizes or wide confidence intervals for all outcomes. We therefore rated the quality of the evidence as very low for all outcomes and have not included the results of individual studies here. We do not have enough evidence to draw conclusions about the effect of HBE during intensive care management of people with TBI. AUTHORS' CONCLUSIONS The lack of consistency among studies, scarcity of data and the absence of evidence to show a correlation between physiological measurements such as ICP, CCP and clinical outcomes, mean that we are uncertain about the effects of HBE during intensive care management in people with severe TBI.Well-designed and larger trials that measure long-term clinical outcomes are needed to understand how and when different backrest positions can affect the management of severe TBI.
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Affiliation(s)
- Jose D Alarcon
- Iberoamerican Cochrane Network, Surcolombian UniversityNeivaHuliaColombia
| | | | - David O Okonkwo
- Department of Neurological Surgery, University of PittsburghBrain Trauma Research CentreUPMC Presbyterian, Suite B‑400200 Lothrop StreetPittsburghPAUSA15213
| | - Jairo Alarcón
- Universidad del ValleDepartment of PediatricsCaliValle del CaucaColombia760001
| | - Maria José Martinez‐Zapata
- CIBER Epidemiología y Salud Pública (CIBERESP)Iberoamerican Cochrane Centre, Biomedical Research Institute Sant Pau (IIB Sant Pau)Sant Antoni Maria Claret 167Pavilion 18BarcelonaCatalunyaSpain08025
- Equinoccial Technological UniversityCochrane Ecuador. Center for Research in Public Health and Clinical Epidemiology (CISPEC). Eugenio Espejo School of Health SciencesAvenida República de El Salvador 733 y Portugal Edificio Gabriela 3. Of. 403 Casilla Postal 17‐17‐525QuitoEcuador
| | - Gerard Urrútia
- CIBER Epidemiología y Salud Pública (CIBERESP)Iberoamerican Cochrane Centre, Biomedical Research Institute Sant Pau (IIB Sant Pau)Sant Antoni Maria Claret 167Pavilion 18BarcelonaCatalunyaSpain08025
| | - Xavier Bonfill Cosp
- CIBER Epidemiología y Salud Pública (CIBERESP)Iberoamerican Cochrane Centre, Biomedical Research Institute Sant Pau (IIB Sant Pau)Sant Antoni Maria Claret 167Pavilion 18BarcelonaCatalunyaSpain08025
- Universitat Autònoma de BarcelonaSant Antoni Maria Claret, 167Pavilion 18 (D‐13)BarcelonaCatalunyaSpain08025
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Bonow RH, Barber J, Temkin NR, Videtta W, Rondina C, Petroni G, Lujan S, Alanis V, La Fuente G, Lavadenz A, Merida R, Jibaja M, Gonzáles L, Falcao A, Romero R, Dikmen S, Pridgeon J, Chesnut RM. The Outcome of Severe Traumatic Brain Injury in Latin America. World Neurosurg 2017; 111:e82-e90. [PMID: 29229352 DOI: 10.1016/j.wneu.2017.11.171] [Citation(s) in RCA: 43] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2017] [Revised: 11/28/2017] [Accepted: 11/30/2017] [Indexed: 11/30/2022]
Abstract
BACKGROUND Traumatic brain injury (TBI) disproportionately affects lower- and middle-income countries (LMIC). The factors influencing outcomes in LMIC have not been examined as rigorously as in higher-income countries. METHODS This study was conducted to examine clinical and demographic factors influencing TBI outcomes in Latin American LMIC. Data were prospectively collected during a randomized trial of intracranial pressure monitoring in severe TBI and a companion observational study. Participants were aged ≥13 years and admitted to study hospitals with Glasgow Coma Scale score ≤8. The primary outcome was Glasgow Outcome Scale, Extended (GOS-E) score at 6 months. Predictors were analyzed using a multivariable proportional odds model created by forward stepwise selection. RESULTS A total of 550 patients were identified. Six-month outcomes were available for 88%, of whom 37% had died and 44% had achieved a GOS-E score of 5-8. In multivariable proportional odds modeling, higher Glasgow Coma Scale motor score (odds ratio [OR], 1.41 per point; 95% confidence interval [CI], 1.23-1.61) and epidural hematoma (OR, 1.83; 95% CI, 1.17-2.86) were significant predictors of higher GOS-E score, whereas advanced age (OR, 0.65 per 10 years; 95% CI, 0.57-0.73) and cisternal effacement (P < 0.001) were associated with lower GOS-E score. Study site (P < 0.001) and race (P = 0.004) significantly predicted outcome, outweighing clinical variables such as hypotension and pupillary examination. CONCLUSIONS Mortality from severe TBI is high in Latin American LMIC, although the rate of favorable recovery is similar to that of high-income countries. Demographic factors such as race and study site played an outsized role in predicting outcome; further research is required to understand these associations.
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Affiliation(s)
- Robert H Bonow
- Department of Neurological Surgery, University of Washington, Seattle, Washington, USA.
| | - Jason Barber
- Department of Neurological Surgery, University of Washington, Seattle, Washington, USA
| | - Nancy R Temkin
- Department of Neurological Surgery, University of Washington, Seattle, Washington, USA
| | | | | | - Gustavo Petroni
- Hospital de Emergencias Dr. Clemente Alvarez, Rosario, Argentina
| | - Silvia Lujan
- Hospital de Emergencias Dr. Clemente Alvarez, Rosario, Argentina
| | - Victor Alanis
- University Hospital San Juan De Dios, Santa Cruz de la Sierra, Bolivia
| | | | | | | | | | | | - Antonio Falcao
- Universidade Estadual de Campinas, Campinas, São Paulo, Brazil
| | | | - Sureyya Dikmen
- Department of Rehabilitation Medicine, University of Washington, Seattle, Washington, USA
| | - James Pridgeon
- Department of Neurological Surgery, University of Washington, Seattle, Washington, USA
| | - Randall M Chesnut
- Department of Neurological Surgery, University of Washington, Seattle, Washington, USA
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Development of a Severe Traumatic Brain Injury Consensus-Based Treatment Protocol Conference in Latin America. World Neurosurg 2017; 110:e952-e957. [PMID: 29203307 DOI: 10.1016/j.wneu.2017.11.142] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2017] [Revised: 11/22/2017] [Accepted: 11/23/2017] [Indexed: 12/22/2022]
Abstract
BACKGROUND Severe traumatic brain injury (sTBI) is a significant global health problem disproportionately affecting low- and middle-income countries (LMICs). Management of intracranial hypertension in sTBI is crucial to survival and optimal recovery. Practitioners in high-income countries routinely use intracranial pressure (ICP) monitors although their usefulness has been questioned. ICP monitors are usually unavailable in LMICs. No consensus-based/tested protocols or literature exists for sTBI treatment without ICP monitoring. METHODS Investigators developed serial SurveyMonkey surveys for Latin American neurointensivists and neurosurgeons to determine current practice. These clinicians had extensive routine ongoing experience in sTBI without ICP monitoring. Surveys were administered and analyzed before/during/after a 2015 Buenos Aires consensus conference. Investigators identified areas of convergence blinded from colleagues' responses. A 47-clinician task force, representing 15 countries, who routinely manage patients with sTBI without monitors developed consensus-based treatment guidelines during a 3-day facilitated conference. RESULTS Elements were added to the protocol at an 80% agreement threshold. Follow-on surveys resolved remaining elements to 97% agreement. The protocol addresses both tapering (on improvement) and neuroworsening. Staged treatment options were identified, plus unique clinical practice issues. This process introduced a research method to a large multidisciplinary group of LMIC clinicians. This report describes the process used to develop an LMIC-specific protocol that is transferable to other diseases/injuries. The protocol is being tested in 5 LMICs. CONCLUSIONS We derived consensus-based guidelines for sTBI treatment without ICP monitoring, and introduced a research method to a large multidisciplinary group of LMIC clinicians naive to such methods.
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Arango-Lasprilla JC, Olabarrieta-Landa L, Ertl MM, Stevens LF, Morlett-Paredes A, Andelic N, Zasler N. Provider perceptions of the assessment and rehabilitation of sexual functioning after Traumatic Brain Injury. Brain Inj 2017; 31:1605-1611. [DOI: 10.1080/02699052.2017.1332784] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Affiliation(s)
- Juan Carlos Arango-Lasprilla
- BioCruces Health Research Institute, Cruces University Hospital, Barakaldo, Bizkaia, Spain
- IKERBASQUE, Basque Foundation for Science, Bilbao, Spain
| | | | - Melissa M. Ertl
- Division of Counseling Psychology, University at Albany, SUNY, Albany, New York, USA
| | - Lillian Flores Stevens
- Hunter Holmes McGuire Veterans Affairs Medical Center, Richmond, Virginia, USA
- Departments of Psychology, Physical Medicine and Rehabilitation, Virginia Commonwealth University, Richmond, Virginia, USA
| | - Alejandra Morlett-Paredes
- Departments of Psychology, Physical Medicine and Rehabilitation, Virginia Commonwealth University, Richmond, Virginia, USA
| | - Nada Andelic
- Department of Physical Medicine and Rehabilitation, Oslo University Hospital, Ulleval, Norway
- Institute of Health and Society, Research Centre for Habilitation and Rehabilitation Models and Services (CHARM), Faculty of Medicine, University of Oslo, Oslo, Norway
| | - Nathan Zasler
- Concussion Care Centre of Virginia, Ltd., Richmond, Virginia, USA
- Tree of Life Services, Inc., Richmond, Virginia, USA
- Department of Physical Medicine and Rehabilitation, Virginia Commonwealth University, Richmond, Virginia, USA
- Department of Physical Medicine and Rehabilitation, University of Virginia, Charlottesville, Virginia, USA
- Vice-Chairperson of the International Brain Injury Association, Alexandria, VA, USA
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Osier ND, Dixon CE. The Controlled Cortical Impact Model: Applications, Considerations for Researchers, and Future Directions. Front Neurol 2016; 7:134. [PMID: 27582726 PMCID: PMC4987613 DOI: 10.3389/fneur.2016.00134] [Citation(s) in RCA: 106] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2016] [Accepted: 08/02/2016] [Indexed: 12/26/2022] Open
Abstract
Controlled cortical impact (CCI) is a mechanical model of traumatic brain injury (TBI) that was developed nearly 30 years ago with the goal of creating a testing platform to determine the biomechanical properties of brain tissue exposed to direct mechanical deformation. Initially used to model TBIs produced by automotive crashes, the CCI model rapidly transformed into a standardized technique to study TBI mechanisms and evaluate therapies. CCI is most commonly produced using a device that rapidly accelerates a rod to impact the surgically exposed cortical dural surface. The tip of the rod can be varied in size and geometry to accommodate scalability to difference species. Typically, the rod is actuated by a pneumatic piston or electromagnetic actuator. With some limits, CCI devices can control the velocity, depth, duration, and site of impact. The CCI model produces morphologic and cerebrovascular injury responses that resemble certain aspects of human TBI. Commonly observed are graded histologic and axonal derangements, disruption of the blood-brain barrier, subdural and intra-parenchymal hematoma, edema, inflammation, and alterations in cerebral blood flow. The CCI model also produces neurobehavioral and cognitive impairments similar to those observed clinically. In contrast to other TBI models, the CCI device induces a significantly pronounced cortical contusion, but is limited in the extent to which it models the diffuse effects of TBI; a related limitation is that not all clinical TBI cases are characterized by a contusion. Another perceived limitation is that a non-clinically relevant craniotomy is performed. Biomechanically, this is irrelevant at the tissue level. However, craniotomies are not atraumatic and the effects of surgery should be controlled by including surgical sham control groups. CCI devices have also been successfully used to impact closed skulls to study mild and repetitive TBI. Future directions for CCI research surround continued refinements to the model through technical improvements in the devices (e.g., minimizing mechanical sources of variation). Like all TBI models, publications should report key injury parameters as outlined in the NIH common data elements (CDEs) for pre-clinical TBI.
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Affiliation(s)
- Nicole D. Osier
- Department of Acute and Tertiary Care, University of Pittsburgh School of Nursing, Pittsburgh, PA, USA
- Safar Center for Resuscitation Research, Pittsburgh, PA, USA
| | - C. Edward Dixon
- Safar Center for Resuscitation Research, Pittsburgh, PA, USA
- Department of Neurosurgery, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
- VA Pittsburgh Healthcare System, Pittsburgh, PA, USA
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Postdischarge Care of Pediatric Traumatic Brain Injury in Argentina: A Multicenter Randomized Controlled Trial. Pediatr Crit Care Med 2016; 17:658-66. [PMID: 27243414 PMCID: PMC4938734 DOI: 10.1097/pcc.0000000000000772] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To develop, in partnership with families of children with traumatic brain injury, a postdischarge intervention that is effective, simple, and sustainable. DESIGN Randomized Controlled Trial. SETTING Seven Level 1 Pediatric Trauma Centers in Argentina. PATIENTS Persons less than 19 years of age admitted to one of the study hospitals with a diagnosis of severe, moderate, or complicated mild traumatic brain injury and were discharged alive. INTERVENTIONS Patients were randomly assigned to either the intervention or standard care group. A specially trained Community Resource Coordinator was assigned to each family in the intervention group. We hypothesized that children with severe, moderate, and complicated mild traumatic brain injury who received the intervention would have significantly better functional outcomes at 6 months post discharge than those who received standard care. We further hypothesized that there would be a direct correlation between patient outcome and measures of family function. MEASUREMENTS AND MAIN RESULTS The primary outcome measure was a composite measured at 6 months post injury. There were 308 patients included in the study (61% men). Forty-four percent sustained a complicated mild traumatic brain injury, 18% moderate, and 38% severe. Sixty-five percent of the patients were 8 years old or younger, and over 70% were transported to the hospital without ambulance assistance. There was no significant difference between groups on the primary outcome measure. There was a statistically significant correlation between the primary outcome measure and the scores on the Family Impact Module of the Pediatric Quality of Life Inventory (ρ = 0.57; p < 0.0001). Children with better outcomes lived with families reporting better function at 6 months post injury. CONCLUSIONS Although no significant effect of the intervention was demonstrated, this study represents the first conducted in Latin America that documents the complete course of treatment for pediatric patients with traumatic brain injury spanning hospital transport through hospital care and into the postdischarge setting.
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Bhatti J, Stevens K, Mir M, Hyder AA, Razzak J. Emergency care of traumatic brain injuries in Pakistan: a multicenter study. BMC Emerg Med 2015; 15 Suppl 2:S12. [PMID: 26691277 PMCID: PMC4682387 DOI: 10.1186/1471-227x-15-s2-s12] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023] Open
Abstract
Background This study assessed factors associated with emergency care outcomes and out-of-pocket treatment costs in traumatic brain injury (TBI) patients in Pakistan. Methods Data on TBI patients were extracted from a four-month surveillance study conducted in the emergency departments (ED) of seven large teaching hospitals. Emergency care access to physicians and imaging facilities were compared with respect to ED outcomes (discharged, admitted or dead). Out-of-pocket treatment costs (in United States dollars [USD]) were compared among different patient strata. Results ED outcomes were available for 1,787 TBI patients. Of them, most were males (79%), aged <25 years (46%) and arrived by ambulances (32%). Nurses or paramedical staff saw almost all patients (95%). Physicians with practice privileges (medical officers, residents or consultants) saw about half (55%) of them. Computerized tomography (CT) scans were performed in two of five patients (40%). Of all, 26% (n = 460) were admitted and 3% died (n = 52). Emergency care factors significantly associated with being admitted or died were arriving by ambulance (adjusted odds ratio [aOR] = 2.37, 95% confidence interval (CI) [95%CI] = 1.78-3.16); seen by medical officer/residents (aOR = 2.11; 95%CI = 1.49-2.99); and had CT scan (aOR = 2.93; 95%CI = 2.25-3.83). Out-of-pocket treatment costs at the ED were reported in 803 patients. Average costs were USD 8, (standard deviation [SD] = 23). Costs were twice as high in those arriving in ambulances (USD 20, SD = 49) or who underwent CT scans (USD 16, SD = 37). Conclusion TBI patients' access to ambulance transport, experienced physicians, and imaging facilities during emergency care needs to be improved in Pakistan.
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Abstract
The characteristics of neurological, psychiatric, developmental and substance-use disorders in low- and middle-income countries are unique and the burden that they have will be different from country to country. Many of the differences are explained by the wide variation in population demographics and size, poverty, conflict, culture, land area and quality, and genetics. Neurological, psychiatric, developmental and substance-use disorders that result from, or are worsened by, a lack of adequate nutrition and infectious disease still afflict much of sub-Saharan Africa, although disorders related to increasing longevity, such as stroke, are on the rise. In the Middle East and North Africa, major depressive disorders and post-traumatic stress disorder are a primary concern because of the conflict-ridden environment. Consanguinity is a serious concern that leads to the high prevalence of recessive disorders in the Middle East and North Africa and possibly other regions. The burden of these disorders in Latin American and Asian countries largely surrounds stroke and vascular disease, dementia and lifestyle factors that are influenced by genetics. Although much knowledge has been gained over the past 10 years, the epidemiology of the conditions in low- and middle-income countries still needs more research. Prevention and treatments could be better informed with more longitudinal studies of risk factors. Challenges and opportunities for ameliorating nervous-system disorders can benefit from both local and regional research collaborations. The lack of resources and infrastructure for health-care and related research, both in terms of personnel and equipment, along with the stigma associated with the physical or behavioural manifestations of some disorders have hampered progress in understanding the disease burden and improving brain health. Individual countries, and regions within countries, have specific needs in terms of research priorities.
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Abstract
Traumatic injury to the brain or spinal cord is one of the most serious public health problems worldwide. The devastating impact of 'trauma', a term used to define the global burden of disease related to all injuries, is the leading cause of loss of human potential across the globe, especially in low- and middle-income countries. Enormous challenges must be met to significantly advance neurotrauma research around the world, specifically in underserved and austere environments. Neurotrauma research at the global level needs to be contextualized: different regions have their own needs and obstacles. Interventions that are not considered a priority in some regions could be a priority for others. The introduction of inexpensive and innovative interventions, including mobile technologies and e-health applications, focused on policy management improvement are essential and should be applicable to the needs of the local environment. The simple transfer of a clinical question from resource-rich environments to those of low- and middle-income countries that lack sophisticated interventions may not be the best strategy to address these countries' needs. Emphasis on promoting the design of true 'ecological' studies that include the evaluation of human factors in relation to the process of care, analytical descriptions of health systems, and how leadership is best applied in medical communities and society as a whole will become crucial.
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Cerecedo-López CD, Kim-Lee JH, Hernandez D, Acosta SA, Borlongan CV. Insulin-associated neuroinflammatory pathways as therapeutic targets for traumatic brain injury. Med Hypotheses 2014; 82:171-4. [PMID: 24332562 PMCID: PMC3915295 DOI: 10.1016/j.mehy.2013.11.028] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2013] [Revised: 11/14/2013] [Accepted: 11/23/2013] [Indexed: 01/04/2023]
Abstract
Traumatic brain injury (TBI) is characterized by an abrupt blow or exchange of force against the head and can be categorized as mild, moderate, and severe. The secondary cell death after TBI displays ischemic-like patterns including neuroinflammation. The scavenger receptor cluster of differentiation (CD) 36 is a lipid-associated protein capable of transducing intracellular signals to promote inflammatory mechanisms within different cell types. Expression and activation of CD36 is closely related to dyslipidemia secondary to diabetes. Diabetes mellitus (DM) has been documented as a co-morbidity factor in TBI, in that patients with a history of diabetes present with more severe brain damage and slower recovery from TBI than non-diabetic patients. Indeed, a strict regulation of blood serum glucose by the use of insulin promotes a better outcome for TBI patients. Based on these recent findings, we now advance the hypothesis that CD36 via DM insulin-associated pathways is closely involved in TBI chronic pathology.
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Affiliation(s)
- Christian D Cerecedo-López
- Departamento de Neuroinmunología, Facultad de Ciencias de la Salud, Universidad Anáhuac México Norte, Estado de México, Mexico; Center of Excellence for Aging and Brain Repair, Department of Neurosurgery and Brain Repair, University of South Florida College of Medicine, Tampa, FL, USA
| | - Jennifer H Kim-Lee
- Departamento de Neuroinmunología, Facultad de Ciencias de la Salud, Universidad Anáhuac México Norte, Estado de México, Mexico; Center of Excellence for Aging and Brain Repair, Department of Neurosurgery and Brain Repair, University of South Florida College of Medicine, Tampa, FL, USA
| | - Diana Hernandez
- Center of Excellence for Aging and Brain Repair, Department of Neurosurgery and Brain Repair, University of South Florida College of Medicine, Tampa, FL, USA
| | - Sandra A Acosta
- Center of Excellence for Aging and Brain Repair, Department of Neurosurgery and Brain Repair, University of South Florida College of Medicine, Tampa, FL, USA
| | - Cesar V Borlongan
- Center of Excellence for Aging and Brain Repair, Department of Neurosurgery and Brain Repair, University of South Florida College of Medicine, Tampa, FL, USA.
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Alarcon JD, Rubiano AM, Okonkwo DO, Urrútia G, Bonfill Cosp X. Elevation of the head during intensive care management in patients with severe traumatic brain injury. Hippokratia 2012. [DOI: 10.1002/14651858.cd009986] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Affiliation(s)
- Jose D Alarcon
- Iberoamerican Cochrane Network. IIB-Sant Pau. Surcolombian University; San Antoni Ma Claret 171 Casa de Convalescència Barcelona Barcelona Spain 08041
| | - Andres M Rubiano
- Neiva University Hospital; Department of Neurosurgery and Critical Care; Calle 5 # 11 - 19 MEDITECH Neiva Huila Colombia
| | - David O Okonkwo
- Department of Neurological Surgery, University of Pittsburgh; Brain Trauma Research Centre; UPMC Presbyterian, Suite B‑400 200 Lothrop Street Pittsburgh PA USA 15213
| | - Gerard Urrútia
- CIBER Epidemiología y Salud Pública (CIBERESP), Spain; Iberoamerican Cochrane Centre - IIB Sant Pau; c/ Sant Antoni Maria Claret 171 Barcelona Spain 08041
| | - Xavier Bonfill Cosp
- CIBER Epidemiología y Salud Pública (CIBERESP), Spain - Universitat Autònoma de Barcelona; Iberoamerican Cochrane Centre - Institute of Biomedical Research (IIB Sant Pau); Sant Antoni M. Claret 171 Casa de Convalescència Barcelona Catalonia Spain 08041
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