An Initial miRNA Profile of Persons With Persisting Neurobehavioral Impairments and States of Disordered Consciousness After Severe Traumatic Brain Injury

OBJECTIVE

To examine the merits of using microRNAs (miRNAs) as biomarkers of disorders of consciousness (DoC) due to traumatic brain injury (TBI).

SETTINGS

Acute and subacute beds.

PARTICIPANTS

Patients remaining in vegetative and minimally conscious states (VS, MCS), an average of 1.5 years after TBI, and enrolled in a randomized clinical trial ( n = 6). Persons without a diagnosed central nervous system disorder, neurotypical controls ( n = 5).

DESIGN

Comparison of whole blood miRNA profiles between patients and age/gender-matched controls. For patients, correlational analyses between miRNA profiles and measures of neurobehavioral function.

MAIN MEASURES

Baseline measures of whole blood miRNAs isolated from the cellular and fluid components of blood and measured using miRNA-seq and real-time polymerase chain reaction (RT-PCR). Baseline neurobehavioral measures derived from 7 tests.

RESULTS

For patients, relative to controls, 48 miRNA were significantly ( P < .05)/differentially expressed. Cluster analysis showed that neurotypical controls were most similar to each other and with 2 patients (VS: n = 1; and MCS: n = 1). Three patients, all in MCS, clustered separately. The only female in the sample, also in MCS, formed an independent group. For the 48 miRNAs, the enriched pathways identified are implicated in secondary brain damage and 26 miRNAs were significantly ( P < .05) correlated with measures of neurobehavioral function.

CONCLUSIONS

Patients remaining in states of DoC an average of 1.5 years after TBI showed a different and reproducible pattern of miRNA expression relative to age/gender-matched neurotypical controls. The phenotypes, defined by miRNA profiles relative to persisting neurobehavioral impairments, provide the basis for future research to determine the miRNA profiles differentiating states of DoC and the basis for future research using miRNA to detect treatment effects, predict treatment responsiveness, and developing targeted interventions. If future research confirms and advances reported findings, then miRNA profiles will provide the foundation for patient-centric DoC neurorehabilitation.

Testosterone replacement in hypogonadal men during inpatient rehabilitation following traumatic brain injury: Results from a double-blind, placebo-controlled clinical pilot study

BACKGROUND

Endocrinopathy, including hypogonadism, is common following traumatic brain injury (TBI). Prior evidence suggests hypogonadism is associated with poorer function.

OBJECTIVE

Determine the feasibility, safety, and efficacy of testosterone (T) therapy in hypogonadal men following TBI in acute rehabilitation.

DESIGN

Randomized, double blind, placebo-controlled pilot trial.

SETTING

Inpatient rehabilitation brain injury unit.

PARTICIPANTS

Men ages 18 -65, post moderate to severe TBI receiving inpatient rehabilitation.

INTERVENTIONS

Transdermal T gel or placebo.

MAIN OUTCOME MEASURES

Revised FIM™ score, strength, adverse events.

RESULTS

Of 498 screened, 70 participants were enrolled, and 22 meeting all criteria were randomized into placebo (n = 10) or physiologic T therapy (n = 12). There was no significant difference between groups in rate of improvement on the FIM™ (intercepts t = -0.31, p = 0.7593, or slopes t = 0.61, p = 0.5472). The Treatment group demonstrated the greatest absolute improvement in FIM™ scores and grip strength compared to Placebo or Normal T groups. There was no difference in adverse events between groups. Percentage of time with agitation or aggression was highest in the Placebo group.

CONCLUSIONS

Although there were no significant differences in rates of recovery, treatment group subjects showed greater absolute functional and strength improvement compared to the Placebo or Normal T groups.

Psychosis Following an Increase in Intrathecal Baclofen

Baclofen is a commonly used medication to treat spasticity in neurologic disorders. In the traumatic brain injury (TBI) population, the intrathecal administration of baclofen is often preferred over oral administration due to cognitive side effects. Here we report on a case of a psychotic episode following an increase in intrathecal baclofen in a young man with a history of a TBI. Although intrathecal baclofen is commonly used and is generally well tolerated, this case highlights an important potential effect of intrathecal baclofen that has rarely been reported in the literature.

LEVEL OF EVIDENCE

V.

Are there cognitive and neurobehavioural correlates of hormonal neuroprotection for women after TBI?

This study examined possible cognitive correlates of hormonal neuroprotection following traumatic brain injury (TBI) using archival neuropsychological findings for 1563 individuals undergoing acute TBI rehabilitation between 1989 and 2002. Presumed age of menopause was based on the STRAW (Stages of Reproductive Aging) staging system (Soules, 2005; Soules et al., 2001) and general linear model (GLM) analysis of performance on neuropsychological testing by participants across gender and age groups (25-34, 35-44, 45-54, and 55-64) was performed. Hypotheses were (1) women with TBI in the oldest age group would have lower scores on neuropsychological tests and functional outcome measures than women in the younger groups, and (2) men in the oldest age group would have higher scores than women of the same age group. Analyses revealed that oldest females had significantly worse Trails B and SDMT written and oral scores than the youngest females. In addition, oldest females had significantly better Trails B, Rey AVLT and SDMT written scores than the oldest males. Possible cohort exposure to hormone replacement therapy, unknown hormonal status at time of testing, and sample-specific injury characteristics may have contributed to these findings.

Relationships among premorbid alcohol use, acute intoxication, and early functional status after traumatic brain injury

OBJECTIVE

To investigate the relationships among intoxication at time of injury, preinjury history of problem drinking, and early functional status in patients with traumatic brain injury (TBI).

DESIGN

Prospective cohort study.

SETTING

Acute inpatient TBI rehabilitation.

PARTICIPANTS

Participants were 1748 persons with TBI.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Blood alcohol levels (BALs) were obtained at admission to the emergency department, and a history of problem drinking was obtained through interview. Study outcomes, Disability Rating Scale (DRS), and FIM instrument scores were gathered at admission to inpatient rehabilitation.

RESULTS

Multivariate regression analysis revealed that BAL and a history of binge drinking were predictive of DRS, but not FIM, scores. A higher BAL was associated with poorer functional status on the DRS. Paradoxically, a history of binge drinking was associated with more intact functional status on the DRS.

CONCLUSIONS

The relationships among intoxication at time of injury, history of problem drinking, and early outcome after TBI were modest. Injury severity had a more significant association with TBI functional status.

The impact of diabetes mellitus on stroke acute rehabilitation outcomes

OBJECTIVE

To examine the impact of diabetes mellitus (DM) on functional outcomes after acute rehabilitation for cerebrovascular accident (CVA).

DESIGN

A retrospective research design was used to analyze outcomes in patients with a primary diagnosis of unilateral stroke (n = 367) admitted to an urban, acute rehabilitation center in the Southeastern United States.

RESULTS

Multivariable hierarchical regression revealed that DM did not contribute statistically significant variance to stroke acute rehabilitation prediction models. Rehabilitation admission functioning scores, rehabilitation length of stay, age, and stroke type were significant predictors of poststroke rehabilitation motor outcomes (r2 = 0.603) and cognitive outcomes (r2 = 0.712). Diabetes also had no significant impact on acute stroke rehabilitation lengths of stay or rehabilitation discharge setting.

CONCLUSIONS

Diabetes does not seem to significantly impact short-term acute rehabilitation outcomes after stroke. Persons with diabetes who suffer a stroke seem to benefit and improve during their acute rehabilitation stay at levels equivalent to peers who are not diagnosed with diabetes. Future research should examine the impact of diabetes subtypes and undiagnosed diabetes on short- and long-term outcomes.

Predictors for return to work after spinal cord injury: a 3-year multicenter analysis

OBJECTIVE

To examine the ability of the Motor Index Score (MIS), in combination with demographic variables, to predict return to work during a 3-year period for individuals with spinal cord injury (SCI).

METHODS

Prospectively collected data, between 1986 and 1995, submitted to the National Spinal Cord Injury Statistical Center were analyzed to determine the prediction of return to work utilizing variables of education, ethnicity, age, marital status, gender, and MIS. Individuals, aged 18 to 65 yrs, employed at the time of their injury, were evaluated at discharge from rehabilitation and at 1 (YR1), 2 (YR2), and 3 (YR3) years postinjury (sample sizes of 1,857, 1,486, and 1,177, respectively).

RESULTS

The most important predictors of return to work were education, MIS, ethnicity, and age at onset of SCI. These variables resulted in a high rate of accuracy for predicting across all 3 yrs (YR1, 81%; YR2, 82%; YR3, 77%).

CONCLUSIONS

The ability to predict return to work after SCI was shown utilizing MIS and demographic variables, with nearly 80% accuracy. This suggests that return to work after SCI is a dynamic process, with the level of importance of each variable changing with time postinjury.

Uterine emergencies. Atony, inversion, and rupture

Uterine atony, inversion, and rupture are potentially fatal events that may occur in pregnancy. They are obstetric emergencies that require immediate attention. Although all women may experience these complications, identification or known risk factors allow the obstetric team to prepare for rapid diagnosis and intervention. This article includes management options to help prepare for these uncommon events.

Laparoscopic management of adnexal masses in premenopausal and postmenopausal women

OBJECTIVE

To evaluate the feasibility and safety of laparoscopic adnexal mass removal in patients without preselection for benign pathology and assess the operative complications and findings.

METHODS

All patients presenting to the gynecologic oncology service between April 1992 and April 1996 with adnexal masses were candidates for laparoscopic management. Patients underwent preoperative radiological studies and office pelvic examination. Laparoscopic management was attempted on patients without evidence of gross metastatic disease or masses that extended above the umbilicus. Laparotomy was performed if indicated by pathologic findings or technical difficulty. All removed adnexal masses were sent for immediate pathologic diagnosis. The type of procedure, intraoperative findings, and complications were all recorded at the time of procedure.

RESULTS

One hundred sixty patients underwent laparoscopic evaluation for an adnexal mass. Benign pathology was discovered in 139 (87%, 95% confidence interval [CI] 84, 90) patients, and 141 (88%, 95% CI 86, 91) patients were managed laparoscopically. Reasons for laparotomy included technical difficulty, operative complications, or malignancy. Frozen section diagnosis was concordant with the final pathology reports in all but five patients (97% concordance), and no discrepancies resulted in treatment delays.

CONCLUSION

Laparoscopic management of adnexal masses can be successful in a gynecologic oncology population if there is expertise in operative laparoscopy, availability of immediate accurate pathologic examination, and appropriate further treatment where indicated.