The utility of serum glucose potassium ratio as a predictive factor for haemorrhagic transformation, stroke recurrence, and mortality among ischemic stroke patients

Background and Objective

Glucose-Potassium Ratio (GPR) has emerged as a biomarker in several pathophysiological conditions. However, the association between GPR and long-term outcomes in stroke patients has not been investigated. Our study evaluated the applicability of baseline GPR as a predictive prognostic tool for clinical outcomes in ischemic stroke patients.

Methods

The multicenter retrospective cohort study included acute-subacute adult ischemic stroke patients who had their baseline serum GPR levels measured. Eligible patients were categorized into two sub-cohorts based on the baseline GPR levels (<1.67 vs. ≥ 1.67). The primary outcome was the incidence of 30-day hemorrhagic transformation, while stroke recurrence, and all-cause mortality within twelve months, were considered secondary.

Results

Among 4083 patients screened, 1047 were included in the current study. In comparison with GPR < 1.67 group, patients with ≥ 1.67 GPR had a significantly higher ratio of all-cause mortality within twelve months (aHR 2.07 [95 % CI 1.21-3.75] p = 0.01), and higher ratio of 30-day hemorrhagic transformation but failed to reach the statistical significance (aHR 1.60 [95 % CI 0.95-2.79], p = 0.08).

Conclusion

Overall, baseline GPR serum is an independent predictor of all-cause mortality within twelve months in patients with acute and subacute ischemic stroke. Further clinical studies are necessary to validate these findings.

Implications of the consciousness state on decannulation in patients with a prolonged Disorder of Consciousness

OBJECTIVE

to prospectively investigate the evolution of the consciousness state and the cannula-weaning progression in patients with prolonged Disorders of Consciousness (pDoC).

DESIGN

non-concurrent cohort study SETTING: rehabilitation unit of the Fondazione Don Gnocchi, Florence PARTICIPANTS: adult patients, with a pDoC following a sABI admitted between 06.2020 and 09.2022 INTERVENTIONS: not applicable MAIN OUTCOME MEASURES: consciousness state was assessed by repeated Coma Recovery Scale-Revised (CRS-R) administration at admission, and weekly afterwards. The dates of the first improvement of consciousness state and the achievement of decannulation were recorded. Decannulation followed an internal protocol of multi-professional rehabilitation.

RESULTS

144 patients were included: age: 69 years, 64 (44.4%) with hemorrhagic etiology, time post-onset: 40 days, CRS-R at admission: 9, median length of stay: 90 days. Seventy-three (50.7%) patients were decannulated. They showed a significantly higher CRS-R (p<0.001) and states of consciousness (p<0.001) at admission, at the first improvement of the consciousness state (p=0.003), and discharge (p<0.001), a lower severity in the Cumulative Illness Rating Scale at admission (p=0.01), and a lower rate of pulmonary infections with recurrence (p=0.021), compared to non-decannulated patients. Almost all decannulated patients (97.3%) improved their consciousness before decannulation. Consciousness states at decannulation were: Unresponsive wakefulness Syndrome: 0 (0%), Minimally conscious state (MCS) minus: 4 (5.5%), MCS plus: 7 (9.6%), Emergence from MCS: 62 (84.9%). Kaplan-Meier analysis showed a significant divergence between the curves with a higher probability of decannulation in patients who improved consciousness (p<0.001).

CONCLUSION

This study showed that the presence of signs of consciousness, even subtle, is a necessary condition for decannulation, suggesting that consciousness may influence some of the components implied in the decannulation process.

From ICU Syndromes to ICU Subphenotypes: Consensus Report and Recommendations For Developing Precision Medicine in ICU

Critical care uses syndromic definitions to describe patient groups for clinical practice and research. There is growing recognition that a "precision medicine" approach is required and that integrated biologic and physiologic data identify reproducible subpopulations that may respond differently to treatment. This article reviews the current state of the field and considers how to successfully transition to a precision medicine approach. In order to impact clinical care, identified subpopulations must do more than differentiate prognosis. They must differentiate response to treatment, ideally by defining subgroups with distinct functional or pathobiological mechanisms (endotypes). There are now multiple examples of reproducible subpopulations of sepsis, acute respiratory distress syndrome, and acute kidney or brain injury described using clinical, physiological, and/or biological data. Many of these subpopulations have demonstrated the potential to define differential treatment response, largely in retrospective studies, and that the same treatment-responsive subpopulations may cross multiple clinical syndromes (treatable traits). To bring about a change in clinical practice, a precision medicine approach must be evaluated in prospective clinical studies requiring novel adaptive trial designs. Several such studies are underway but there are multiple challenges to be tackled. Such subpopulations must be readily identifiable and be applicable to all critically ill populations around the world. Subdividing clinical syndromes into subpopulations will require large patient numbers. Global collaboration of investigators, clinicians, industry and patients over many years will therefore be required to transition to a precision medicine approach and ultimately realize treatment advances seen in other medical fields. This article is open access and distributed under the terms of the Creative Commons Attribution Non-Commercial No Derivatives License 4.0 (http://creativecommons.org/licenses/by-nc-nd/4.0/).

Hyperoxia and brain: the link between necessity and injury from a molecular perspective

Oxygen (O2) supplementation is commonly used to treat hypoxia in patients with respiratory failure. However, indiscriminate use can lead to hyperoxia, a condition detrimental to living tissues, particularly the brain. The brain is sensitive to reactive oxygen species (ROS) and inflammation caused by high concentrations of O2, which can result in brain damage and mitochondrial dysfunction, common features of neurodegenerative disorders. Hyperoxia leads to increased production of ROS, causing oxidative stress, an imbalance between oxidants and antioxidants, which can damage tissues. The brain is particularly vulnerable to oxidative stress due to its lipid composition, high O2 consumption rate, and low levels of antioxidant enzymes. Moreover, hyperoxia can cause vasoconstriction and decreased O2 supply to the brain, posing a challenge to redox balance and neurodegenerative processes. Studies have shown that the severity of hyperoxia-induced brain damage varies with inspired O2 concentration and duration of exposure. Therefore, careful evaluation of the balance between benefits and risks of O2 supplementation, especially in clinical settings, is crucial.

A retrospective cohort study

CLINICAL TRIALS REGISTRATION NUMBER

NCT05145855.

Left Barrel Cortical Neurons Activity following Transplantation of Stem Cells into Right Lesioned-Barrel Cortex in Rats

OBJECTIVE

Stem cells (SCs) can improve the functional defects of brain injury. Rodents use their whiskers to get tactile information from their surroundings. The aim of this study was to investigate whether the transplantation of SCs into the lesioned barrel cortex can help neuronal function in the contralateral cortex.

MATERIALS AND METHODS

Sixteen male Wistar rats (200-230 g) were used in this experimental study. We induced a mechanical lesion in the right barrel cortex area of rats by removing this area by a 3 mm skin punch. Four groups containing one intact group of rats: group 1: control, and three lesion groups, group 2: lesion+un-differentiated dental pulp SCs (U-DPSCs), group 3: lesion+differentiated dental pulp SCs (D-DPSCs), and group 4: cell medium (vehicle) that were injected in the lesion area. Three weeks after transplantation of SCs or cell medium, the rats' responses of left barrel cortical neurons to controlled deflections of right whiskers were recorded by using the extracellular single-unit recordings technique.

RESULTS

The results showed that the neural spontaneous activity and response magnitude of intact barrel cortex neurons in the lesion group decreased significantly (P<0.05) compared to the control group while ON and OFF responses were improved in the D-DPSCs (P<0.001) group compared to the vehicle group three weeks after transplantation.

CONCLUSION

Transplantation of dental pulp mesenchymal SCs significantly improved the neural responses of the left barrel cortex that was depressed in the vehicle group.

The Scholarly and Pedagogical Benefits of the Legal Laboratory: Lessons from the Consortium for the Advanced Study of Brain Injury at Yale Law School

In our article, we share the lessons we have learned after creating and running a successful legal laboratory over the past seven years at Yale Law School. Our legal laboratory, which focuses on the intersection of law and severe brain injury, represents a unique pedagogical model for legal academia, and is closely influenced by the biomedical laboratory.

FGF2 Functions in H2S's Attenuating Effect on Brain Injury Induced by Deep Hypothermic Circulatory Arrest in Rats

Deep hypothermic circulatory arrest (DHCA) can protect the brain during cardiac and aortic surgery by cooling the body, but meanwhile, temporary or permanent brain injury may arise. H2S protects neurons and the central nervous system, especially from secondary neuronal injury. We aim to unveil part of the mechanism of H2S's attenuating effect on brain injury induced by DHCA by exploring crucial target genes, and further promote the clinical application of H2S in DHCA. Nine SD rats were utilized to provide histological and microarray samples, and further the differential expression analysis. Then we conducted GO and KEGG pathway enrichment analyses on candidate genes. The protein-protein interaction (PPI) networks were performed by STRING and GeneMANIA. Crucial target genes' expression was validated by qRT-PCR and western blot. Histological study proved DHCA's damaging effect and H2S's repairing effect on brain. Next, we got 477 candidate genes by analyzing differentially expressed genes. The candidate genes were enriched in 303 GO terms and 28 KEGG pathways. Then nine genes were selected as crucial target genes. The function prediction by GeneMANIA suggested their close relation to immunity. FGF2 was identified as the crucial gene. FGF2 plays a vital role in the pathway when H2S attenuates brain injury after DHCA. Our research provides more information for understanding the mechanism of H2S attenuating brain injury after DHCA. We infer the process might probably be closely associated with immunity.

Motor deficits are associated with increased glial cell activation in the hypothalamus and cerebellum of young rats subjected to cerebral palsy

Cerebral palsy (CP) is a syndrome characterized by a wide range of sensory and motor damage, associated with behavioral and cognitive deficits. The aim of the present study was to investigate the potential of a model of CP using a combination of perinatal anoxia and sensorimotor restriction of hind paws to replicate motor, behavioral and neural deficits. A total of 30 of male Wistar rats were divided into Control (C, n = 15), and CP (CP, n = 15) groups. The potential of the CP model was assessed by evaluating food intake, the behavioral satiety sequence, performance on the CatWalk and parallel bars, muscle strength, and locomotor activity. The weight of the encephalon, soleus, and extensor digitorum longus (EDL) muscles, and the activation of glial cells (microglia and astrocytes) were also measured. The CP animals showed delayed satiety, impaired locomotion on the CatWalk and open field test, reduced muscle strength, and reduced motor coordination. CP also reduced the weight of the soleus and muscles, brain weight, liver weight, and quantity of fat in various parts of the body. There was also found to be an increase in astrocyte and microglia activation in the cerebellum and hypothalamus (arcuate nucleus, ARC) of animals subjected to CP.

Hyperbaric Oxygen and Outcomes Following the Brain Injury: A Systematic Review

Introduction

Hyperbaric oxygen therapy (HBO2) aims to address ischemia resulting from brain injury by subjecting patients to an atmosphere that dramatically raises the concentration of inspired oxygen (100% O2 at greater than 1 ATA). This results in elevated levels of oxygen in the plasma, which in turn boosts the delivery of oxygen for diffusion to the brain tissue.

Objective

To study the efficacy of hyperbaric oxygen (HBO)-based modalities in brain injury.

Method

Preferred reporting items for systematic reviews protocol was applied to perform literature search regarding this analytical review.

Results

In our study, fifteen studies are included in this review, involving 1067 people. The mean age group of patients enrolled was 57.0±11.6 and the mean NIHSS score was 10.5±8.7, of which 21 participants had moderate to severe neurological impairment. The total number of HBO treatments was 8 to 70 times (28.3±17.9), at the end of the 6-month follow-up period. mRS (modified Rankin scale) ≤3 was found in 25 cases, of which 12 patients with high-grade aSAH recovered. Poor prognosis was prevalent in patients who experienced delayed cerebral ischemia, this was true for 22.7% of patients in this study. In 3 studies conducted by Rockswold, ICP (mm Hg) was significantly lower in the HBO2 group after the treatment than pretreatment. (p<0.05). 4 studies showed an improvement in GCS score after HBO2 therapy.One trial (Imai 2006) reported that three patients in the HBO group died due to pneumonia (two) and heart failure (one) and one patient died in the control group due to heart failure. Overall, it is relatively safe to use HBO in the treatment of brain-related haemorrhage, strokes, and injury as there were no major complications reported.

Conclusion

This systematic review demonstrates that HBO2 has significant clinical potential in treatment of brain related haemorrhages, stroke and injury.

Association between toxic drug events and encephalopathy in British Columbia, Canada: a cross-sectional analysis

BACKGROUND

Encephalopathy can occur from a non-fatal toxic drug event (overdose) which results in a partial or complete loss of oxygen to the brain, or due to long-term substance use issues. It can be categorized as a non-traumatic acquired brain injury or toxic encephalopathy. In the context of the drug toxicity crisis in British Columbia (BC), Canada, measuring the co-occurrence of encephalopathy and drug toxicity is challenging due to lack of standardized screening. We aimed to estimate the prevalence of encephalopathy among people who experienced a toxic drug event and examine the association between toxic drug events and encephalopathy.

METHODS

Using a 20% random sample of BC residents from administrative health data, we conducted a cross-sectional analysis. Toxic drug events were identified using the BC Provincial Overdose Cohort definition and encephalopathy was identified using ICD codes from hospitalization, emergency department, and primary care records between January 1st 2015 and December 31st 2019. Unadjusted and adjusted log-binomial regression models were employed to estimate the risk of encephalopathy among people who had a toxic drug event compared to people who did not experience a toxic drug event.

RESULTS

Among people with encephalopathy, 14.6% (n = 54) had one or more drug toxicity events between 2015 and 2019. After adjusting for sex, age, and mental illness, people who experienced drug toxicity were 15.3 times (95% CI = 11.3, 20.7) more likely to have encephalopathy compared to people who did not experience a drug toxicity event. People who were 40 years and older, male, and had a mental illness were at increased risk of encephalopathy.

CONCLUSIONS

There is a need for collaboration between community members, health care providers, and key stakeholders to develop a standardized approach to define, screen, and detect neurocognitive injury related to drug toxicity.

The American Congress of Rehabilitation Medicine Diagnostic Criteria for Mild Traumatic Brain Injury

OBJECTIVE

To develop new diagnostic criteria for mild traumatic brain injury (TBI) that are appropriate for use across the lifespan and in sports, civilian trauma, and military settings.

DESIGN

Rapid evidence reviews on 12 clinical questions and Delphi method for expert consensus.

PARTICIPANTS

The Mild Traumatic Brain Injury Task Force of the American Congress of Rehabilitation Medicine Brain Injury Special Interest Group convened a Working Group of 17 members and an external interdisciplinary expert panel of 32 clinician-scientists. Public stakeholder feedback was analyzed from 68 individuals and 23 organizations.

RESULTS

The first two Delphi votes asked the expert panel to rate their agreement with both the diagnostic criteria for mild TBI and the supporting evidence statements. In the first round, 10 of 12 evidence statements reached consensus agreement. Revised evidence statements underwent a second round of expert panel voting, where consensus was achieved for all. For the diagnostic criteria, the final agreement rate, after the third vote, was 90.7%. Public stakeholder feedback was incorporated into the diagnostic criteria revision prior to the third expert panel vote. A terminology question was added to the third round of Delphi voting, where 30 of 32 (93.8%) expert panel members agreed that 'the diagnostic label 'concussion' may be used interchangeably with 'mild TBI' when neuroimaging is normal or not clinically indicated.'

CONCLUSIONS

New diagnostic criteria for mild TBI were developed through an evidence review and expert consensus process. Having unified diagnostic criteria for mild TBI can improve the quality and consistency of mild TBI research and clinical care.

Neuroprotective effect of tangeretin against chromium-induced acute brain injury in rats: targeting Nrf2 signaling pathway, inflammatory mediators, and apoptosis

Potassium dichromate (PD) is an environmental xenobiotic commonly recognized as teratogenic, carcinogenic, and mutagenic in animals and humans. The present study was conducted to investigate the role of tangeretin (TNG) as a neuro-protective drug against PD-induced brain injury in rats. Thirty-two male adult Wistar rats were blindly divided into four groups (8 rats/group). The first group received saline intranasally (i.n.). The second group received a single dose of PD (2 mg/kg, i.n.). The third group received TNG (50 mg/kg; orally), for 14 days followed by i.n. of PD on the last day of the experiment. The fourth group received TNG (100 mg/kg; orally) for 14 days followed by i.n. of PD on the last day of the experiment. Behavioral indices were evaluated 18 h after PD administration. Neuro-biochemical indices and histopathological studies were evaluated 24 h after PD administration. Results of the present study revealed that rats intoxicated with PD induced- oxidative stress and inflammation via an increase in malondialdehyde (MDA) and a decrease in nuclear factor erythroid 2-related factor 2 (Nrf2) signaling pathway and glutathione(GSH) levels with an increase in brain contents of tumor necrosis factor-alpha (TNF-α) and interleukin (IL-6). Pre-treatment with TNG (100 mg/kg; orally) ameliorated behavior, cholinergic activities, and oxidative stress and decreased the elevated levels of pro-inflammatory mediators; TNF-α and IL-6 with a decrease in brain content of chromium residues detected by Plasma-Optical Emission Spectrometer. Also, the histopathological picture of the brain was improved significantly in rats that received TNG (100 mg/kg). Additionally, TNG decreased caspase-3 expression in the brain of PD rats. In conclusion, TNG possesses a significant neuroprotective role against PD-induced acute brain injury via modulating the Nrf2 signaling pathway and quenching the release of inflammatory mediators and apoptosis in rats.

Therapeutic educational workshops for caregivers of patients with severe acquired brain injury

Abstract

Severe acquired brain injury (sABI) leads to a wide range of functional limitations in cognitive, moto and behavioural abilities. These changes impact the patient's family in terms of the feeling of emotional and physical health, social life and financial condition. Caregivers are often intensely involved in the patient's management exposing them to negative effects of caregiving including stress, mood disorders and decreased quality of life. Implementing forms of active involvement of caregivers in the rehabilitative program could be useful. Thus, in the present study, therapeutic educational workshops (TEWs) for caregivers during the post-acute intensive hospitalization were organized during the post-acute intensive hospitalization of patients with sABI. The caregivers were asked to participate in the workshops to actively involve them in the patient's care and neurorehabilitation program. Each workshop session provided indications regarding the management of the patient with aphasia, neglect, behavioural and swallowing disorders. A questionnaire of 22 items has been designed in order to represent possible indicators of usefulness and effectiveness of the TEWs. The primary aim of this study was to develop a reliable and valid questionnaire able to assess the caregivers' satisfaction with the modalities of carrying out the TEW as a novel activity during the post-acute hospitalization of patients with sABI. The second aim was to assess the caregivers' satisfaction with the utility of the TEW as a tool to enhance their skills in the management of patients' disabilities. 100 caregivers of patients with sABI who attended at least one TEW session and completed the questionnaire were included in the analysis. In conclusion the administered questionnaire has proven to be a valid and reliable tool to evaluate sABI caregivers' satisfaction with TEW. Moreover, caregivers were satisfied with the organization of the TEW and with their usefulness in the management of the patients with sABI.

Vinpocetine restores cognitive and motor functions in Traumatic brain injury challenged rats

Traumatic brain damage is common worldwide and the treatments are not well-defined. Vinpocetine is a synthetic derivative of the vinca alkaloid vincamine and is clinically being used for various brain disorders. Here in the current study, we have investigated the neuroprotective potential of vinpocetine against traumatic brain injury. TBI was induced by the Marmarou weight drop method in rats. Brain damage was evaluated using cognitive and motor functions and the alterations in biomolecules. Injured rats were treated with different doses of vinpocetine (2.5, 5, and 10 mg/kg) for 4 weeks. Traumatic brain injury in rats produced significant deterioration of cognition and motor functions, which was accompanied by increased oxidative stress and significant alterations in brain monoamine levels as compared with the sham control group (p < 0.05). Vinpocetine alleviated TBI-induced oxidative burden, altered neurochemistry, and improved the cognitive and motor functions as compared with that of the TBI control group (p < 0.05). The observed neuroprotective potential of vinpocetine may be due to the observed antioxidant potential and its ability to restore the levels of brain neurochemicals under stressed conditions. The outcomes of the current study may help the repositioning of vinpocetine for preventing or treating traumatic brain injuries.

Traumatic brain injury epidemiology and rehabilitation in Ireland: a protocol paper

Background: Traumatic brain injury (TBI) is a leading cause of death and disability worldwide. In Ireland, a dearth of research means that we neither know the number of people affected by TBI, nor have the required data to improve neuro-rehabilitation services. This is a study protocol to examine the epidemiology and pathways through rehabilitation for a cohort of TBI survivors in the Republic of Ireland. Aims:  1. To document the epidemiological data of TBIs in Ireland. 2. To explore the pathway of TBI survivors through rehabilitation/health services. 3. To document the experiences of those providing care for TBI survivors in Ireland Methods: This is a quantitative cohort study. Existing routine datasets will be used to report epidemiological data. Participants with moderate or severe TBI will be recruited through two brain injury service providers, two acute hospitals that provide neurosurgical services, and the National Rehabilitation Hospital. Participants with TBI will be surveyed on two separate occasions, to explore their use of health and rehabilitation services. Those providing care or support to TBI survivors will be surveyed, on one occasion. Additionally, data from the medical records of TBI survivors will be extracted to capture key information about their TBI, such as mechanism of injury, severity, hospitalisation and follow-up. TBI survivors' use of health care will be followed prospectively for six months. Expected outcomes: The epidemiological data of TBI in Ireland will be documented. Data on survivors' experiences of how rehabilitation services are accessed, and any barriers encountered with rehabilitation/health services will be reported. The experiences of those providing care or support for TBI survivors will be captured. It is expected that the outcomes of the study will support advocacy efforts toward the redevelopment of neuro-rehabilitation services in the Republic of Ireland.

Mechanisms of Tertiary Neurodegeneration after Neonatal Hypoxic-Ischemic Brain Damage

Neonatal encephalopathy linked to hypoxia-ischemia (H-I) which is regarded as the most important neurological problem of the newborn, can lead to a spectrum of adverse neurodevelopmental outcomes such as cerebral palsy, epilepsy, hyperactivity, cognitive impairment and learning difficulties. There have been numerous reviews that have focused on the epidemiology, diagnosis and treatment of neonatal H-I; however, a topic that is less often considered is the extent to which the injury might worsen over time, which is the focus of this review. Similarly, there have been numerous reviews that have focused on mechanisms that contribute to the acute or subacute injury; however, there is a tertiary phase of recovery that can be defined by cellular and molecular changes that occur many weeks and months after brain injury and this topic has not been the focus of any review for over a decade. Therefore, in this article we review both the clinical and pre-clinical data that show that tertiary neurodegeneration is a significant contributor to the final outcome, especially after mild to moderate injuries. We discuss the contributing roles of apoptosis, necroptosis, autophagy, protein homeostasis, inflammation, microgliosis and astrogliosis. We also review the limited number of studies that have shown that significant neuroprotection and preservation of neurological function can be achieved administering drugs during the period of tertiary neurodegeneration. As the tertiary phase of neurodegeneration is a stage when interventions are eminently feasible, it is our hope that this review will stimulate a new focus on this stage of recovery towards the goal of producing new treatment options for neonatal hypoxic-ischemic encephalopathy.

Examining the Use of a Rest-Activity Ratio in a Pediatric Rehabilitation Setting

OBJECTIVE

To examine the relationship between an estimate of sleep/wake regulation derived from actigraphy would be sensitive to neurocognitive dysfunction associated with acquired brain injury (ABI) in a pediatric rehabilitation sample.

DESIGN

cross-sectional design SETTING: Inpatient pediatric rehabilitation facility PARTICIPANTS: A sample of 31 males (72.1%) and 12 females (27.9%) admitted to a pediatric rehabilitation hospital wore an actigraph (wrist accelerometer) for one week. Ages ranged from 8 to 17 years (M=13.1, SD=2.7).

INTERVENTIONS

not applicable MAIN OUTCOME MEASURE(S): Raw actigraphy activity counts in 1-minute epochs were used to derive a rest-activity ratio over each 24-hour period and a 5-day average value was calculated covering Monday through Friday. Brain injury status was derived through medical record review and three groups were formed: traumatic brain injury (n=14), non-traumatic brain injury (n=16), and a non-ABI control group (n=13). Functional status was measured using WeeFIM Cognitive and Motor scores extracted from the medical records.

RESULTS

Unadjusted models showed a significant main group effect for brain injury status (p=0.012). Compared with controls, the rest-activity ratio was significantly lower in both the traumatic brain injury (p = 0.005), and non-traumatic brain injury (p = 0.023) groups. However, the main group effect was no longer significant in an adjusted model controlling for WeeFIM Cognitive and WeeFIM Motor scores at admission. In the context of the adjusted model, there was a significant relationship between the rest-activity ratio and WeeFIM Cognitive scores at admission.

CONCLUSIONS

Individuals with lower functional status at admission, especially in the cognitive domain, had lower rest-activity ratios, suggesting poorer sleep/wake regulation. Similar to findings in adults with acquired brain injury, this ratio may have utility in tracking sleep/wake regulation in the pediatric rehabilitation setting. Future studies should investigate sensitivity to change over the course of recovery and responsiveness to clinical interventions to improve sleep.

Intranasal administration of DHED protects against exhaustive exercise-induced brain injury in rats

DHED (10β,17β-dihydroxyestra-1,4-dien-3-one) is a brain-selective prodrug of 17β-estradiol and has been reported to have a strong neuroprotective effect. In this study, the exhaustive swimming rat model was used to investigate the therapeutic effects and mechanisms of intranasal DHED treatment. Male eight-week-old healthy Sprague Dawley rats were randomly divided into three groups: control group (Cont), exhaustive swimming (ES), and DHED + exhaustive swimming (DHED). The open-field test and beam-walking test were performed to measure exploratory behavior and general activity in rats. Immunofluorescence staining, western blotting, ELISA analysis and related assay kits were applied to measure brain damage, inflammatory cytokines, and apoptosis pathways. Behavioral data shows that DHED intranasal administration can prevent neurobehavioral impairment caused by exhaustive swimming. Using a series of bioanalytical assays, we demonstrated that DHED markedly abated neuronal injury compared to the exhaustive swimming group, as evidenced by the reduced expression of apoptosis-regulated proteins, the improvement of neural survival, and the prevention of myelin loss. In addition, mitochondrial fission was attenuated distinctly, and a dynamic equilibrium was restored. Intranasal administration of DHED likewise significantly suppressed reactive gliosis and the release of inflammatory cytokines in the rat cerebral motor cortex. Consistent with previous reports, DHED treatment ameliorated changes of excitatory neurotransmitters. These results provide strong support for the promising therapeutic effects of DHED on neuroprotection during exhaustive swimming. The underlying mechanisms may rely on mitochondrial dynamics, neuroinflammation, and the balance of neurotransmitters.

The impact of using implementation intentions as task instructions on prospective memory performance after stroke

Prospective Memory (PM), the ability to remember to carry out intentions in the future, is often impaired after stroke. Little is known about rehabilitation of PM post-stroke with literature limited by small sample sizes and reliance on self-reported memory performance. Implementation intentions may make prospective remembering more automatic and follow a simple if-then structure (if X occurs, then I will do Y), focusing on the cue rather than the task. We aimed to investigate the effect of implementation intentions on PM post-stroke. Twenty-eight individuals with stroke and 27 controls were randomly allocated to a standard instruction or implementation intention condition and completed an assessment battery over two sessions. Implementation intention instructions were provided for PM tasks on the Delayed Message Task, Lexical Decision Prospective Memory Task (LDPMT), and the Virtual Reality Prospective Memory Shopping Task. The implementation intention groups performed better on all PM tasks compared to the standard instruction group, but no results reached statistical significance, likely due to the small sample size. In addition, the implementation intentions group monitored the time significantly more on the LDPMT than those in the standard instruction group.

Eletromagnetic Detection of Mild Brain Injury: A Novel Imaging Approach to Post Concussive Syndrome

INTRODUCTION

Mild traumatic brain injury (mTBI) is a common injury, with nearly 3 - 4 million cases annually in the United States alone. Neuroimaging in patients with mTBI provides little benefit, and is usually not indicated as the diagnosis is primarily clinical. It is theorized that microvascular trauma to the brain may be present in mTBI, that may not be captured by routine MRI and CT scans. Electromagnetic (EM) waves may provide a more sensitive medical imaging modality to provide objective data in the diagnosis of mTBI.

METHODS

COMSOL simulation software was utilized to mimic the anatomy of the human skull including skin, cranium, cerebrospinal fluid (CSF), gray-matter tissue of the brain, and microvasculature within the neural tissue. The effects of penetrating EM waves were simulated using the finite element analysis software and results were generated to identify feasibility and efficacy. Frequency ranges from 7 GHz to 15 GHz were considered, with 0.6 and 1 W power applied.

RESULTS

Variations between the differing frequency levels generated different energy levels within the neural tissue-particularly when comparing normal microvasculature versus hemorrhage from microvasculature. This difference within the neural tissue was subsequently identified, via simulation, serving as a potential imaging modality for future work.

CONCLUSION

The use of electromagnetic imaging of the brain after concussive events may play a role in future mTBI diagnosis. Utilizing the proper depth frequency and wavelength, neural tissue and microvascular trauma may be identified utilizing finite element analysis.

The dimensions of white matter injury in preterm neonates

White matter injury (WMI) represents a frequent form of parenchymal brain injury in preterm neonates. Several dimensions of WMI are recognized, with distinct neuropathologic features involving a combination of destructive and maturational anomalies. Hypoxia-ischemia is the main mechanism leading to WMI and adverse white matter development, which result from injury to the oligodendrocyte precursor cells. Inflammation might act as a potentiator for WMI. A combination of hypoxia-ischemia and inflammation is frequent in several neonatal comorbidities such as postnatal infections, NEC and bronchopulmonary dysplasia, all known contributors to WMI. White matter injury is an important predictor of adverse neurodevelopmental outcomes. When WMI is detected on neonatal brain imaging, a detailed characterization of the injury (pattern of injury, severity and location) may enhance the ability to predict outcomes. This clinically-oriented review will provide an overview of the pathophysiology and imaging diagnosis of the multiple dimensions of WMI, will explore the association between postnatal complications and WMI, and will provide guidance on the signification of white matter anomalies for motor and cognitive development.

The incidence and nature of adverse events in rehabilitation inpatients with acquired brain injuries

INTRODUCTION

Patient safety is important in all healthcare settings. Few studies have examined the state of patient safety in rehabilitation and none have examined patient safety in the setting of acquired brain injury (ABI) rehabilitation.

OBJECTIVES

To determine the incidence, most common types, and severities of adverse events among inpatients undergoing ABI rehabilitation.

DESIGN

Retrospective case series descriptive study.

SETTING

The inpatient ABI rehabilitation program at an academic, tertiary rehabilitation hospital in Canada.

PARTICIPANTS

108 consecutive inpatients with acquired brain injuries.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURE(S)

Patient charts and incident reports from the hospital's voluntary reporting system were reviewed by three board-certified physiatrists to determine the incidence, type, severity and preventability of adverse events. Adverse events were identified and classified for severity and type using the WHO International Classification for Patient Safety. Preventability was rated on a 6-point Likert scale.

RESULTS

During the study period, the incidence of adverse events was 17.42 ± 3.86 per 1000 patient days. Adverse events affected 52.8% of patients. Most adverse events identified were mild in severity (98.51%) and the rest were of moderate severity. The two most common types of adverse events were 1) patient incidents (56.72%) such as falls, pressure ulcers and skin tears, and 2) patient behaviors such as missing patient, assault, or sexual behaviors (16.42%). Of the 80 adverse events identified in the study, 44.78% were preventable. The hospital's voluntary reporting system did not capture 57.9% of the adverse events identified.

CONCLUSIONS

Future efforts to improve patient safety in ABI rehab should focus on reducing falls, skin injuries and behaviors, and removing barriers to voluntary incident reporting. Detecting adverse events through chart reviews provide a more complete understanding of patient safety risks in ABI rehab than relying on incident reporting alone. This article is protected by copyright. All rights reserved.

Levels of Cognitive Functioning Assessment Scale: Italian cross-cultural adaptation and validation

STUDY DESIGN

Cross-sectional study.

OBJECTIVE

To develop an Italian version of the Levels of Cognitive Functioning Assessment Scale (LOCFAS) and examine its reliability and validity.

SUBJECT

Patients with acquired brain injury in an early post-coma state.

METHODS

The original scale was translated from English to Italian using the guidelines set forth in the Translation and Cultural Adaptation of Patient Reported Outcomes Measures-Principles of Good Practice. Intra-rater reliability was examined using the intraclass correlation coefficient (ICC). Concurrent validity was evaluated using Pearson's correlation coefficients with some of the functional and disability components of the International Classification of Functioning, Disability and Health (ICF), excluding environmental factors.

SETTING

The highly specialized neurorehabilitation department of "San Raffaele" Hospital, Cassino.

RESULTS

The Italian version of the LOCFAS (LOCFAS-I) was administered to 38 subjects from May 9, 2017 to August 31, 2017. The mean ± SD of the LOCFAS-I score was 3.05 ± 1.88. All LOCFAS-I items were either identical or similar in meaning to the original version's items. Test-retest reliability (ICC) was 0.996 (p<0.01). The Pearson correlation coefficient of the LOCFAS-I scores with some of the functional and disability components of the ICF was > 0.536 (p<0.01).

CONCLUSIONS

The LOCFAS-I was found to be reliable and a valid measurement tool for the assessment of cognitive functioning post-coma in the Italian population.

An Exploratory Study of Endogenous Pain Modulatory Function in Patients Following Mild Traumatic Brain Injury

BACKGROUND

Recent animal research suggests that mild traumatic brain injury (mTBI) facilitates abnormal endogenous modulation of pain, potentially underlying the increased risk for persistent headaches following injury. However, no human studies have directly assessed the functioning of endogenous facilitory and inhibitory systems in the early stages after an mTBI.

OBJECTIVE

The purpose of this exploratory study was to examine trigeminal sensitization and endogenous pain inhibitory capacity in mTBI patients in the acute stage of injury compared with matched controls. We also examined whether post-traumatic headache pain intensity within the mTBI sample was related to sensitization and pain inhibitory capacity.

METHODS

Twenty-four mTBI patients recruited from emergency departments and 21 age-, race-, and sex-matched controls completed one experimental session. During this session, participants completed quantitative sensory tests measuring trigeminal sensitization (pressure pain thresholds and temporal summation of pain in the head) and endogenous pain inhibition (conditioned pain modulation). Participants also completed validated questionnaires measuring headache pain, depression, anxiety, and pain catastrophizing.

RESULTS

The results revealed that the mTBI group exhibited significantly decreased pressure pain thresholds of the head and decreased pain inhibition on the conditioned pain modulation test compared with the control group. Furthermore, correlational analysis showed that the measures of trigeminal sensitization and depression were significantly associated with headache pain intensity within the mTBI group.

CONCLUSIONS

In conclusion, mTBI patients may be at risk for maladaptive changes to the functioning of endogenous pain modulatory systems following head injury that could increase risk for post-traumatic headaches.

Metformin Attenuates Brain Injury by Inhibiting Inflammation and Regulating Tight Junction Proteins in Septic Rats

OBJECTIVE

Metformin has a potent inhibitory activity against inflammation and oxidative stress, which inevitably occur in sepsis-associated encephalopathy (SAE). The precise mechanisms underlying neuroprotective effects of metformin in SAE, are still unclear. In the present work, the protective effect of metformin on SAE using cecal ligation and puncture (CLP) model of sepsis, was assessed.

MATERIALS AND METHODS

In this experimental study, CLP procedure was performed in Wistar rats and 50 mg/kg metformin was administered immediately. Specific markers of sepsis severity, inflammation, blood brain barrier (BBB) dysfunction, and brain injury, were investigated. Specific assay kits and real-time polymerase chain reaction (RT-PCR) were used. Histopathological assessment was also carried out.

RESULTS

Treatment with metformin decreased murine sepsis score (MSS), lactate, platelet lymphocyte ratio (PLR), and high mobility group box (HMGB1) levels. The expression levels of claudin 3 (Cldn3) and claudin 5 (Cldn5) were increased following treatment with metformin. Metformin decreased the expression of S100b, neuron specific enolase (Nse), and glial fibrillary acidic protein (Gfap).

CONCLUSION

Our study suggests that metformin may inhibit inflammation and increase tight junction protein expressions which may improve BBB function and attenuate CLP-induced brain injury. Hence, the potential beneficial effects of metformin in sepsis, should be considered in future.

Trajectories of self-reported competency up to 10 years following moderate-to-severe traumatic brain injury

Objectives: To describe trajectories of self-reported functional competency up to 10 years following traumatic brain injury (TBI) and identify their predictors from baseline socio-demographic and injury severity characteristics.Design and methods: Data from 94 participants from a longitudinal cohort of patients with moderate-to-severe TBI were analyzed. Socio-demographic and injury severity data were recorded at baseline. Participants completed the Patient Competency Rating Scale (PCRS) at 1, 2, 5, and 10 years. Hierarchical linear modeling was used to examine PCRS trajectories over time and assess baseline predictors.Results: There was no significant change in average PCRS scores across the follow-up time points in the full sample. Emotional and cognitive competencies had the lowest mean scores. Gender, employment, and the interaction term between gender and time were significant predictors of PCRS trajectories. Females and those who were unemployed at the time of injury showed lower trajectories of self-reported competency.Conclusion: Self-reported competency remained stable from one-year post-injury for men only. Lower mean scores in the domains of emotional and cognitive competencies suggest a need for continued rehabilitation focus in the chronic phase after TBI. Special attention to women and individuals who are unemployed at the time of injury may be warranted.

Impact of the EMG normalization method on muscle activation and the antagonist-agonist co-contraction index during active elbow extension: Practical implications for post-stroke subjects

Electromyographic (EMG) raw signals are sensitive to intrinsic and extrinsic factors. Consequently, EMG normalization is required to draw proper interpretations of standardized data. Specific recommendations are needed regarding a relevant EMG normalization method for participants who show atypical EMG patterns, such as post-stroke subjects. This study compared three EMG normalization methods ("isometric MVC", "isokinetic MVC", "isokinetic MVC kinematic-related") on muscle activations and the antagonist-agonist co-contraction index. Fifteen post-stroke subjects and fifteen healthy controls performed active elbow extensions, followed by isometric and isokinetic maximum voluntary contractions (MVC). Muscle activations were obtained by normalizing EMG envelopes during active movement using a reference value determined for each EMG normalization method. The results showed no significant difference between the three EMG normalization methods in post-stroke subjects on muscle activation and the antagonist-agonist co-contraction index. We highlighted that the antagonist-agonist co-contraction index could underestimate the antagonist co-contraction in the presence of atypical EMG patterns. Based on its practicality and feasibility, we recommend the use of isometric MVC as a relevant procedure for EMG normalization in post-stroke subjects. We suggest combined analysis of the antagonist-agonist co-contraction index and agonist and antagonist activations to properly investigate antagonist co-contraction in the presence of atypical EMG patterns during movement.

Predictive Value of Cranial Ultrasound for Neurodevelopmental Outcomes of Very Preterm Infants with Brain Injury

Background:

Compared with full-term infants, very preterm infants are more vulnerable to injury and long-term disability and are at high risk of death. The predictive value of ultrasound and imaging on the neurodevelopment is one of the hot topics. This study aimed to investigate the relationship between cranial ultrasound (cUS) variables and neurodevelopmental outcomes of very preterm infants.

Methods:

Totally 129 very preterm infants (gestational age ≤28 weeks) in neonatal intensive care unit of Hunan Children's Hospital between January 2012 and November 2014 were included in this retrospective study. Serial cUS (weekly before discharge and monthly after discharge) was performed on the infants until 6 months or older. Magnetic resonance imaging (MRI) was performed on the infants at approximately the term-equivalent age. The mental developmental index (MDI) and psychomotor developmental index (PDI) were followed up until the infants were 24 months or older. The relationship between brain injury and MDI/PDI scores was analyzed.

Results:

The consistency rate between cUS and MRI was 88%. At the first cUS, germinal matrix hemorrhage (GMH) Grades 3 and 4, hospitalization duration, and weight are significantly correlated with MDI/PDI and prognosis (MDI: odds ratio [OR] = 8.415, 0.982, and 0.042, P = 0.016, 0.000, and 0.004; PDI: OR = 7.149, 0.978, and 0.012, P = 0.025, 0.000, and 0.000, respectively). At the last cUS, gestational age, extensive cystic periventricular leukomalacia (c-PVL), and moderate and severe hydrocephaly are significantly correlated with MDI (OR = 0.292, 60.220, and 170.375, P = 0.004, 0.003, and 0.000, respectively). Extensive c-PVL and moderate and severe hydrocephaly are significantly correlated with PDI (OR = 76.861 and 116.746, P = 0.003 and 0.000, respectively).

Conclusions:

Very premature infants with GMH Grades 3 and 4, short hospitalization duration, and low weight have low survival rates and poorly developed brain nerves. Cerebral palsy can result from severe cerebral hemorrhage, moderate and severe hydrocephaly, and extensive c-PVL. The sustained, inhomogeneous echogenicity of white matter may suggest subtle brain injury.

Rights language and disorders of consciousness: a call for advocacy

Drawing upon sources in neuroethics, civil rights, and disability rights law, we argue for the reintegration of people with severe brain injury back into the nexus of their families and communities consistent with the Americans with Disabilities Act (ADA) and the UN Convention on the Rights of Persons with Disabilities, both of which call for the maximal integration of people with disability into society. To this end, we offer a rights-based argument to address the care of people with severe brain injury. Instead of viewing the provision of rehabilitation as a reimbursement issue, which it surely is, we argue that it can be productively understood as a question of civil rights for a population generally segregated from the medical mainstream and from society itself. Their segregation in the chronic care sector constitutes disrespect for persons, made all the more consequential because recent advances in brain injury rehabilitation make reintegration into civil society an aspirational, if not achievable goal.

Decreased Anticipatory Postural Adjustments During Gait Initiation Acutely Postconcussion

OBJECTIVE

To investigate anticipatory postural adjustments (APAs) during the transitional movement task of gait initiation (GI) in individuals acutely after a concussion.

DESIGN

Cohort study.

SETTING

University research center.

PARTICIPANTS

A population-based sample of participants (N=84) divided into 2 equal groups of acutely postconcussion and healthy student athletes.

INTERVENTION

Participants were tested on 2 occasions: a preinjury baseline test and then the concussion group was retested acutely postconcussion and the healthy student athlete group again at a similar time. All participants completed 5 trials of GI on 4 forceplates.

MAIN OUTCOME MEASURES

The dependent variables were the displacement and velocity of the center of pressure (COP) during the APA phase and initial step kinematics. Comparisons were made with a 2 (group) × 2 (time) repeated-measures analysis of variance.

RESULTS

There was a significant interaction for COP posterior displacement (P<.001) and lateral displacement (P<.001). Posteriorly, post hoc testing identified a significant reduction in the concussion group (pretest: 5.7±1.6cm; posttest: 2.6±2.1cm; P<.001), but no difference in the healthy student athlete group (pretest: 4.0±1.6cm; posttest: 4.0±2.5cm; P=.921). Laterally, post hoc testing identified a significant reduction in the concussion group (pretest: 5.8±2.1cm; posttest: 3.8±1.8cm; P<.001), but no difference in the healthy student athlete group (pretest: 5.0±2.5cm; posttest: 5.2±2.4cm; P=.485).

CONCLUSIONS

The results of this study suggest difficulty in the planning and execution of GI acutely postconcussion, and posterior APA displacement and velocity are highly effective measures of impaired postural control. Finally, the APA phase is linked to the supplementary motor area, which suggests a supraspinal contribution to postconcussion impaired postural control.

Paroxysmal Sympathetic Hyperactivity in Children: An Exploratory Evaluation of Nursing Interventions

BACKGROUND

Paroxysmal sympathetic hyperactivity (PSH) produces symptoms of autonomic instability and muscle over-activity; however, the majority of nursing interventions used in clinical practice are anecdotal and not evidenced based.

OBJECTIVE

The primary objective was to report nursing documentation of PSH events, and to describe the clinical nursing interventions and care provided to children who have suffered a severe brain injury and are exhibiting PSH. The secondary objective was to demonstrate how the Symptom Management Theory (SMT) can serve as a framework for research related to brain injury and PSH.

METHODOLOGY

The study consisted of a retrospective chart review of nursing progress notes using direct content analysis. The nested sample of ten randomly selected charts was chosen from a larger quantitative study of 83 children who had suffered severe brain injuries with and without PSH. Textual analysis of verbatim nursing progress notes was used to describe nursing interventions that were used and documented for this patient population.

RESULTS

The priority nursing interventions to manage these symptoms included medication administration, facilitation of family presence, and strategies to target auditory, tactile, and visual stimuli. The sample received different individual interventions for PSH. Additionally, individual subjects demonstrated different patterns of interventions.

IMPLICATIONS

While tactile interventions were documented most frequently, there was not a uniform approach to interventions. The SMT can be useful to provide a framework that organizes and tests clinical care and management of PSH strategies.

The Child Sport Concussion Assessment Tool 5th Edition (Child SCAT5): Background and rationale

This article presents the Child Sport Concussion Assessment Tool 5th Edition (Child SCAT5). The Sport Concussion Assessment Tool was introduced in 2004, following the 2nd International Conference on Concussion in Sport in Prague, Czech Republic. Following the 4th International Consensus Conference, held in Zurich, Switzerland, in 2012, the SCAT 3rd edition (Child SCAT3) was developed for children aged between 5 and12 years. Research to date was reviewed and synthesised for the 5th International Consensus Conference on Concussion in Sport in Berlin, Germany, leading to the current revision of the test, the Child SCAT5. This article describes the development of the Child SCAT5.

Challenges in neurologic prognostication after neonatal brain injury

Parents often ask neonatologists and neurologists to determine neurologic prognosis in the preterm and term infant after neonatal brain injury. Prognostication in these populations remains rather full of uncertainties. Knowledge of available diagnostic tests and their limitations allows the clinician to synthesize the most likely outcomes after neurologic injury. In this review, we describe the diagnostic tools available to the clinician, active areas of research, and challenges in neurologic prognostication of the neonate.

Ecologically relevant outcome measure for post-inpatient rehabilitation

BACKGROUND

Transfer of skills learned within the clinic environment to patients' home or community is important in post-inpatient brain injury rehabilitation (PBIR). Outcome measures used in PBIR assess level of independence during functional tasks; however, available functional instruments do not quantitate the environment in which the behaviors occur.

OBJECTIVE

To examine the reliability and validity of an instrument used to assess patients' functional abilities while quantifying the amount of structure and distractions in the environment.

METHODS

2501 patients who sustained a traumatic brain injury (TBI) or cerebrovascular accident (CVA) and participated in a multidisciplinary PBIR program between 2006 and 2014 were identified retrospectively for this study. The PERPOS and MPAI-4 were used to assess functional abilities at admission and at discharge. Construct validity was assessed using a bivariate Spearman rho analysis A subsample of 56 consecutive admissions during 2014 were examined to determine inter-rater reliability. Intra-class correlation coefficient (ICC) and Kappa coefficients assessed inter-rater agreement of the total PERPOS and PERPOS subscales respectively.

RESULTS

The PERPOS and MPAI-4 demonstrated a strong negative association among both TBI and CVA patients. Kappa scores for the three PERPOS scales each demonstrated good to excellent inter-rater agreement. The ICC for overall PERPOS scores fell in the good agreement range.

CONCLUSION

The PERPOS can be used reliably in PBIR to quantify patients' functional abilities within the context of environmental demands.

Developing Azeri aphasia screening test and preliminary validity and reliability

Background: As there is no standard aphasia screening tool for Azeri language yet, the aim of this study was to develop an aphasia screening test with acceptable validity and reliability. Methods: The present study was conducted in two phases. In the first phase, by literature search, the screening test was designed and to obtain validity it was peer reviewed by expert panel. After collecting experts' ratings and comments, appropriate modifications were applied. For test-retest reliability in the second phase, edited test was administered in 32 patients with brain injuries, then the retest was performed two weeks later. Results: The developed test had eight subscales including: A) picture description, B) syntax, C) linguistic reasoning, D) descriptive naming, E) perception of minimal pairs, F) comprehensive vocabulary, G) expressive vocabulary, H) verbal fluency. Each section had five questions except verbal fluency which had 3 items. Content validity ratio (CVR) according to Lawshe's approach, was 82% for the whole test. Intraclass correlation for all subscales were more than 0.8. Cronbach's alpha coefficient for internal reliability was 0.901. Conclusion: This aphasia screening test seems to have acceptable psychometric properties. This test can probably be used in clinical setting by specialists.

Aqueous Date Fruit Efficiency as Preventing Traumatic Brain Deterioration and Improving Pathological Parameters after Traumatic Brain Injury in Male Rats

Objective

Following traumatic brain injury, disruption of blood-brain-barrier and consequent brain edema are critical events which might lead to increasing intracranial pressure (ICP), and nerve damage. The current study assessed the effects of aqueous date fruit extract (ADFE) on the aforementioned parameters.

Materials and Methods

In this experimental study, diffused traumatic brain injury (TBI) was generated in adult male rats using Marmarou’s method. Experimental groups include two pre-treatment (oral ADFE, 4 and 8 mL/kg for 14 days), vehicle (distilled water, for 14 days) and sham groups. Brain edema and neuronal injury were measured 72 hours after TBI. Veterinary coma scale (VCS) and ICP were determined at -1, 4, 24, 48 and 72 hours after TBI. Differences among multiple groups were assessed using ANOVA. Turkey’s test was employed for the ANOVA post-hoc analysis. The criterion of statistical significance was sign at P<0.05.

Results

Brain water content in ADFE-treated groups was decreased in comparison with the TBI+vehicle group. VCS at 24, 48 and 72 hours after TBI showed a significant increase in ADFE groups in comparison with the TBI+vehicle group. ICP at 24, 48 and 72 hours after TBI, was decreased in ADFE groups, compared to the TBI+vehicle. Brain edema, ICP and neuronal injury were also decreased in ADFE group, but VCS was increased following on TBI.

Conclusion

ADFE pre-treatment demonstrated an efficient method for preventing traumatic brain deterioration and improving pathological parameters after TBI.

The UCLA study of Predictors of Cognitive Functioning Following Moderate/Severe Pediatric Traumatic Brain Injury

OBJECTIVES

Following pediatric moderate-to-severe traumatic brain injury (msTBI), few predictors have been identified that can reliably identify which individuals are at risk for long-term cognitive difficulties. This study sought to determine the relative contribution of detailed descriptors of injury severity as well as demographic and psychosocial factors to long-term cognitive outcomes after pediatric msTBI.

METHODS

Participants included 8- to 19-year-olds, 46 with msTBI and 53 uninjured healthy controls (HC). Assessments were conducted in the post-acute and chronic stages of recovery. Medical record review provided details regarding acute injury severity. Parents also completed a measure of premorbid functioning and behavioral problems. The outcome of interest was four neurocognitive measures sensitive to msTBI combined to create an index of cognitive performance.

RESULTS

Results indicated that none of the detailed descriptors of acute injury severity predicted cognitive performance. Only the occurrence of injury, parental education, and premorbid academic competence predicted post-acute cognitive functioning. Long-term cognitive outcomes were best predicted by post-acute cognitive functioning.

DISCUSSION

The findings suggest that premorbid factors influence cognitive outcomes nearly as much as the occurrence of a msTBI. Furthermore, of youth with msTBI who initially recover to a level of moderate disability or better, a brief cognitive battery administered within several months after injury can best predict which individuals will experience poor long-term cognitive outcomes and require additional services.

Exploring the experience of sleep and fatigue in male and female adults over the 2 years following traumatic brain injury: a qualitative descriptive study

OBJECTIVES

To explore the experience of fatigue and sleep difficulties over the first 2 years after traumatic brain injury (TBI).

DESIGN

Longitudinal qualitative descriptive analysis of interviews completed as part of a larger longitudinal study of recovery following TBI. Data relating to the experience of fatigue and/or sleep were extracted and coded by two independent researchers.

SETTING

Community-based study in the Hamilton and Auckland regions of New Zealand.

PARTICIPANTS

30 adult participants who had experienced mild, moderate or severe brain injury within the past 6 months (>16 years of age). 15 participants also nominated significant others to take part. Interviews were completed at 6, 12 and 24 months postinjury.

RESULTS

Participants described feeling unprepared for the intensity, impact and persistent nature of fatigue and sleep difficulties after injury. They struggled to learn how to manage their difficulties by themselves and to adapt strategies in response to changing circumstances over time. Four themes were identified: (1) Making sense of fatigue and sleep after TBI; (2) accepting the need for rest; (3) learning how to rest and; (4) need for rest impacts on ability to engage in life.

CONCLUSIONS

Targeted support to understand, accept and manage the sleep and fatigue difficulties experienced may be crucial to improve recovery and facilitate engagement in everyday life. Advice needs to be timely and revised for relevance over the course of recovery.

The effect of brain injury on the inflammatory response following severe trauma

INTRODUCTION

The inflammatory response is an important part of the pathophysiology of severe injury and, in particular, of severe traumatic brain injury (TBI). This study evaluates the inflammatory course following major trauma and focuses on the effect of severe TBI on inflammatory markers.

MATERIAL AND METHODS

This was a retrospective analysis of prospectively collected data in 123 severely injured (ISS ≥16) trauma patients. The study cohort was divided into patients with isolated TBI (Head AIS ≥3, all other AIS <3), polytraumatized patients with severe TBI (Head AIS ≥3; AIS of other body area ≥3; Polytrauma+TBI) and polytraumatized patients without TBI (Head AIS <3; Polytrauma). Levels of inflammatory markers (Interleukin-6 [IL-6], C-reactive Protein [CRP], leukocytes) measured upon arrival and through hospital days 1-3 were compared between the groups.

RESULTS

On admission and through hospital day 3, IL-6 levels were significantly different between the 3 groups (admission: isolated TBI vs. Polytrauma+TBI vs. Polytrauma; 94±16 vs. 149±20 vs. 245±50pg/mL; p<0.05). Interleukin-6 levels peaked on hospital day 1 and declined thereafter. C-reactive protein and leukocyte counts were not significantly different between the cohorts on arrival and peaked on hospital day 2 and 1, respectively. In patients with severe TBI, admission IL-6 levels significantly predicted the development of septic complications (ROC analysis, AUC: 0.88, p=0.001, 95% CI: 0.79-0.97) and multiple organ dysfunction (ROC analysis, AUC: 0.83, p=0.001, 95% CI: 0.69-0.96).

CONCLUSION

Severe TBI reduced the inflammatory response following trauma. Significant correlations between admission IL-6 values and the development of MOF, sepsis and the neurological outcome were found in patients with TBI.

Effects of Repetitive Transcranial Magnetic Stimulation on Behavioral Recovery during Early Stage of Traumatic Brain Injury in Rats

Repetitive transcranial magnetic stimulation (rTMS) is a promising technique that modulates neural networks. However, there were few studies evaluating the effects of rTMS in traumatic brain injury (TBI). Herein, we assessed the effectiveness of rTMS on behavioral recovery and metabolic changes using brain magnetic resonance spectroscopy (MRS) in a rat model of TBI. We also evaluated the safety of rTMS by measuring brain swelling with brain magnetic resonance imaging (MRI). Twenty male Sprague-Dawley rats underwent lateral fluid percussion and were randomly assigned to the sham (n=10) or the rTMS (n=10) group. rTMS was applied on the fourth day after TBI and consisted of 10 daily sessions for 2 weeks with 10 Hz frequency (total pulses=3,000). Although the rTMS group showed an anti-apoptotic effect around the peri-lesional area, functional improvements were not significantly different between the two groups. Additionally, rTMS did not modulate brain metabolites in MRS, nor was there any change of brain lesion or edema after magnetic stimulation. These data suggest that rTMS did not have beneficial effects on motor recovery during early stages of TBI, although an anti-apoptosis was observed in the peri-lesional area.

Comparing Cognitive Failures and Metacognitive Beliefs in Mild Traumatic Brain Injured Patients and Normal Controls in Kashan

BACKGROUND

Head trauma is associated with multiple destructive cognitive symptoms and cognitive failure. Cognitive failures include problems with memory, attention and operation. Cognitive failures are considered as a process associated with metacognition.

OBJECTIVES

This study aimed to compare cognitive failures and metacognitive beliefs in mild Traumatic Brain Injured (TBI) patients and normal controls in Kashan.

PATIENTS AND METHODS

The study was performed on 40 TBI patients referred to the Shahid Beheshti Hospital of Kashan city and 40 normal controls in Kashan. Traumatic brain injured patients and normal controls were selected by convenience sampling. Two groups filled out the demographic sheet, Cognitive Failures Questionnaire (CFQ) and Meta-Cognitions Questionnaire 30 (MCQ-30). The data were analyzed by the SPSS-19 software with multivariate analysis of variance.

RESULTS

The results of this study showed that there were no significant differences between TBI and controls in total scores and subscales of CFQ and MCQ (F = 0.801, P = 0.61).

CONCLUSIONS

Based on these findings, it seems that mild brain injuries don't make significant metacognitive problems and cognitive failures.

All the right moves: the need for the timely use of hyperbaric oxygen therapy for treating TBI/CTE/PTSD

Background

The modern age of hyperbaric medicine began in 1937; however, today few know about hyperbaric oxygen’s effects on the body and medical conditions outside of diving medicine and wound care centers - a serious ethical issue as there are 20 US military veterans committing suicide every day directly related to Traumatic Brain Injury/Post Traumatic Stress Disorder. The problem is not whether hyperbaric oxygen is effective for treating brain injuries, but why the interference in offering this therapy to those who need it.

Discussion

Up against black-boxed anti-depressants that are not efficacious, it should be a “no-brainer” to use a safe, off-label drug, but in the case of military veterans, every suicide might be seen as a tremendous cost saving to certain technocrats. The unspoken rationale is that if the military were to embrace hyperbaric oxygen as the efficacious therapy that it is then current active troops that have suffered injuries will come forward and seek treatment and benefits for their Traumatic Brain Injuries now that they know there is a viable therapy and in so doing troop strength will be decimated. So, to attempt to delay the acceptance of hyperbaric oxygen the Department of Defense has funded faux-studies claiming low pressure room air to be a placebo or sham, and then proclaiming there is no statistical difference between treatment arms and sham or placebo treatment arms. With few who understand hyperbaric medicine there is almost no one to call them on this subterfuge and prevarication. Many peer-reviewed articles have been published in the last decade that demonstrate hyperbaric oxygen is effective in repairing an injured brain even long after that injury took place. One of the most notable showed that blast-induced brain injured war veterans experienced a 15 point IQ increase (p < 0.001).

Summary

Hyperbaric oxygen is an efficacious, benign and humanitarian way to affect brain repair but it has not been adopted because it lacks patent protection and has no large corporate sponsors. It has also met interference because other agendas are present be they the protection of the status quo, myopic budgetary constraints, or perceived liability issues.

Mental health status of patients with mild traumatic brain injury admitted to shahid beheshti hospital of kashan, iran

Background:

Planning for providing mental health services to the mentally patients due to brain injury need awareness of mental health status of the patient.

Objectives:

This study aimed to assess the mental health of patients with mild TBI.

Patients and Methods:

The descriptive cross-sectional study was performed on 286 patients with mild TBI who were admitted to department of neurosurgery of Shahid Beheshti Hospital, Kashan, Iran, during the first eight months of 2013. Enrolled patients were 15 to 70 years old who able to respond to questionnaires. The Brief Symptom Inventory (BSI) questionnaire is used to assess the mental health status of the patients. The data were presented using logistic regression and descriptive statistics.

Results:

A total of 286 patients, 79.7% males and 20.3% females with male to female ratio of 4:1, completed the study. Female had significantly higher Global Severity Index (GSI) compared to males. There was a significant association between, psychologic disorders’ symptoms and age (P = 0.00). The mean (SD) of GSI on the Symptom Checklist-90 (SCL-90) was 1.39 (0.58).

Conclusions:

This study showed that 36% of the patients with mild TBI symptoms had mental health problems. Given the high rates of psychologic disorders among patients with mild TBI, it is necessary to reduce the factors that caused the disorder.

Protective effect of topiramate on hypoxic-ischemic brain injury in neonatal rat

OBJECTIVE

To explore protective effect of topiramate (TPM) on hypoxic-ischemic brain injury.

METHODS

A total of 360 neonatal rats were selected then randomly divided into sham operation group, ischemia and hypoxia group, conventional treatment group and degradation therapy group (n=90). After surgical treatment, sham and ischemic hypoxia group were treat with normal saline; conventional treatment group was received TPM solution 100 mg/kg, 2 times/d; degradation therapy group received TPM solution 150 mg/kg, 2 times/d, per 3 d treatment each dosage was reduced 50 mg/kg, the lowest reduced to 50 mg/kg. Four groups received continuous treatment for 10 d. After treatment for 1 d, 4 d, 7 d, 10 d the cerebral edema, neuron-specific enolase (NSE) and γ-aminobutyric acid (GABA) levels and cognitive abilities of four groups were observed.

RESULTS

After 1 d, 4 d of treatment, the brain water content and NSE levels in ischemia and hypoxia group, the conventional treatment group and the degradation therapy group were significantly higher than that in sham group (P<0.05), the brain water content and NSE levels of the conventional treatment group and the degradation therapy group were significantly lower than that in the ischemic hypoxia group (P<0.05). GABA levels and learning ability of the ischemia and hypoxia group, the conventional treatment group and degradation therapy group were significantly lower than the sham group (P<0.05), the GABA levels and learning ability of the conventional treatment group and degradation therapy group were significantly higher than the ischemia and hypoxia group (P<0.05). After 7 d, 10 d of treatment, the brain water content and NSE levels in the sham operation group, the conventional treatment group and degradation therapy group were significantly lower than the ischemia and hypoxia group (P<0.05), while the GABA levels and learning ability of these three groups were significantly higher than that in the ischemia and hypoxia group (P<0.05), the GABA levels in the conventional treatment group were significantly higher than degradation therapy group (P<0.05); After 10 d of treatment, the GABA levels of the conventional treatment group were significantly higher than the sham group, the learning ability of the degradation therapy group and sham operation group were significantly higher than the conventional treatment group (P<0.05).

CONCLUSIONS

The correct amount of short-term TPM has protective effect on hypoxic-ischemic brain injury, but long-term or excessive use may cause new damage to the brain and reduce the cognitive ability.

Dynamic testing of learning potential in adults with cognitive impairments: A systematic review of methodology and predictive value

Dynamic testing includes procedures that examine the effects of brief training on test performance where pre- to post-training change reflects patients' learning potential. The objective of this systematic review was to provide clinicians and researchers insight into the concept and methodology of dynamic testing and to explore its predictive validity in adult patients with cognitive impairments. The following electronic databases were searched: PubMed, PsychINFO, and Embase/Medline. Of 1141 potentially relevant articles, 24 studies met the inclusion criteria. The mean methodological quality score was 4.6 of 8. Eleven different dynamic tests were used. The majority of studies used dynamic versions of the Wisconsin Card Sorting Test. The training mostly consisted of a combination of performance feedback, reinforcement, expanded instruction, or strategy training. Learning potential was quantified using numerical (post-test score, difference score, gain score, regression residuals) and categorical (groups) indices. In five of six longitudinal studies, learning potential significantly predicted rehabilitation outcome. Three of four studies supported the added value of dynamic testing over conventional testing in predicting rehabilitation outcome. This review provides preliminary support that dynamic tests can provide a valuable addition to conventional tests to assess patients' abilities. Although promising, there was a large variability in methods used for dynamic testing and, therefore, it remains unclear which dynamic testing methods are most appropriate for patients with cognitive impairments. More research is warranted to further evaluate and refine dynamic testing methodology and to further elucidate its predictive validity concerning rehabilitation outcomes relative to other cognitive and functional status indices.

Agreement of cerebral state index and glasgow coma scale in brain-injured patients

Background:

Variables derived from electroencephalogram like cerebral state index (CSI) have been used to monitor the anesthesia depth during general anesthesia. Observed evidences show such variables have also been used as a detector of brain death or outcome predictor in traumatic brain-injured (TBI) patients.

Objectives:

The current study was designed to determine the correlation between Glasgow coma score (GCS) and CSI among TBI patients.

Patients and Methods:

In 60 brain-injured patients who did not need and receive sedatives, GCS and CSI were daily measured during the first ten days of their hospital stay. Correlation between GCS and CSI was studied using the Pearson's correlation test. The Gamma agreement coefficient was also calculated between the two variables for the first day of hospitalization.

Results:

A significant correlation coefficient of 0.611-0.796 was observed between CSI and GCS in a ten-day period of the study (P < 0.001). Gamma agreement coefficient was 0.79 (P < 0.001) for CSI and GCS for the first day of hospitalization. An increased daily correlation was observed in both CSI and GCS values. However, this increase was less significant in CSI compared with the GCS.

Conclusions:

A statistically significant correlation and agreement was found between GCS and CSI in the brain-injured patients and GCS was also found to be more consistent and reliable compared with CSI.

Prevalence of hyponatremia in intensive care unit patients with brain injury in kashan shahid-beheshti hospital in 2012

Background

Hyponatremia is a common disorder in patients with brain injury. It can result in acute and chronic complications providing this electrolytic disorder is not diagnosed and treated in due time.

Objectives

The aim of this study was to evaluate the prevalence of hyponatremia in 95 brain injury patients hospitalized in the intensive care unit (ICU) in Kashan Shahid-Veheshti hospital.

Patients and Methods

This trans-sectional study was conducted on brain injury patients (brain traumas, brain hemorrhage, meningitis and brain tumors) during their six-month stay in the ICU in Kashan Shahid-Beheshti hospital. Data were analyzed after excluding cases of pseudohyponatremia.

Results

Ninety-five patients with brain injury (69.5% male and 30.5% female ( had a mean age of 42.85 ± 22.59 years, while the hyponatremic patients had a mean age of 48.37 ± 24.03 years. Prevalence and occurrence of hyponatremia were 31.6% and 9.29 ± 6.8 days, respectively. This study revealed no meaningful differences between age, sex, underlying disease and the prevalence of hyponatremia.

Conclusions

Our study showed an elevated frequency of hyponatremia in patients with brain injuries in ICU which demands the effective approaches for an accurate and timely diagnosis of this electrolyte disorder.

Effects of neurosurgical treatment and severity of head injury on cognitive functioning, general health and incidence of mental disorders in patients with traumatic brain injury

Background

Neurosurgical treatment and the severity of head injury (HI) can have remarkable effect on patients’ neuropsychiatric outcomes.

Objectives

This research aimed to study the effect of these factors on cognitive functioning, general health and incidence of mental disorders in patients with a traumatic brain injury (TBI).

Patients and Methods

In this descriptive, longitudinal study, 206 TBI patients entered the study by consecutive sampling; they were then compared according to neurosurgery status and severity of their HI. Both groups underwent neurosurgical and psychological examinations. The mini mental state examination (MMSE) and general health questionnaire–28 items (GHQ-28) were administered to the study participants. At follow-up, four months later, the groups underwent a structured clinical interview by a psychiatrist based on the diagnostic and statistical manual of mental disorders, fourth edition (DSM-IV) diagnostic criteria regarding the presence of mental disorders.

Results

Analysis of covariance (ANCOVA) and multivariate analysis of covariance (MANCOVA) were performed and adjusted for the effect of confounding variables (age, gender, Glasgow outcome scale (GOS) , and level of education). The severity of HI had the most significant effect for the following variables; cognitive functioning and physical symptoms (P < 0.05). The effect of the neurosurgical treatment factor was not significant; however, the interaction effect of the two variables on social dysfunction, and total score of the GHQ-28 questionnaire appeared to be significant (P < 0.05). Fisher's exact test indicated that after a four month follow-up period, no significant differences were seen between the two groups (with or without neurosurgery) in the incidence of mental disorders, while χ² Test showed that having a more severe HI is significantly correlated with the incidence of mental disorders (P < 0.01).

Conclusions

The implications of this study should be discussed with an emphasis on negative, effective factors on the cognitive – behavioral and neuropsychiatric outcomes of a TBI.