Screening for job loss: development of a work instability scale for traumatic brain injury

Objective: The objective of this study was to explore the concept of work instability (a mis-match between an individual's functional and cognitive abilities and the demands of their job) following traumatic brain injury (TBI) and develop a work instability scale specific to this population.

Method: Work instability (WI) following TBI was explored through qualitative interviews which were then used to generate items for a work instability scale (WIS). Rasch analysis was used to examine the scaling properties of the TBI-WIS which was then validated against a gold standard of expert vocational assessment by occupational psychologists.

Results and conclusion: The resulting measure is a 36 item, self-administered scale which can be scored in three bands indicating low, medium and high risk of job retention problems. The scale meets modern psychometric requirements for measurement and presents an opportunity in routine clinical practice to take positive action to prevent job loss.     

Influence of sensorimotor adaptation and learning process for rehabilitation on the functional mobility of a patient with traumatic brain injury: A case report

This case report reveals the implementation of sensorimotor adaptation and learning process for rehabilitation in a patient with traumatic brain injury to achieve optimum recovery which is permanent in nature in compliance to the disability rating scale. A twenty two year old gentleman who had a history of fall was diagnosed as having subarachnoid hemorrhage along with diffuse axonal injury of the brain and bilateral lung contusion with pneumothorax. He underwent a total of ten months of sensorimotor adaptation and learning process for rehabilitation, which achieved functional mobility with a walker.     

Effectiveness of communication/interaction strategies with patients who have neurological injuries in a rehabilitation setting

Primary objective: A correlational research design was used to examine the relationship between use of interaction strategies and success of interactions between patients with neurological injuries and licensed healthcare providers. It was hypothesized that using specific interaction strategies would increase the success of interactions between patients and staff.

Methods and procedures: One hundred and two 5-minute interactions between licensed healthcare providers and adults with neurogenic cognitive-linguistic impairments were videotaped. Staff members involved in the interactions completed a questionnaire stating how successful they felt the interaction was and what positively or negatively impacted the interaction. Five speech-language pathologists viewed the interactions, rated the overall success of each, reported which interaction strategies they observed being used and indicated which strategies they felt most positively impacted the interactions.

Results: Use of communication strategies aided the interactions. It was found that as more strategies were used success of the interactions increased.

Conclusions: Interactions were aided by the use of communication strategies, especially when multiple strategies were used. Some strategies were more beneficial than others. Training staff in the use of communication strategies may help improve patients' satisfaction and success in rehabilitation.     

Traumatic brain injury state planning grant: preparing for change in a rural state

Purpose: The overarching purpose of this work was to generate a framework on which to build a traumatic brain injury (TBI) system-support action plan for individuals with a TBI living in a rural state.

Methods: Four research questions were posed aimed at describing rural service/support needs and service satisfaction among persons with a TBI, as well as rural service/support availability as defined by providers. One hundred and ninety-four providers/agencies and 250 individuals/family members completed one of two versions (provider/agency, individual/family member) of a Needs and Resources Assessment.

Results: Data analyses indicated that the majority of individual respondents lived at an impoverished income level and lived with a TBI for ∼12 years. Quality of life was perceived as significantly lower after the TBI than before. Employment decreased significantly following a TBI. Reasons for unemployment included a perceived inability to work, problems regarding proper accommodation and/or perceptions regarding being chosen as suitable job candidates.

Conclusions: Provider data confirmed that many important services are rarely available or specific to TBIs. Basic assistance with employment, cognitive training and occupational therapy were among those most needed. Paradoxically, a high proportion of individuals reported feeling satisfied with most services. Applications of these data along with recommendations for other rural states are described.     

Surgical complications secondary to decompressive craniectomy in patients with a head injury: a series of 108 consecutive cases

Background  Decompressive craniectomy is an important method for managing refractory intracranial hypertension in patients with head injury. We reviewed a large series of patients who underwent this surgical procedure to establish the incidence and type of postoperative complications. Methods  From 1998 to 2005, decompressive craniectomy was performed in 108 patients who suffered from a closed head injury. The incidence rates of complications secondary to decompressive craniectomy and risk factors for developing these complications were analysed. In addition, the relationship between outcome and clinical factors was analysed. Findings  Twenty-five of the 108 patients died within the first month after surgical decompression. A lower GCS at admission seemed to be associated with a poorer outcome. Complications related to surgical decompression occurred in 54 of the 108 (50%) patients; of these, 28 (25.9%) patients developed more than one type of complication. Herniation through the cranial defect was the most frequent complication within 1 week and 1 month, and subdural effusion was another frequent complication during this period. After 1 month, the “syndrome of the trephined” and hydrocephalus were the most frequent complications. Older patients and/or those with more severe head trauma had a higher occurrence rate of complications. Conclusions  The potential benefits of decompressive craniectomy can be adversely affected by the occurrence of complications. Each complication secondary to surgical decompression had its own typical time window for occurrence. In addition, the severity of head injury was related to the development of a complication. X. F. Yang and L. Wen contributed equally to this study.     

Traumatic brain injury in Finland 1991-2005: a nationwide register study of hospitalized and fatal TBI

Primary objective: To examine the epidemiology of traumatic brain injury (TBI) in Finland in 1991-2005.

Research design: Nationwide population based data of hospitalized and fatal TBI collected from the national registers of Finland. The incidence, age and gender distribution, aetiology, external causes, cursory outcome and mortality are presented.

Methods and procedures: The data were collected from the National Hospital Discharge Register of Finland and from the official cause-of-death register of Statistics Finland.

Main outcome and results: The average incidence of hospitalized TBI was 101/100 000 population and the mortality rate 18.1/100 000. The incidence increased by 59.4% in the patients aged 70 years or older while the incidence decreased by 2.4% in the younger age groups. The mortality rate decreased in men. The most common external causes were falls. The oldest patients needed 6.8-times longer stay in the hospital than the youngest. After discharge 54% of the patients needed at least occasional care.

Conclusions: TBI prevention should be focused to the main groups at risk. The need for further care, rehabilitation and increasing the awareness of TBI is obvious.     

The characteristics of patients who do not seek medical treatment for traumatic brain injury

Primary objective: To identify factors associated with not seeking medical care for traumatic brain injury (TBI).

Research Design: Internet survey.

Methods and procedures: The survey consisted of 17 questions related to demographics, TBI case ascertainment, location and mechanism of injury, type of treatment sought, and post-concussive (PC) symptoms. Logistic regression was used to identify factors associated with not seeking medical care.

Main outcome and results: Of the 1381 survey respondents with TBI, 584 (42%) did not seek medical care. TBI respondents were less likely to seek care if they were older (OR 0.98, 95% CI 0.97-0.99), suffered a mild TBI grade 2/3 (OR 0.42, 95% CI 0.31-0.58), or were injured in the home (OR 0.53, 95% CI 0.36-0.78).

Conclusions: Several factors associated with not seeking medical care after TBI were identified. Raising public awareness of the signs and symptoms of TBI, and the benefits of medical care, could help increase the number of TBI patients who seek medical care.     

Transcranial Doppler pulsatility index is not a reliable indicator of intracranial pressure in children with severe traumatic brain injury

BackgroundThe TCD-derived PI has been associated with ICP in adult studies but has not been well investigated in children. We examined the relationship between PI and ICP and CPP in children with severe TBI.MethodsData were prospectively collected from consecutive TCD studies in children with severe TBI undergoing ICP monitoring. Ipsilateral ICP and CPP values were examined with Spearman correlation coefficient (mean values and raw observations), with a GEE, and as binary values (1 and 20 mm Hg, respectively).ResultsThirty-four children underwent 275 TCD studies. There was a weak relationship between mean values of ICP and PI (P = .04, r = 0.36), but not when raw observations (P = .54) or GEE (P = .23) were used. Pulsatility index was 0.76 when ICP was lower than 20 mm Hg and 0.86 when ICP was 20 mm Hg or higher. When PI was 1 or higher, ICP was lower than 20 mm Hg in 62.5% (25 of 40 studies), and when ICP was 20 mm Hg or higher, PI was lower than 1 in 75% (46 of 61 studies). The sensitivity and specificity of a PI threshold of 1 for examining the ICP threshold of 20 mm Hg were 25% and 88%, respectively. The relationship between CPP and PI was stronger (P = .001, r = ?0.41), but there were too few observations below 50 mm Hg to examine PI at this threshold.ConclusionThe absolute value of the PI is not a reliable noninvasive indicator of ICP in children with severe TBI. Further study is required to examine the relationship between PI and a CPP threshold of 50 mm Hg.     

Outcome of penetrating intracranial injuries in a military setting

Background

Penetrating intracranial injuries are common in the deployed military medical environment. Early assessment of prognosis includes initial conscious level. There has been no previous identification of different outcomes depending on mechanism of penetrating injury. The aim of this study was to define outcome from penetrating head injury in our population, and to compare outcome between gunshot wound (GSW) and blast fragment injury, in order to detect a difference in survival.

Methods

A retrospective database review was undertaken using the UK Joint Theatre Trauma Registry (JTTR) between the dates 2003 and 2011 to identify all cases of penetrating head injury. Data collected included mechanism of injury, first recorded GCS, injury severity score (ISS), abbreviated injury scale (AIS) head score, concomitant extracranial injury, surgical intervention, hospital length of stay, and survival.

Results

813 patients sustained a penetrating head injury, of whom 625 were injured by blast fragmentation and 188 were injured by GSW; overall 336 patients (41.3%) died. There was a significant difference between survival from GSW (41.5%) and blast fragment (63.8%; p < 0.001). In addition, the GCS in patients injured by GSW was significantly lower than that in patients injured by blast fragment. 157 cases sustained isolated head injury (79 GSW, 78 blast). The difference in injury severity between these groups was marked; median AIS was higher in the GSW group, survival lower (42% vs. 88%; p < 0.001) and distribution of GCS categories less favourable (p < 0.001). 338 of 343 patients (98.5%) with a best recorded GCS > 5, survived to discharge.

Conclusion

Most patients who present following penetrating intracranial injury, who have a GCS > 5, survive to discharge. There is a significant difference in survival to hospital discharge following penetrating injury caused by blast fragment compared to those caused by GSW, partly attributable to a difference in injury severity. This is the first study to specifically highlight and define this difference.     

Validity of administrative data for characterizing traumatic brain injury-related hospitalizations

Primary objective: To examine the validity of Maryland Hospital Discharge (MHD) data for identifying and characterizing traumatic brain injury (TBI)-related hospitalizations.

Methods: All TBI-related hospitalizations in 1999 were identified using MHD and Maryland Trauma Registry (MTR) data. In addition, a sample of records were abstracted to compare agreement between MHD and chart data.

Results: The MHD file identified fewer TBI cases (61%) compared to the MTR (95%). Overall, TBI-related hospitalization rates based on MHD were significantly fewer (95; 95% CI 92, 98) vs MHD and MTR (144; 95% CI 140, 147). There was good agreement between the MHD and chart data regarding skull fractures or intracranial lesions (κ = 0.73 and 0.83, respectively), but poor agreement for neurologic abnormalities or amnesia. The MHD significantly underestimated TBI severity.

Conclusions: TBI cases, especially mild ones, were under-reported by MHD data. MHD data are better at detecting anatomic injuries compared to TBI symptoms and sequella.     

大鼠自由落体脑外伤模型的制作

目的改进Feeney‘s自由落体模型装置并制作大鼠脑外伤模型,探讨该模型的病理学特点及对临床实验的价值.方法采用电磁铁释控开关自由落体模型,以不同冲击力(200g×cm、600g×cm、1000g×cm)致大鼠轻、中、重度脑损伤,并进行一系列病理学观察.结果病理学证实脑组织出现不同程度的改变,与致力伤大小成正比.结论本模型对脑外伤实验和临床研究有实用价值.     

Inconsistencies with screening for traumatic brain injury in spinal cord injury across the continuum of care

Objective: Explore how traumatic brain injury (TBI) is screened among spinal cord injury (SCI) patients across the continuum of care.

Design: Retrospective chart review

Setting: Emergency department, trauma, inpatient rehabilitation

Participants: 325 patients with SCI from inpatient rehabilitation facility (IRF) between March 1, 2011 and December 31, 2014 were screened. 49 eligible subjects had traumatic SCI and received care in adjoining acute care (AC) hospital.

Outcome Measures: Demographic characteristics and variables that capture diagnosis of TBI/SCI included documentation from ambulance, emergency department, AC, and IRF including ICD-9 codes, altered mental status, loss of consciousness (LOC), Glasgow Coma Score, Post Traumatic Amnesia (PTA), neuroimaging, and cognitive assessments.

Results: Participants were male (81%), white (55%), privately insured (49%), and aged 39.3±18.0 years with 51% paraplegic and 49% tetraplegic. Mechanisms of injury were gunshot wound (31%), fall (29%), and motor vehicle accident (20%). TBI occurred in 65% of SCI individuals, however documentation of identification of TBI, LOC, and CT imaging results varied in H&P, discharge notes, and ICD-9 codes across the continuum. Cognitive assessments were performed on 16% of subjects.

Conclusions: Documentation showed variability between AC and IRF and among disciplines. Imaging and GCS were more consistently documented than LOC and PTA. It is necessary to standardize screening processes between AC and IRF to identify dual diagnosis.     

Resource utilization and indications for helicopter transport of head-injured children

Introduction

Helicopter emergency medical services (HEMS) have provided benefit for severely injured patients. However, HEMS are likely overused for the transportation of both adult and pediatric trauma patients. In this study, we aim to evaluate the degree of overuse of helicopter as a mode of transport for head-injured children. In addition, we propose criteria that can be used to determine if a particular patient is suitable for air versus ground transport.

Being restricted in participation after a traumatic brain injury is negatively associated by passive coping style of the caregiver

Purpose: To examine whether the caregivers' coping style is associated with the functional outcome of the traumatic brain injury (TBI) patient 1 year post-injury.

Method: A cross-sectional study among patients with a TBI, including their primary caregivers. The study included 51 patients aged 17-64 years with a moderate-to-severe TBI and 51 caregivers (23 parents and 28 partners) aged 23-67 years. The coping preferences of the caregivers were assessed at minimum 6 and maximum 12 months post-injury, by filling out the Utrecht Coping List (UCL) and were related to limitations in activity, as measured with the Frenchay Activities Index and with restrictions in participation as measured with the Sickness Impact Profile-68 of TBI patients 1 year post-injury. The patients were interviewed at their homes; the caregivers received and returned the UCL by mail.

Results: The patients' age and the caregivers' coping style are independently associated with restrictions in participation 1 year post-injury.

Conclusions: A passive coping style of the primary caregiver is negatively associated with the patient's functional outcome in terms of participation in society.     

Domains of a TBI minimal data set: community reintegration phase

Efforts to establish a minimal data set for the period of community integration after traumatic brain injury (TBI) have been the focus of a working group of leading researchers, clinicians and advocates attending the Galveston Brain Injury Symposium in 2001 and 2002. The purpose of the data set is to increase the consistency and interpretability of TBI research and programme evaluation by providing a common set of measures to document key aspects of community integration. It is intended to be sensitive to intervention, comprehensive, reflect satisfaction and outcome and promote future treatment/therapy. In deciding on the components of a minimal data set, the tri-partite model of outcomes was adopted (initially employed in psychotherapy, adapted to TBI) which focuses on the needs of the individual, society and the health provider. Scales are recommended for the respective components of the model.     

Puerarin ameliorates oxidative stress in a rodent model of traumatic brain injury

Background

A wealth of evidence has suggested that oxidative stress is involved in the secondary brain injury after traumatic brain injury (TBI). Recently, numerous in vivo and in vitro studies were reported that puerarin could inhibit oxidative stress through the activation of phosphatidylinositol 3-kinase (PI3K)-Akt pathway. It is unknown, however, whether puerarin can provide neuroprotection and reduce oxidative stress after TBI. The present study investigated the effects of puerarin on the TBI-induced neurodegeneration, oxidative stress, and the possible role of PI3K-Akt pathway in the neuroprotection of puerarin, in a rat model of TBI.

Materials and methods

Rats were randomly distributed into various subgroups undergoing the sham surgery or TBI procedures. Puerarin (200 mg/kg) was given intraperitoneally at 10 min before injury and PI3K-Akt pathway inhibitor LY294002 was also administered intracerebroventricular in one subgroup. All rats were killed at 24 h after TBI for examination.

Results

Our data indicated that puerarin could significantly reduce TBI-induced neuronal degeneration, accompanied by the partial restoration of the redox disturbance and enhanced expression of phospho-Akt in the pericontusional cortex after TBI. Moreover, PI3K-Akt pathway inhibitor LY294002 could partially abrogate the neuroprotection of puerarin in rats with TBI.

Conclusions

These results indicate that puerarin can ameliorate oxidative neurodegeneration after TBI, at least in part, through the activation of PI3K-Akt pathway.     

The presence and impact of traumatic brain injury among clients in treatment for co-occurring mental illness and substance abuse

Objectives: To compare diagnostic and treatment-related differences between persons participating in treatment for dually diagnosed substance use disorders and severe mental illness who have or do not have a history of traumatic brain injury (TBI).

Design: Prospective cohort.

Interventions: Not applicable.

Primary measures: Demographic information, diagnostic data, pre-treatment status, treatment participation and staff assessment of functioning.

Results: Seventy-two percent of participants in treatment for dually diagnosed substance use disorders and severe mental illness reported a history of at least one TBI. Participants with TBI had greater morbidity as reflected in more complex psychiatric diagnoses and greater likelihood of being diagnosed with an Axis II personality disorder. Participants with a TBI showed tendencies toward earlier onset of substance use and worse current functioning. Both a greater number of injuries and earlier age at first TBI showed some indications of being associated with worse morbidity.

Conclusions: Individuals dually diagnosed with substance use disorders and severe mental illness may have a high rate of TBI, which in turn could contribute to important clinical and treatment differences. Results also suggested the need for validated methods of identifying aspects of a prior history of TBI that provide more information than presence/absence.     

外伤性丘脑基底节区血肿的临床预后分析

目的探讨外伤性丘脑基底节区血肿的相关危险因素,为早期诊断及治疗提供依据。方法收集杭州师范大学医学院附属余杭医院自2000至2009年收治的外伤性丘脑基底节区血肿患者57例,根据预后分为两组,预后不良组和预后良好组,多因素回归分析相关因素对预后的影响。结果单因素分析显示血肿大小、入院GCS评分、合并其他颅内出血、瞳孔变化、PLT对外伤性丘脑基底节区血肿的预后的影响具有统计学意义（P〈0.05）。多因素logistic回归分析显示血肿大小、入院GCS评分、瞳孔变化是外伤性丘脑基底节区血肿的预后的独立危险因素。结论对于血肿量大、入院GCS评分较低、瞳孔有变化者常提示预后不良,因此要及时观察病情变化,早期救治,对提高外伤性丘脑基底节区血肿的预后有着积极的作用。