Sexuality in individuals with traumatic brain injury and their partners

Whilst previous research has detailed the impact of TBI on an individual’s sexuality, few studies have investigated couples’ sexuality where one partner has sustained a TBI. The study assessed sexual function in individuals with TBI and their partners. Fifty five individuals who had sustained TBI and their partners completed the Derogatis Interview for Sexual Function—Self Report (DISF-SR). All participants scored below the 50th percentile in relation to norms. Whilst participants with TBI obtained lower T-scores than partners on all subscales (except for sexual behaviour/experiences where scores were equivalent), as well as the total score, none of these differences was significant. Item analysis indicated that female participants with TBI reported significantly lower scores than female partners on frequency of having normal lubrication. Normative comparisons revealed that approximately one-third of individuals with TBI and one-fifth of their partners scored below the second percentile. Given the high frequency of sexual problems in individuals with TBI, which also impact their partners, addressing sexual problems should be a priority in rehabilitation and beyond.     

Long-term neurological and neuropsychological outcome in patients with severe traumatic brain injury

Background

Severe traumatic brain injury (TBI) remains a major cause of death and disability worldwide. The aim of the study was to evaluate predictors for neurological and neuropsychological long-term outcome in patients with severe TBI treated according to an intracranial pressure (ICP-) targeted therapy.

Methods

From 08/2005 to 12/2008, 46 patients with severe TBI and more than 12 h of intensive care treatment were included in this study. Neurological outcome was assessed with the Glasgow Outcome Scale (GOS). Neuropsychological performance assessing 9 different domains was evaluated at long-term follow-up (median 20.5 months; range 10–46). Logistic regression was used to identify favourable outcomes according to the GOS and Fisher's exact tests were used to identify predictors of severe neuropsychological impairments at follow-up.

Results

Twenty-nine patients were available for neuropsychological assessment at long-term follow-up. Only 2 out of 29 patients presented normal or average neuropsychological findings throughout all 9 neuropsychological domains at long-term follow-up. The percentage of a favourable outcome (GOS 4-5) increased from 13.8% at hospital discharge to 75.8% at rehabilitation discharge to 79.3% at long-term follow-up, respectively. Age ≤40 was found to be a strong predictor of favourable outcome at follow-up (OR 5.95, 95% CI 1.41 25.00, p = 0.015). The GOS at hospital discharge was not a predictor for severe impairments in any of the 9 different neuropsychological domains (all p-values were p > 0.268). In contrast, the GOS at rehabilitation discharge was found to be a predictor of severe impairments at follow-up in all but one domain assessed (all p-values less than p < 0.038).

Conclusions

The GOS at rehabilitation discharge should be regarded as a better predictor for neuropsychological impairments at long-term follow-up than the GOS at hospital discharge. Even in patients with favourable GOS after finishing a course of rehabilitation, three quarters of these patients may have at least one severe neuropsychological deficit. Therefore, it remains of paramount importance to provide long-term neuropsychological support to further improve outcome after TBI.     

Role of valued living and associations with functional outcome following traumatic brain injury

Valued living (VL) is associated with improved enjoyment and engagement with daily activities despite negative emotional state or ongoing pain. However, the role of VL in recovery following traumatic brain injury (TBI) has yet to be investigated. This study aimed to examine changes in VL over the course of recovery and variables associated with VL. Participants with moderate-to-severe TBI were recruited from a rehabilitation hospital in three cohorts: “Early” (n?=?25), “Mid” (n?=?9) and “Late” (n?=?36) post-TBI. All participants were assessed at time of recruitment and 12 months later. The main measure was the Valued Living Questionnaire. Compared to pre-injury estimates, VL was significantly reduced at 12 months post-injury. Levels of VL remained reduced between 2 and 3 years and increased between 3 and 6 years post-injury. VL was strongly associated with improved functional and psychosocial outcomes. Changes in VL occur over at least 3–5 years post-injury, with 12 months post-TBI a suitable time for intervention given VL remains low over the next 24 to 36 months post injury. Targeted intervention to modify values and/or valued activities to be consistent with post-injury capacity could improve rates of return to pre-injury levels of VL.     

Influence of glibenclamide on outcome in patients with type 2 diabetes and traumatic brain injury

Background and purpose

The influence of sulfonylurea receptor 1 (SUR1) and its inhibitor glibenclamide on progressive secondary hemorrhage (PSH), progressive hemorrhagic necrosis (PHN), and brain edema has been studied in rat models of traumatic brain injury (TBI) and ischemia. These studies indicate that blocking SUR1 may exert protective effects in terms of outcome.

Methods

We discuss the effects of glibenclamide on outcome in patients with type 2 diabetes mellitus and TBI. We collected demographic, clinical, and imaging data from the clinical records of TBI patients with type 2 diabetes who were admitted to the neurosurgery department at Shanghai 6th People's Hospital between 2001 and 2012. Data from patients who met the inclusion criteria were analyzed. Patients were divided into glibenclamide group and insulin group.

Results

Of 70 patients fit criteria for inclusion, no significant difference was observed except for age and fasting plasma glucose between the two groups. Outcome indicators, including GCS discharge, GOS discharge, length of study in hospital (LOS-H), and the presence of PSH showed no significant difference too (p > 0.05), except for length of stay in neuro-intensive care unit (LOS-NICU) (p < 0.05). Age, hours between the initial CT scan and the injury (HCT1) and GCS at admission were observed as factors associated with PSH after logistic regression.

Conclusions

In general, the use of glibenclamide to control plasma glucose after TBI had no significant effect on patient outcome at discharge but it could reduce the LOS-NICU (p < 0.05). Glibenclamide also had no apparent effect on the presence of PSH in TBI patients with type 2 diabetes mellitus.     

Sequelae following traumatic brain injury: The cerebrovascular perspective

Traumatic brain injury (TBI) initiates a huge repertoire of biochemical perturbations. On one hand, destructive events are set into motion while on the other hand, protective and recovery mechanisms are evoked, each with their own temporal and spatial characteristics. The brain exists as a finely tuned balance between vascular, neuronal and glial interactions and so a complex interplay between these factors will dictate the final evolution of pathogenesis. Although vascular damage is a key event, it remains a somewhat neglected component to the underlying degenerative processes that evolve following injury to the brain. The present review will act to integrate the current knowledge of the vascular events proceeding injury to the brain, with an emphasis on how this impacts the control of vascular function and thus cerebral blood flow.     

脑室内颅内压持续监测和阶梯式治疗重型颅脑外伤

目的探讨脑室内颅内压持续监测对重型颅脑损伤后颅内压增高治疗的指导意义及阶梯式干预治疗的效果。方法对上海市神经外科急救中心2004年11月至2006年1月间收治128例重型颅脑损伤患者,其中GCS 3～5分55例,6～8分73例全部行脑室内颅内压监测术,116例行Codman脑室探头置入颅内压监测术,12例行Camino脑室探头颅内压监测术。根据颅内压变化予以相应的阶梯式治疗,以达到理想的颅内压控制及维持脑灌注压。结果预后良好72例(56.3%);中残12例(9.4%);重残23例(18.0%);植物状态10例(7.8%);死亡11例(8.6%)。结论脑室内颅内压监测下通过阶梯式治疗能有效控制颅内压,维持脑灌注压,降低重型颅脑外伤的病残率和死亡率。     

COMT Val158Met polymorphism is associated with post-traumatic stress disorder and functional outcome following mild traumatic brain injury

Mild traumatic brain injury (mTBI) results in variable clinical trajectories and outcomes. The source of variability remains unclear, but may involve genetic variations, such as single nucleotide polymorphisms (SNPs). A SNP in catechol-o-methyltransferase (COMT) is suggested to influence development of post-traumatic stress disorder (PTSD), but its role in TBI remains unclear. Here, we utilize the Transforming Research and Clinical Knowledge in Traumatic Brain Injury Pilot (TRACK-TBI Pilot) study to investigate whether the COMT Val¹⁵⁸Met polymorphism is associated with PTSD and global functional outcome as measured by the PTSD Checklist – Civilian Version and Glasgow Outcome Scale Extended (GOSE), respectively. Results in 93 predominately Caucasian subjects with mTBI show that the COMT Met¹⁵⁸ allele is associated with lower incidence of PTSD (univariate odds ratio (OR) of 0.25, 95% CI [0.09–0.69]) and higher GOSE scores (univariate OR 2.87, 95% CI [1.20–6.86]) 6-months following injury. The COMT Val¹⁵⁸Met genotype and PTSD association persists after controlling for race (multivariable OR of 0.29, 95% CI [0.10–0.83]) and pre-existing psychiatric disorders/substance abuse (multivariable OR of 0.32, 95% CI [0.11–0.97]). PTSD emerged as a strong predictor of poorer outcome on GOSE (multivariable OR 0.09, 95% CI [0.03–0.26]), which persists after controlling for age, GCS, and race. When accounting for PTSD in multivariable analysis, the association of COMT genotype and GOSE did not remain significant (multivariable OR 1.73, 95% CI [0.69–4.35]). Whether COMT genotype indirectly influences global functional outcome through PTSD remains to be determined and larger studies in more diverse populations are needed to confirm these findings.     

华东六省一市颅脑创伤合并颅面损伤住院患者调查

目的掌握华东六省一市颅脑创伤合并颅面损伤住院患者临床流行病学特点。方法从《2004年华东六省一市颅脑创伤住院患者》数据库中整群抽取合并颌面损伤患者,用SPSS13.0统计软件包分析。结果15611例颅脑创伤患者中合并颌面损伤患者占40.37%,男女比3.59：1,平均年龄（38.70±16.93）岁,17～58岁患者占所有年龄组的80.04%,各年龄组上性别对于颅脑创伤合并颅面损伤的发病有统计学意义（P〈0.01）。主要受害者是农民（46.11%）、工人（28.07%）、学生及儿童（9.08%）,文化程度以中学（55.16%）、小学（29.50%）和文盲（6.22%）最多。公路（67.22%）、公共场所（11.35%）和矿山工地（9.46%）是主要发生地点;主要致伤原因是车祸伤（66.20%）、击打伤（12.20%）和高处坠落伤（10.71%）,而且在各年龄组中车祸伤都是主要致伤原因（P〈0.01）。颅脑创伤合并颅面损伤较其他颅脑创伤病情重,合并伤多,预后差。结论颅颌面损伤是颅脑创伤中最常见的合并症,多为中青年男性,且文化层次相对较低,这类患者较其他损伤病情重,预后差,在检查、诊断和治疗上需要各学科通力合作。     

Personal narrative approaches in rehabilitation following traumatic brain injury: A synthesis of qualitative research

Although narrative storytelling has been found to assist identity construction, there is little direct research regarding its application in rehabilitation following traumatic brain injury (TBI). The aim of this review was to identify published evidence on the use of personal narrative approaches in rehabilitation following TBI and to synthesise the findings across this literature. A systematic search of four databases was conducted in December 2016. No limit was set on the start date of the search. Personal narrative approaches were defined as direct client participation in sharing personal stories using written, spoken or visual methods. The search retrieved 12 qualitative research articles on the use of personal narrative approaches in TBI rehabilitation. Thematic synthesis of the narrative data and authors’ reported findings of the 12 articles yielded an overall theme of building a strengths-based identity and four sub-themes: 1) expressing and communicating to others; 2) feeling validated by the act of someone listening; 3) reflecting and learning about oneself; and 4) being productive. The findings of this review support the use of personal narrative approaches in addressing loss of identity following TBI. Healthcare professionals and the community are encouraged to seek opportunities for survivors of TBI to share their stories.     

Long term outcome following mild traumatic brain injury in Moroccan patients

Primary objectives

To describe the symptoms of chronic post-concussion syndrome (PCS) and to investigate the relationship between the persistence of these symptoms and different aspects of social life (return to work, quality of life, sport and leisure activities and family relationships) in Moroccan patients with mild traumatic brain injury (MTBI), one year after the trauma.

Methods

Forty-two adult patients who sustained MTBI were reviewed one year after trauma. We investigated the persistence of PCS by using the “Problem Checklist” questionnaire. We also assessed their quality of life using a visual analogue scale, and noted the changes in employment status, social activities and family relationships. Then, we examined whether there were significant relationships between these different data.

Results

More than half of the patients (n = 23, 54.8%) were found with persistent post-concussion symptoms at one year post-injury. Chronic PCS was significantly more common in married persons (p = 0.008) and significantly related to both non return to work (p ≤ 0.01), and QoL deterioration (p ≤ 0.001).

Conclusion

In this study, a large proportion of persons who sustained a MTBI experienced persistent symptoms up to one year after trauma. MTBI might have significant and lasting impact on the quality of life, which is to be verified by further studies.     

Outcome measures for traumatic brain injury

Traumatic brain injury (TBI) is a major public health problem resulting in death and disabilities of young and productive people. Though the mortality of TBI has decreased substantially in recent years the disability due to TBI has not appreciably reduced. Various outcome scales have been proposed and used to assess disability after TBI. A few, commonly used are Glasgow Outcome Scale (GOS) with or without extended scores, Disability Rating Scale (DRS), Functional Independence Measure (FIM), Community Integration Questionnaire (CIQ), and the Functional Status Examination (FSE). These scales assess disability resulting from physical and cognitive impairments. For patients with good physical recovery a cognitive and neuropsychological outcome measure is required. Such measures include Neurobehavioural Function Inventory and specific neuropsychological tests like Rey Complex Figure for visuoconstruction and memory, Controlled Oral Word Association for verbal fluency, Symbol Digit Modalities (verbal) for sustained attention and Grooved Pegboard for fine motor dexterity. A more holistic and complete outcome measure is Quality of Life (QOL). Disease specific QOL measure for TBI, Quality of Life after Brain Injury (QOLIBRI) has also been recently proposed. The problems with outcome measures include poor operational definitions, lack of sensitivity or low ceiling effects, inability to evaluate patients who cannot report, lack of integration of morbidity and mortality categories, and limited domains of functioning assessed. GOSE-E satisfies most of the criteria of good outcome scale and in combination with neuropsychological tests is a near complete instrument for assessment of outcome after TBI.     

Chronic ibuprofen administration worsens cognitive outcome following traumatic brain injury in rats

Traumatic brain injury (TBI) can induce progressive neurodegeneration in association with chronic inflammation. Since chronic treatment with the non-steroidal anti-inflammatory drug (NSAID), ibuprofen, improves functional and histopathologic outcome in a mouse model of Alzheimer's disease (AD), we investigated whether it would also improve long-term outcome following TBI. Anesthetized adult rats were subjected to fluid percussion brain injury. Over the following 4 months the injured animals received ibuprofen per os (formulated in feed) at the approximate doses of 20 mg/kg body wt/day (n=13), 40 mg/kg body wt/day (n=13), or control (feed only, n=12). Sham animals underwent surgery without injury or ibuprofen treatment (n=9). At 4 months post-injury, a Morris water maze task revealed a profound learning dysfunction in all three injured groups compared to the sham group. Surprisingly, the learning ability of injured animals treated with either chronic ibuprofen regimen was significantly worsened compared to non-treated injured animals. However, there was no difference in the extent of progressive atrophy of the cortex or hippocampus between treated and non-treated injured animals. These data may have important implications for TBI patients who are often prescribed NSAIDs for chronic pain.     

Effects of progesterone on neurologic and morphologic outcome following diffuse traumatic brain injury in rats

Previous studies have identified that progesterone may be neuroprotective following traumatic brain injury (TBI). However, most of these have utilized models of TBI that produce a focal lesion or a significant ischemic component, neither of which is necessarily present in diffuse TBI. The current study uses a model of diffuse TBI in rats to examine the effects of progesterone on morphological changes and functional outcome following TBI. Male and ovariectomized female rats were subject to severe impact-acceleration injury under halothane anesthesia. After injury, animals were given a physiological, subcutaneous dose of progesterone (1.67 mg/kg) or equal volume of vehicle (sesame oil) daily throughout a 9-day neurologic assessment period where functional outcome was assessed using the rotarod and Barnes maze tests. There was a similar post-injury performance of male and ovariectomized female animals. Post-injury administration of progesterone improved the motor and cognitive performance of ovariectomized and male animals compared to vehicle-treated controls. Morphological differences between these animals, such as dark cell change, caspase-3 and APP immunoreactivity, were also investigated. Progesterone-treated males showed comparatively less dead or dying neurons, and marked attenuation of caspase-3 immunoreactivity. Both ovariectomized female and male animals treated with progesterone showed a profound reduction in axonal injury (seen via diminished APP immunoreactivity) when compared to controls. We conclude that physiological concentrations of progesterone administered after diffuse TBI confers beneficial effects on morphologic and functional outcome in both ovariectomized female and male animals.     

Age-dependent synuclein pathology following traumatic brain injury in mice

Synucleins (Syn), a family of synaptic proteins, includes alpha-Syn, which plays a pivotal role in Parkinson's disease and related neurodegenerative diseases (synucleinopathies) by forming distinct brain pathologies (Lewy bodies and neurites). Since traumatic brain injury (TBI) is a poorly understood risk factor for Parkinson's disease, we examined the effects of TBI in the young and aged mouse brain on alpha-, beta-, and gamma-Syn. Immunohistochemical analysis showed that brains from sham-injured young and aged mice had normal alpha- and beta-Syn immunoreactivity (IR) in neuropil of cortex, striatum, and hippocampus with little or no gamma-Syn IR. At 1 week post TBI, the aged mouse brain showed a transient increase of alpha- and beta-Syn IR in the neuropil as well as an induction of gamma-Syn IR in subcortical axons. This was associated with strong labeling of striatal axon bundles by antibodies to altered or nitrated epitopes in alpha-Syn as well as by antibodies to inducible nitric oxide synthase. However, these TBI-induced changes disappeared by 16 weeks post TBI, and altered Syn IR was not seen in young mice subjected to TBI nor in alpha-Syn knockout mice while Western blots confirmed that TBI induced transient alterations of alpha-Syn in the mouse brains. This model of age-dependent TBI-induced transient alterations in alpha-Syn provides an opportunity to examine possible links between TBI and mechanisms of disease in synucleinopathies.     

Randomized treatment trial in mild traumatic brain injury

OBJECTIVE: To determine whether multidisciplinary treatment of mild traumatic brain injury (MTBI) improves neurobehavioral outcome at 6 months postinjury. METHODS: Subjects with MTBI were randomly assigned to treatment (n=97) or nontreatment (control, n=94) groups. Treated patients were assessed within 1 week of injury and thereafter managed by a multidisciplinary team according to clinical need for a further 6 months. Control subjects were not offered treatment. Six-month outcome measures included: severity of postconcussive symptoms (Rivermead Post-Concussion Disorder Questionnaire), psychosocial functioning (Rivermead Follow-up Questionnaire), psychological distress (General Health Questionnaire), and cognition (neurocognitive battery). RESULTS: Treatment and control subjects were well-matched for demographic and MTBI severity data. In addition, the two groups did not differ on any outcome measure. However, in individuals with preinjury psychiatric difficulties (22.9% of the entire sample), subjects in the treatment group had significantly fewer depressive symptoms 6 months postinjury compared with untreated controls (P=.01). CONCLUSIONS: These findings suggest that routine treatment of all MTBI patients offers little benefit; rather, targeting individuals with preinjury psychiatric problems may prove a more rational and cost-effective approach.     

A comparison of functional outcomes in hypoxia and traumatic brain injury: a pilot study

We present our experience with 30 patients on functional outcomes of patients with anoxic brain injury (ABI, n = 15) due to cardiac etiologies from freestanding inpatient rehabilitation hospital. A convenience sample of patient with traumatic brain injury (TBI, n = 15) with similar demographic characteristic to ABI was used for comparison on indices of activity of daily living, cognition, mobility as well as other indices of functional prognosis such as hospital length of stay, cost and discharge predisposition. No statistical significant differences were found between the two groups on the presently employed outcome measures. This investigation supports the positive impact of inpatient rehabilitation for individuals with hypoxia of cardiac etiology. Future research comparing outcomes of ABI to TBI with larger, controlled trials is warranted.     

Outcomes of traumatic brain injury in Hong Kong: Validation with the TRISS,CRASH, and IMPACT models

We aimed to test prognostic models (the Trauma Injury Severity Score, International Mission for Prognosis and Analysis of Clinical Trials in Traumatic Brain Injury, and Corticosteroid Randomisation After Significant Head Injury models) for 14-day mortality, 6-month mortality, and 6-month unfavorable outcome in a cohort of trauma patients with traumatic brain injury (TBI) in Hong Kong. We analyzed 661 patients with significant TBI treated in a regional trauma centre in Hong Kong over a 3-year period. The discriminatory power of the models was assessed as the area under the receiver operating characteristic curve. One-sample t-tests were used to compare actual outcomes in the cohort against predicted outcomes. All three prognostic models were shown to have good discriminatory power and no significant systemic over-estimation or under-estimation. In conclusion, all three predictive models are applicable to eligible TBI patients in Hong Kong. These predictive models can be utilized to audit TBI management outcomes for trauma service development in the future.     

Increased serum-GFAP in patients with severe traumatic brain injury is related to outcome

OBJECTIVES: Several studies have established the relevance of S-100 in blood as a marker of brain damage after traumatic brain injury. However, a more specific marker is required and glial fibrillary acidic protein (GFAP) is considered to be a good candidate. METHODS: In order to assess the increase of GFAP in serum (s-GFAP) after a severe traumatic brain injury (TBI) we collected daily serum samples from 59 patients with severe TBI starting on the day of the trauma. S-GFAP was measured using a sandwich ELISA. The Glasgow outcome scale (GOS) assessed outcome after 1 year. RESULTS: All but one patient had maximal s-GFAP values above the laboratory reference value (median increased 10-fold). The highest detected levels were seen during the first days after TBI and then decreased gradually. Patients with unfavourable outcome had significantly (p<0.001) higher maximal s-GFAP values in the acute phase compared with patients with favourable outcome. All patients (n=5) with s-GFAP>15.04 microg /L died (reference level<0.15 microg/L). We found no significant difference in the maximal s-GFAP levels of patients with isolated brain injury in comparison with patients with multiple traumas. CONCLUSION: Serum-GFAP is increased during the first days after a severe traumatic brain injury and related to clinical outcome.     

颅脑外伤对患者智能状况的影响及相关因素研究

目的：研究颅脑外伤对患者智能状况的影响,探讨与之相关的生物、心理、社会因素。方法：本研究对63例急性期颅脑外伤患者,采用标准化测评工具,包括《格拉斯哥昏迷评分（GCS）》、《简易智力状态检查》、《数字划消测验》、《社会支持评定量表》、《日常生活能力量表》及自制颅脑外伤患者人口学与相关因素调查表等,逐例进行现场临床测评,将拟分析的因素进行量化,最后将汇总的资料进行整理,分析、总结。所有统计分析均使用SAS软件包完成。结果：颅脑外伤患者智能缺陷的发生率为71．43％,其显著性差异表现在文化程度、治疗措施及手术类型三个方面,主要影响因素有外伤程度、外伤部位、社会支持、文化程度及治疗措施。结论：不同外伤类型的颅脑外伤对患者的智能状 况产生不同程度的影响,其相关因素包括生物、心理、社会学三个方面,基础的生物学病因虽然对智能起决定作用,而社会心理因素的影响仍不可忽视。     

大鼠颅脑创伤后肝细胞生长因子表达变化的实验研究

目的 探讨肝细胞生长因子(HGF)在颅脑创伤后的表达趋势,为颅脑创伤治疗中的HGF干预策略提供前期研究基础. 方法 96只wistar大鼠按随机数字表法分为实验组和假手术组,实验组为液压冲击中度颅脑创伤大鼠,并分为伤后2h、6h、12h、24 h、72h、168 h、336 h组,假手术组不致伤,每组再分为两个亚组.每亚组6只,一组行HE及免疫组化染色,观察伤后病理变化及HGF的表达部位和表达量,另外一组用RT-PCR的方法 观察创伤后HGF mRNA表达情况.结果 在创伤后的大鼠大脑皮层组织中,HGF在蛋白水平以及基因水平都出现表达增高的情况.创伤边缘区HGF阳性细胞数从伤后24 h开始增多,168 h达高峰,336 h有所下降,但仍高于伤前水平,差异有统计学意义(P<0.05).HGF mRNA表达量从创伤后72 h开始增加,168 h达高峰,与假手术组比较差异有统计学意义(P<0.05). 结论 HGF作为神经营养因子和血管生长因子,可能参与了颅脑创伤后神经元的保护和组织的修复、再生.