Traumatic Brain Injury in Iowa: Iowa Brain Injury Resource Network Outcome Evaluation 2007-2009, August 2011

Termed the “silent epidemic,” traumatic brain injury (TBI) is the most debilitating outcome of injury, and is characterized by the irreversibility of its damages, long-term effects on quality of life and healthcare costs. The latest data available from the CDC estimate that nationally, 52,000 people die each year from TBI2. In Iowa, TBI is a major public health problem. The numbers and rates of hospitalizations and emergency department (ED) visits due to TBIs are steadily increasing. From 2006 to 2008, there were on average 545 injury deaths per year. Among the injured Iowans, TBI constituted nearly 30 percent (545) of all injury deaths, ten percent (1,591) of people hospitalized and seven percent (17,696) of ED visitors. 3 The state of Iowa has been supporting secondary prevention services to TBI survivors for several years. An Iowa organization that has made a significant effort in assisting TBI survivors is the Brain Injury Association of Iowa (BIAIA). The BIAIA administers the IBIRN program in cooperation with the Iowa Department of Public Health (IDPH) through HRSA TBI Implementation grant funding and state appropriations.

Alterations in the local myocardial motion pattern in patients suffering from pressure overload due to aortic stenosis.

BACKGROUND: MR tissue tagging allows the noninvasive assessment of the locally and temporally resolved motion pattern of the left ventricle. Alterations in cardiac torsion and diastolic relaxation of the left ventricle were studied in patients with aortic stenosis and were compared with those of healthy control subjects and championship rowers with physiological volume-overload hypertrophy. METHODS AND RESULTS: Twelve aortic stenosis patients, 11 healthy control subjects with normal left ventricular function, and 11 world-championship rowers were investigated for systolic and diastolic heart wall motion on a basal and an apical level of the myocardium. Systolic torsion and untwisting during diastole were examined by use of a novel tagging technique (CSPAMM) that provides access to systolic and diastolic motion data. In the healthy heart, the left ventricle performs a systolic wringing motion, with a counterclockwise rotation at the apex and a clockwise rotation at the base. Apical untwisting precedes diastolic filling. In the athlete's heart, torsion and untwisting remain unchanged compared with those of the control subjects. In aortic stenosis patients, torsion is significantly increased and diastolic apical untwisting is prolonged compared with those of control subjects or athletes. CONCLUSIONS: Torsional behavior as observed in pressure- and volume-overloaded hearts is consistent with current theoretical findings. A delayed diastolic untwisting in the pressure-overloaded hearts of the patients may contribute to a tendency toward diastolic dysfunction.

Brain injury program to ensure greater access to community-based services, July 11, 2006

More than 2,200 Iowans each year experience a traumatic brain injury that requires hospitalization. Of those, more than 750 will experience long-term disability as a result. According to a 2000 CDC report, there are an estimated 50,000 such individuals living in Iowa – a number similar to the population of Ames. As part of an enterprise-wide effort to ensure that all Iowans, including those with brain injuries, have access to quality healthcare, Governor Tom Vilsack signed the Brain Injury Services program bill on May 23. The bill will allow the Iowa Department of Public Health (IDPH) to implement a one-of-a-kind program to help those with brain injuries and their families in navigating and maximizing the Iowa community-based service system.

Circadian Variations of Ischemic Burden Among Patients with Myocardial Infarction Undergoing Primary Percutaneous Coronary Intervention

Introduction Le rythmes circadiens influencent différents paramètres de la physiologie et de la physiopathologie cardiovasculaire. Récemment, une relation entre la taille d'un infarctus et l'heure du jour à laquelle il se produit a été suggérée dans des modèles expérimentaux d'infarctus du myocarde. Le but de cette étude a été de déterminer si les rythmes circadiens pouvaient influencer la gravité d'un infarctus en terme de taille et de mortalité chez les patients hospitalisés pour un infarctus du myocarde avec sus-décalage du segment ST (STEMI) ayant bénéficié d'une intervention coronarienne percutanée primaire (ICPP). Méthode Chez 353 patients consécutifs admis avec un STEMI et traités par ICPP, l'heure à la survenue des symptômes, le pic de créatine kinase (reflet de la taille d'un infarctus) et le suivi à 30 jours ont été collectés. Les patients ont été répartis en 4 groupes en fonction de l'heure de survenue de leurs symptômes (00 :00 - 05h59, 06:00 - 11 59 12 00-17h59 et 18h00-23h59). Résultats Aucune différence statistiquement significative n'a été retrouvée entre les différents groupes en ce qui concerne les caractéristiques des patients ou de leur prise en charge. Après analyse multivariée, nous avons mis en évidence une différence statistiquement significative entre les pics de créatine kinase chez les patients avec survenue des symptômes entre 00 :00 et 05:59, qui étaient plus élevés que les pics de créatine kinase chez les patients avec survenue des symptômes à tout autre moment de la journée (augmentation moyenne de 38,4%, ρ <0.05). A 30 jours, la mortalité des patients avec survenue des symptômes entre 00 :00 et 05:59 était également significativement plus élevé que celle des patients avec survenue à tout autre moment de la journée (p <0.05). Conclusion Notre étude démontre une corrélation indépendante entre la taille d'un infarctus STEMI traité par ICPP et le moment de la journée où les symptômes apparaissent. Ces résultats suggèrent que ce moment devrait être un paramètre important à prendre en compte pour évaluer le pronostic des patients.

Upregulation of the GABA transporter GAT-1 in the gracile nucleus in the spared nerve injury model of neuropathic pain.

Neuropathic pain is a major health issue and is frequently accompanied by allodynia (painful sensations in response to normally non-painful stimulations), and unpleasant paresthesia/dysesthesia, pointing to alterations in sensory pathways normally dedicated to the processing of non-nociceptive information. Interestingly, mounting evidence indicate that central glial cells are key players in allodynia, partly due to changes in the astrocytic capacity to scavenge extracellular glutamate and gamma-aminobutyric acid (GABA), through changes in their respective transporters (EAAT and GAT). In the present study, we investigated the glial changes occurring in the dorsal column nuclei, the major target of normally innocuous sensory information, in the rat spared nerve injury (SNI) model of neuropathic pain. We report that together with a robust microglial and astrocytic reaction in the ipsilateral gracile nucleus, the GABA transporter GAT-1 is upregulated with no change in GAT-3 or glutamate transporters. Furthermore, [(3)H] GABA reuptake on crude synaptosome preparation shows that transporter activity is functionally increased ipsilaterally in SNI rats. This GAT-1 upregulation appears evenly distributed in the gracile nucleus and colocalizes with astrocytic activation. Neither glial activation nor GAT-1 modulation was detected in the cuneate nucleus. Together, the present results point to GABA transport in the gracile nucleus as a putative therapeutic target against abnormal sensory perceptions related to neuropathic pain.

Influence of socioeconomic factors on delays, management and outcome amongst patients with acute myocardial infarction undergoing primary percutaneous coronary intervention.

The outcome after primary percutaneous coronary intervention (pPCI) for ST-elevation myocardial infarction (STEMI) is strongly affected by time delays. In this study, we sought to identify the impact of specific socioeconomic factors on time delays, subsequent STEMI management and outcomes in STEMI patients undergoing pPCI, who came from a well-defined region of the French part of Switzerland. A total of 402 consecutive patients undergoing pPCI for STEMI in a large tertiary hospital were retrospectively studied. Symptom-to-first-medical-contact time was analysed for the following socioeconomic factors: level of education, origin and marital status. Main exclusion criteria were: time delay beyond 12 hours, previous treatment with fibrinolytic agents or patients immediately referred for coronary artery bypass graft surgery. Therefore, 222 patients were finally included. At 1 year, there was no difference in mortality between the different socioeconomic groups. Furthermore, there was no difference in management characteristics between them. Symptom-to-first-medical-contact time was significantly longer for patients with a low level of education, Swiss citizens and unmarried patients, with median differences of 23 minutes, 18 minutes and 13 minutes, respectively (p <0.05). Nevertheless, no difference was found regarding in-hospital management and clinical outcome. This study demonstrates that symptom-to-first-medical-contact time is longer amongst people with a lower educational level, Swiss citizens and unmarried people. Because of the low mortality rate in general, these differences in delays did not affect clinical outcomes. Still, tertiary prevention measures should particularly focus on these vulnerable populations.

Improved myocardial tagging contrast in cine balanced SSFP images.

PURPOSE: To improve the tag persistence throughout the whole cardiac cycle by providing a constant tag-contrast throughout all the cardiac phases when using balanced steady-state free precession (bSSFP) imaging. MATERIALS AND METHODS: The flip angles of the imaging radiofrequency pulses were optimized to compensate for the tagging contrast-to-noise ratio (Tag-CNR) fading at later cardiac phases in bSSFP imaging. Complementary spatial modulation of magnetization (CSPAMM) tagging was implemented to improve the Tag-CNR. Numerical simulations were performed to examine the behavior of the Tag-CNR with the proposed method, and to compare the resulting Tag-CNR with that obtained from the more commonly used spoiled gradient echo (SPGR) imaging. A gel phantom, as well as five healthy human volunteers, were scanned on a 1.5T scanner using bSSFP imaging with and without the proposed technique. The phantom was also scanned with SPGR imaging. RESULTS: With the proposed technique, the Tag-CNR remained almost constant during the whole cardiac cycle. Using bSSFP imaging, the Tag-CNR was about double that of SPGR. CONCLUSION: The tag persistence was significantly improved when the proposed method was applied, with better Tag-CNR during the diastolic cardiac phase. The improved Tag-CNR will support automated tagging analysis and quantification methods.

Vasopressine lors d'infarctus myocardique aigu: implications cliniques [Vasopressin in acute myocardial infarct: clinical implications]

Since current data on vasopressin (AVP) secretion during the early phase of myocardial infarction is not extensive, plasma AVP was measured in 26 patients with acute myocardial infarction. Twelve had an increased AVP concentration (23.2 +/- 7.0 pg/ml; mean +/- SEM) whereas 14 had an AVP level less than 3 pg/ml (1.96 +/- 0.14 pg/ml). The patients with AVP greater than 3 pg/ml had higher heart rate and plasma osmolality than those with AVP less than 3 pg/ml. Blood pressure values were the same in both groups of patients. There was no difference in peak CPK and iso CPK activities between the two groups. Seven patients with AVP greater than 3 pg/ml died within the next few days, while only 1 patient with AVP less than pg/ml died. It thus appears that increased AVP concentration during acute myocardial infarction is associated with a poor prognosis. Whether it is a cause or a consequence of an unfavourable course of myocardial infarction remains to be determined.

Acute multivessel revascularization improves 1-year outcome in ST-elevation myocardial infarction: a nationwide study cohort from the AMIS Plus registry.

BACKGROUND: The optimal strategy for percutaneous coronary intervention (PCI) of ST-segment elevation myocardial infarction (STEMI) in multi-vessel disease (MVD), i.e., multi-vessel PCI (MV-PCI) vs. PCI of the infarct-related artery only (IRA-PCI), still remains unknown. METHODS: Patients of the AMIS Plus registry admitted with an acute coronary syndrome were contacted after a median of 378 days (interquartile range 371-409). The primary end-point was all-cause death. The secondary end-point included all major adverse cardiovascular and cerebrovascular events (MACCE) including death, re-infarction, re-hospitalization for cardiac causes, any cardiac re-intervention, and stroke. RESULTS: Between 2005 and 2012, 8330 STEMI patients were identified, of whom 1909 (24%) had MVD. Of these, 442 (23%) received MV-PCI and 1467 (77%) IRA-PCI. While all-cause mortality was similar in both groups (2.7% both, p>0.99), MACCE was significantly lower after MV-PCI vs. IRA-PCI (15.6% vs. 20.0%, p=0.038), mainly driven by lower rates of cardiac re-hospitalization and cardiac re-intervention. Patients undergoing MV-PCI with drug-eluting stents had lower rates of all-cause mortality (2.1% vs. 7.4%, p=0.026) and MACCE (14.1% vs. 25.9%, p=0.042) compared with those receiving bare metal stents (BMS). In multivariate analysis, MV-PCI (odds ratio, OR 0.69, 95% CI 0.51-0.93, p=0.017) and comorbidities (Charlson index ≥ 2; OR 1.42, 95% CI 1.05-1.92, p=0.025) were independent predictors for 1-year MACCE. CONCLUSION: In an unselected nationwide real-world cohort, an approach using immediate complete revascularization may be beneficial in STEMI patients with MVD regarding MACCE, specifically when drug-eluting stents are used, but not regarding mortality. This has to be tested in a randomized controlled trial.

Impact of tight glycemic control on cerebral glucose metabolism after severe brain injury: a microdialysis study.

OBJECTIVES: To analyze the effect of tight glycemic control with the use of intensive insulin therapy on cerebral glucose metabolism in patients with severe brain injury. DESIGN: Retrospective analysis of a prospective observational cohort. SETTING: University hospital neurologic intensive care unit. PATIENTS: Twenty patients (median age 59 yrs) monitored with cerebral microdialysis as part of their clinical care. INTERVENTIONS: Intensive insulin therapy (systemic glucose target: 4.4-6.7 mmol/L [80-120 mg/dL]). MEASUREMENTS AND MAIN RESULTS: Brain tissue markers of glucose metabolism (cerebral microdialysis glucose and lactate/pyruvate ratio) and systemic glucose were collected hourly. Systemic glucose levels were categorized as within the target "tight" (4.4-6.7 mmol/L [80-120 mg/dL]) vs. "intermediate" (6.8-10.0 mmol/L [121-180 mg/dL]) range. Brain energy crisis was defined as a cerebral microdialysis glucose <0.7 mmol/L with a lactate/pyruvate ratio >40. We analyzed 2131 cerebral microdialysis samples: tight systemic glucose levels were associated with a greater prevalence of low cerebral microdialysis glucose (65% vs. 36%, p < 0.01) and brain energy crisis (25% vs.17%, p < 0.01) than intermediate levels. Using multivariable analysis, and adjusting for intracranial pressure and cerebral perfusion pressure, systemic glucose concentration (adjusted odds ratio 1.23, 95% confidence interval [CI] 1.10-1.37, for each 1 mmol/L decrease, p < 0.001) and insulin dose (adjusted odds ratio 1.10, 95% CI 1.04-1.17, for each 1 U/hr increase, p = 0.02) independently predicted brain energy crisis. Cerebral microdialysis glucose was lower in nonsurvivors than in survivors (0.46 +/- 0.23 vs. 1.04 +/- 0.56 mmol/L, p < 0.05). Brain energy crisis was associated with increased mortality at hospital discharge (adjusted odds ratio 7.36, 95% CI 1.37-39.51, p = 0.02). CONCLUSIONS: In patients with severe brain injury, tight systemic glucose control is associated with reduced cerebral extracellular glucose availability and increased prevalence of brain energy crisis, which in turn correlates with increased mortality. Intensive insulin therapy may impair cerebral glucose metabolism after severe brain injury.