Comparative costs and outcomes of traumatic brain injury from biking accidents with or without helmet use

Contexte: Évaluer les déterminants de maladies évitables et leurs coûts est nécessaire dans le contexte d’assurance maladie universelle. Le moment d’évaluer les impacts des traumatismes crâniocérébraux (TCC) survenus lors d’accidents de vélo est idéal vu la popularité récente du cyclisme au Québec. Objectifs: Comparer les caractéristiques démographiques et médicales, ainsi que les coûts sociétaux qu’engendrent les TCC de cyclistes portant ou non un casque. Méthodologie: Étude rétrospective de 128 cyclistes avec TCC admis à l’Hôpital Général de Montréal entre 2007 et 2011. Les variables indépendantes sont sociodémographiques, cliniques et le port du casque. Les variables dépendantes sont la durée de séjour, l’échelle GOS-E, l’échelle ISS, l’orientation au congé, les décès et les coûts à la société. Résultats: Le groupe portant un casque était plus vieux, plus éduqué, retraité et marié; au niveau médical, ils avaient des TCCs moins sévères à l’imagerie, des hospitalisations aux soins intensifs plus courtes et moins de neurochirurgies. Les coûts médians à la société pour les TCC isolés de cyclistes avec casque étaient significativement moindres. Conclusion: Dans cette étude, le port du casque semblait prévenir certaines complications des TCC et permettait de faire économiser de l’argent à l’état. Le port de casque est recommandé.

Rest-activity cycle disturbances in the acute phase of moderate to severe traumatic brain injury

Background. Sleep-wake disturbances are among the most persistent sequelae after traumatic brain injury (TBI) and probably arise during the hospital stay following TBI. These disturbances are characterized by difficulties sleeping at night and staying awake during the day. Objective. The aim of the present study was to document rest-activity cycle consolidation in acute moderate/severe TBI using actigraphy and to assess its association with injury severity and outcome. Methods. In all, 16 hospitalized patients (27.1 ± 11.3 years) with moderate/severe TBI wore actigraphs for 10 days, starting in the intensive care unit (ICU) when continuous sedation was discontinued and patients had reached medical stability. Activity counts were summed for daytime (7:00-21:59 hours) and nighttime periods (22:00-6:59 hours). The ratio of daytime period activity to total 24-hour activity was used to quantify rest-activity cycle consolidation. An analysis of variance was carried out to characterize the evolution of the daytime activity ratio over the recording period. Results. Rest-activity cycle was consolidated only 46.6% of all days; however, a significant linear trend of improvement was observed over time. Greater TBI severity and longer ICU and hospital lengths of stay were associated with poorer rest-activity cycle consolidation and evolution. Patients with more rapid return to consolidated rest-activity cycle were more likely to have cleared posttraumatic amnesia and have lower disability at hospital discharge. Conclusions. Patients with acute moderate/ severe TBI had an altered rest-activity cycle, probably reflecting severe fragmentation of sleep and wake episodes, which globally improved over time. A faster return to rest-activity cycle consolidation may predict enhanced brain recovery.

Specificity of cognitive and behavioral complaints in post-traumatic stress disorder and mild traumatic brain injury.

Characterization of cognitive and behavioral complaints is explored in Post-traumatic stress disorder (PTSD) and mild traumatic brain injury (MTBI) samples according to the severity of PTSD, depression and general anxiety conditions. Self-reported questionnaires on cognitive and behavioral changes are administered to PTSD, MTBI, MTBI/PTSD and control groups. Confounding variables are controlled. All groups report more complaints since the traumatic event. PTSD and MTBI/PTSD groups report more anxiety symptoms, depression and complaints compared to the MTBI group. Relatives of the PTSD group confirm most of the behavioral changes reported. Results suggest the utility of self-reported questionnaires to personalize cognitive and behavioral interventions in PTSD and MTBI to cope with the impacts of the traumatic event.

Objective neuropsychological deficits in post-traumatic stress disorder and mild traumatic brain injury: what remains beyond symptom similarity?

This exploratory study intends to characterize the neuropsychological profile in persons with post-traumatic stress disorder (PTSD) and mild traumatic brain injury (mTBI) using objective measures of cognitive performance. A neuropsychological battery of tests for attention, memory and executive functions was administered to four groups: PTSD (n = 25), mTBI (n = 19), subjects with two formal diagnoses: Post-traumatic Stress Disorder and Mild Traumatic Brain Injury (mTBI/PTSD) (n = 6) and controls (n = 25). Confounding variables, such as medical, developmental or neurological antecedents, were controlled and measures of co-morbid conditions, such as depression and anxiety, were considered. The PTSD and mTBI/PTSD groups reported more anxiety and depressive symptoms. They also presented more cognitive deficits than the mTBI group. Since the two PTSD groups differ in severity of PTSD symptoms but not in severity of depression and anxiety symptoms, the PTSD condition could not be considered as the unique factor affecting the results. The findings underline the importance of controlling for confounding medical and psychological co-morbidities in the evaluation and treatment of PTSD populations, especially when a concomitant mTBI is also suspected.

A study of sexuality following traumatic brain injury : moving towards the validation of a biopsychosocial model

L’étude de la sexualité dans le contexte des maladies neurologiques est un domaine émergent qui nous permet de mieux comprendre les corrélats cérébraux et neurocomportementaux de divers aspects de la sexualité. Les changements au sujet de la sexualité sont fréquents à la suite de troubles neurologiques tels que les blessures de la moelle épinière, la sclérose en plaques, l’accident vasculaire cérébral, l'épilepsie et les traumatismes craniocérébraux (TCC). Compte tenu de la complexité de la sexualité après un TCC, celle-ci doit être analysée à partir d'une perspective biopsychosociale qui comprend trois facteurs interdépendants : a) les facteurs neuropsychologiques et psychologiques, b) les variables médicales et physiques, et c) les facteurs relationnels. L’objectif de cette thèse était d’étudier certains éléments de la sexualité auprès de personnes ayant subi un TCC afin de fournir des preuves empiriques pour contribuer à la validation d’une perspective biopsychosociale de la sexualité après un TCC. Trois études quantitatives originales ont été effectuées auprès de personnes ayant subi un TCC léger, modéré ou grave et ayant reçu des services de réadaptation post-TCC, et d’un groupe de témoins en bonne santé, tous vivant dans la communauté. Les groupes étaient comparables en ce qui concerne l’âge, le sexe, le nombre d’années de scolarité, le statut d’emploi et relationnel, et le revenu annuel. Les variables ciblant la sexualité, incluses dans cette thèse, étaient la qualité de vie sexuelle, le comportement sexuel à risque, et la sociosexualité (p. ex., les différences individuelles en ce qui concerne la volonté d’une personne à avoir des relations sexuelles sans engagement). Les variables neuropsychologiques et psychologiques incluaient les fonctions exécutives, la dépression et l’anxiété. Les aspects médicaux et physiques englobaient les symptômes postcommotionnels. Les facteurs relationnels comprenaient les attitudes envers l'infidélité. Les résultats démontrent que par rapport aux témoins en santé, les individus avec un TCC ont montré une diminution de la qualité de vie sexuelle, alors que les groupes étaient comparables sur le plan du comportement sexuel à risque, de la sociosexualité et des attitudes envers l'infidélité. Par ailleurs, les résultats ont montré une différence entre les hommes et les femmes sur le plan de la sociosexualité (p. ex., plus restrictive chez la femme). Chez les personnes ayant subi un TCC, une faible qualité de vie sexuelle était significativement associée à un nombre élevé de symptômes postcommotionnels, un comportement sexuel plus à risque corrélait avec une plus grande fréquence de symptômes dysexécutifs, et une plus faible acceptation de l'infidélité était liée à une sociosexualité moins restrictive. Les résultats de ces trois études soutiennent une perspective biopsychosociale de la sexualité après le TCC. Elles apportent des connaissances nouvelles en ce qui a trait aux domaines de la sexualité qui peuvent être touchés après un TCC, ainsi qu’à certaines variables neuropsychologiques et psychologiques, médicales et physiques, et relationnelles qui sont associées à ces changements. Les implications théoriques, ainsi que pour la pratique clinique et la réadaptation sont discutées. Les limitations des études sont présentées et des recommandations pour la recherche sont proposées. Le modèle biopsychosocial peut être utilisé comme une référence pour guider la recherche future dans ce domaine. D’autres études sur la sexualité et le développement d'interventions multidisciplinaires dans ce domaine pour les personnes TCC sont nécessaires.

Brain injury: Assessment of hemineglect occurence and of attentional deficit through cancellation tasks

Hemineglect (HN) is a widely studied syndrome after unilateral lesions due to stroke. However, although there are some studies with HN rehabilitation of posttraumatic brain injury (TBI), there seems to be no published data about the prevalence of HN in TBI through cancellation tasks. Thus, the objective of this study was to characterize the occurrence of this syndrome and of attentional deficits in patients with TBI by means of the Bells Test and of a line cancellation task. The sample was comprised of 21 patients with TBI and 21 healthy controls matched by education, age and frequency of written language habits. There was a poorer performance of patients with TBI with a greater number of omissions on the left side and lower speed processing. In addition, suggestive signs of HN were found in 38 % of the sample of TBI patients. More research is needed to characterize clinical syndromes regarding the occurrence of HN after a TBI through the traditionally known cancellation paradigm.

Theory of mind in children with traumatic brain injury

Objective: This study was designed to examine the existence of deficits in mentalizing or theory of mind (ToM) in children with traumatic brain injury (TBI). Research design: ToM functioning was assessed in 12 children aged 6-12 years with TBI and documented frontal lobe damage and compared to 12 controls matched for age, sex and verbal ability. Brief measures of attention and memory were also included. Main outcome and results: The TBI group was significantly impaired relative to controls on the advanced ToM measure and a measure of basic emotion recognition. No difference was found in a basic measure of ToM. Conclusion: Traumatic brain damage in childhood may disrupt the developmental acquisition of emotion recognition and advanced ToM skills. The clinical and theoretical importance of these findings is discussed and the implications for the assessment and treatment of children who have experienced TBI are outlined.

The effect of a perceptual cognitive task on exercise performance: the dual-task condition after brain injury

Objective: To examine the effect of additional cognitive demand on cycling performance in individuals with acquired brain injury (ABI). Design: Prospective observational study. Setting: Rivermead Rehabilitation Centre. Participants: Ten individuals with ABI ( 7 men, 3 women) ( traumatic brain injury 7, tumour 1, stroke 2) and 10 healthy controls ( 6 men, 4 women). Intervention: Individuals were asked to maintain a set cadence during a three-stage incremental cycling test in both single-task ( no additional task) and dual-task ( whilst performing an additional cognitive task) conditions. Results: The ABI group showed a slight slowing in cadence in stages 1 and 3 of the graded exercise test from the single-to the dual-task condition, although this was not significant ( p less than or equal to 0.05). The control group showed no slowing of cadence at any incremental stage. When directly comparing the ABI with the control group, the change in cadence observed in dual-task conditions was only significantly different in stage 3 ( p less than or equal to 0.05). Conclusions: Clinicians should be aware of the possibility that giving additional cognitive tasks ( such as monitoring exercise intensity) while individuals with acquired brain injury are performing exercises may detrimentally affect performance. The effect may be more marked when the individuals are performing exercise at higher intensities.

Challenging behaviour profiles of people with acquired brain injury living in community settings

Primary objective: To determine the type and severity of challenging behaviours among a cohort of brain-injured persons referred to a community-based behaviour management service; and to determine whether different behaviour profiles were associated with aetiology of brain injury.
Methods and procedures: A sample of clients (n= 190) referred to the ABI Behaviour Consultancy for assessment and treatment of challenging behaviours was evaluated using the Overt Behaviour Scale (OBS) and other measures of disability and support needs.
Main outcomes and results: The most common challenging behaviour categories were, in order of frequency: verbal aggression, inappropriate social behaviours and lack of initiation. Clients typically exhibited four categories of challenging behaviour and multiple kinds of the behaviours represented by each category. There was some evidence of differences in occurrence of specific behaviours associated with aetiology of brain injury, particularly for hypoxia and alcohol-related brain injury.
Conclusions: A systematic assessment of challenging behaviours in community settings has revealed the profiles of broad behavioural disturbance that can occur following ABI. Assessing the breadth of disturbance is important in understanding a client's presentation and thus planning appropriate behaviour management interventions.

Momentary lives : supporting people with acquired brain injury

Personal adjustment following an acquired brain injury is influenced by a comprehensive, complex, and dynamic range of factors. This study found that a useful approach to service provision in the ABI sector would involve a holistic approach that addresses all life domains of the individual within an ecological systems framework.

Identification of a by-product of nitric oxide synthase activity in human acute brain injury with in vivo proton magnetic resonance spectroscopy

BACKGROUND AND PURPOSE: Laboratory studies have been used to identify nitric oxide as a notable mediator in neuronal death after acute brain injury. To our knowledge, this has not previously been confirmed with in vivo study in humans. Our purpose was to seek in vivo evidence for the induction of nitric oxide synthase (NOS) in human acute brain injury by using proton MR spectroscopy.

METHODS: In vitro proton MR spectra were obtained in neural extracts from 30 human cadavers, and in vivo spectra were obtained in 20 patients with acute brain injury and in a similar number of control subjects.

RESULTS: We identified a unique peak at 3.15 ppm by using in vivo proton MR spectroscopy in eight of 20 patients with acute brain injury but not in 20 healthy volunteers (P < .002). On the basis of in vitro data, we have tentatively assigned this peak to citrulline, a NOS by-product.

CONCLUSION: To our knowledge, our findings suggest, for the first time, that excitotoxicity may occur in human acute brain injury. Confirmation with the acquisition of spectra in very early acute cerebral injury would provide a rationale for the use of neuroprotective agents in these conditions, as well as a new noninvasive method for quantification.

Pretend play of children with acquired brain injury : an exploratory study

Objective: This exploratory study aimed to describe the self-initiated pretend play of three children who had sustained an acquired brain injury (ABI). No previous research was found.

Methods: Three children aged 3.0–6.0 years were recruited through purposive sampling. Pretend play ability was assessed using the Child-Initiated Pretend Play Assessment.

Results: Two of the three children scored below the range expected for children their age and one child scored above the range, indicating a wide range of pretend play ability for the children. None of the children could sustain their engagement in pretend play to complete the time of the assessment.

Conclusion: Complex pretend play ability is a functional assessment of cognitive ability involving sequential planning, problem-solving, language and social understanding. Cognitive fatigue is argued to explain the children's limited ability to engage in play for the time expected for their ages. More research is required.

Modelling skill acquisition in acquired brain injury

Acquired brain injury (ABI) is a debilitating condition often requiring extensive rehabilitation. Although cognitive rehabilitation is concerned with overcoming a skills deficit, the application of skill acquisition research in this context has been non-existent. Examining post-injury learning in terms of the qualitative variables associated with different phases of skill acquisition is likely to be beneficial in assessing patient status and monitoring progress, as well as identifying changing needs over the course of learning. However, current models of skill acquisition overlook the potential impact of variables such as emotion, implicit learning, metacognition, motivation, and strategies that can be leveraged to improve skill acquisition. The current paper attempts to lay the groundwork for modelling and improving skill acquisition in ABI.

Thai emergency nurses’ management of patients with severe traumatic brain injury: comparison of knowledge and clinical management with best available evidence

Background:
In Thailand, the rate of TBI-related hospitalisation is increasing, however, little is known about the evidence-based management of severe TBI in the developing world. The aim of this study was to explore Thai emergency nurses’ management of patients with severe TBI.

Methods:
An exploratory descriptive mixed method design was used to conduct this two stage study: survey methods were used to examine emergency nurses’ knowledge regarding management of patients with severe TBI (Stage 1) and observational methods were used to examine emergency nurses’ clinical management of patients with severe TBI (Stage 2). The study setting was the emergency department (ED) at a regional hospital in Southern Thailand.

Results:
34 nurses participated in Stage 1 (response rate 91.9%) and the number of correct responses ranged from 33.3% to 95.2%. In Stage 2, a total of 160 points of measurement were observed in 20 patients with severe TBI over 40 h. In this study there were five major areas identified for the improvement of care of patients with severe TBI: (i) end-tidal carbon dioxide (ETCO2) monitoring and targets; (ii) use of analgesia and sedation; (iii) patient positioning; (iv) frequency of nursing assessment; and (v) dose of Mannitol diuretic.

Conclusions:
There is variation in Thai nurses’ knowledge and care practices for patients with severe TBI. To increase consistency of evidence-based TBI care in the Thai context, a knowledge translation intervention that is ecologically valid, appropriate to the Thai healthcare context and acceptable to the multidisciplinary care team is needed.