Subarachnoid haemorrhage: an unusual complication of implantation of an intrathecal baclofen pump

STUDY DESIGN

Single case-report.

OBJECTIVES

To describe subarachnoid haemorrhage; an unusual complication following implantation of an intrathecal baclofen pump in an adult with spinal cord injury.

SETTING

Princess Royal Spinal Injuries Unit, Sheffield, UK.

METHODS

Review of the medical notes and literature.

RESULTS

A 77-year-old man with an incomplete ASIA-C spinal cord injury at C5 level sustained 2 years previously, developed subarachnoid haemorrhage following implantation of an intrathecal baclofen pump for the management of spasticity that was unresponsive to treatment with oral antispasticity agents.

CONCLUSION

Subarachnoid haemorrhage can occur as a rare complication of insertion of Intrathecal baclofen pump. This need to be considered while evaluating patients who present with headache, confusion and seizures in the post operative period.

SPONSORSHIP

Not applicable.

Traumatic Brain Injury Rehabilitation Comparative Effectiveness Research: Introduction to the Traumatic Brain Injury-Practice Based Evidence Archives Supplement

This supplement of the Archives of Physical Medicine and Rehabilitation is devoted to the Traumatic Brain Injury-Practice Based Evidence study, the first practice-based evidence study, to our knowledge, of traumatic brain injury rehabilitation. The purpose of this preface is to place this study in the broader context of comparative effectiveness research and introduce the articles in the supplement.

Readmission to an Acute Care Hospital During Inpatient Rehabilitation for Traumatic Brain Injury

OBJECTIVE

To assess the incidence of, causes for, and factors associated with readmission to an acute care hospital (RTAC) during inpatient rehabilitation for traumatic brain injury (TBI).

DESIGN

Prospective observational cohort.

SETTING

Inpatient rehabilitation.

PARTICIPANTS

Individuals with TBI admitted consecutively for inpatient rehabilitation (N=2130).

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

RTAC incidence, RTAC causes, rehabilitation length of stay (RLOS), and rehabilitation discharge location.

RESULTS

A total of 183 participants (9%) experienced RTAC for a total of 210 episodes. Of 183 participants, 161 patients experienced 1 RTAC episode, 17 had 2, and 5 had 3. The mean time from rehabilitation admission to first RTAC was 22±22 days. The mean duration in acute care during RTAC was 7±8 days. Eighty-four participants (46%) had ≥1 RTAC episodes for medical reasons, 102 (56%) had ≥1 RTAC episodes for surgical reasons, and 6 (3%) participants had RTAC episodes for unknown reasons. Most common surgical RTAC reasons were neurosurgical (65%), pulmonary (9%), infection (5%), and orthopedic (5%); most common medical reasons were infection (26%), neurological (23%), and cardiac (12%). Any RTAC was predicted as more likely for patients with older age, history of coronary artery disease, history of congestive heart failure, acute care diagnosis of depression, craniotomy or craniectomy during acute care, and presence of dysphagia at rehabilitation admission. RTAC was less likely for patients with higher admission FIM motor scores and education less than high school diploma. RTAC occurrence during rehabilitation was significantly associated with longer RLOS and smaller likelihood of discharge home.

CONCLUSIONS

Approximately 9% of patients with TBI experienced RTAC episodes during inpatient rehabilitation for various medical and surgical reasons. This information may help inform interventions aimed at reducing interruptions in rehabilitation for RTAC. RTACs were associated with longer RLOS and discharge to an institutional setting.

Effects of Patient Preinjury and Injury Characteristics on Acute Rehabilitation Outcomes for Traumatic Brain Injury

OBJECTIVE

To examine associations of patient and injury characteristics with outcomes at inpatient rehabilitation discharge and 9 months postdischarge for patients with traumatic brain injury (TBI).

DESIGN

Prospective, longitudinal observational study.

SETTING

Inpatient rehabilitation centers.

PARTICIPANTS

Consecutive patients (N=2130) enrolled between 2008 and 2011, admitted for inpatient rehabilitation after index TBI, and divided into 5 subgroups based on rehabilitation admission FIM cognitive score.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Rehabilitation length of stay, discharge to home, and FIM at discharge and 9 months postdischarge.

RESULTS

Severity indices increased explained variation in outcomes beyond that accounted for by patient characteristics. FIM motor scores were generally the most predictable. Higher functioning subgroups had more predictable outcomes then subgroups with lower cognitive function at admission. Age at injury, time from injury to rehabilitation admission, and functional independence at rehabilitation admission were the most consistent predictors across all outcomes and subgroups.

CONCLUSIONS

Findings from previous studies of the relations among patient and injury characteristics and rehabilitation outcomes were largely replicated. Discharge outcomes were most strongly associated with injury severity characteristics, whereas predictors of functional independence at 9 months postdischarge included both patient and injury characteristics.

Rehospitalization During 9 Months After Inpatient Rehabilitation for Traumatic Brain Injury

OBJECTIVE

To assess the frequency of, causes for, and factors associated with acute rehospitalization during 9 months after discharge from inpatient rehabilitation for traumatic brain injury (TBI).

DESIGN

Multicenter observational cohort.

SETTING

Community.

PARTICIPANTS

Individuals with TBI (N=1850) admitted for inpatient rehabilitation.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Occurrences of proxy or self-report of postrehabilitation acute care rehospitalization, as well as length of and causes for rehospitalizations.

RESULTS

A total of 510 participants (28%) had experienced 775 acute rehospitalizations. All experienced 1 admission (510 participants [66%]), whereas 154 (20%) had 2 admissions, 60 (8%) had 3, 23 (3%) had 4, 27 had between 5 and 11, and 1 had 12. The most common rehospitalization causes were infection (15%), neurological (13%), neurosurgical (11%), injury (7%), psychiatric (7%), and orthopedic (7%). The mean time from rehabilitation discharge to first rehospitalization was 113 days. The mean rehospitalization duration was 6.5 days. Logistic regression analyses revealed that older age, history of seizures before injury or during acute care or rehabilitation, history of brain injuries, and non-brain injury medical severity increased the risk of rehospitalization. Injury etiology of motor vehicle collision and high motor functioning at discharge decreased rehospitalization risk.

CONCLUSIONS

Approximately 28% of patients with TBI were rehospitalized within 9 months of TBI rehabilitation discharge owing to various medical and surgical reasons. Future research should evaluate whether some of these occurrences may be preventable (such as infections, injuries, and psychiatric disorders) and should evaluate the extent to which persons at risk may benefit from additional screening, surveillance, and treatment protocols.

Psychotropic Medication Use During Inpatient Rehabilitation for Traumatic Brain Injury

OBJECTIVE

To describe psychotropic medication administration patterns during inpatient rehabilitation for traumatic brain injury (TBI) and their relation to patient preinjury and injury characteristics.

DESIGN

Prospective observational cohort.

SETTING

Multiple acute inpatient rehabilitation units or hospitals.

PARTICIPANTS

Individuals with TBI (N=2130; complicated mild, moderate, or severe) admitted for inpatient rehabilitation.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Not applicable.

RESULTS

Most frequently administered were narcotic analgesics (72% of sample), followed by antidepressants (67%), anticonvulsants (47%), anxiolytics (33%), hypnotics (30%), stimulants (28%), antipsychotics (25%), antiparkinson agents (25%), and miscellaneous psychotropics (18%). The psychotropic agents studied were administered to 95% of the sample, with 8.5% receiving only 1 and 31.8% receiving ≥6. Degree of psychotropic medication administration varied widely between sites. Univariate analyses indicated younger patients were more likely to receive anxiolytics, antidepressants, antiparkinson agents, stimulants, antipsychotics, and narcotic analgesics, whereas those older were more likely to receive anticonvulsants and miscellaneous psychotropics. Men were more likely to receive antipsychotics. All medication classes were less likely administered to Asians and more likely administered to those with more severe functional impairment. Use of anticonvulsants was associated with having seizures at some point during acute care or rehabilitation stays. Narcotic analgesics were more likely for those with history of drug abuse, history of anxiety and depression (premorbid or during acute care), and severe pain during rehabilitation. Psychotropic medication administration increased rather than decreased during the course of inpatient rehabilitation in each of the medication categories except for narcotics. This observation was also true for medication administration within admission functional levels (defined by cognitive FIM scores), except for those with higher admission FIM cognitive scores.

CONCLUSIONS

Many psychotropic medications are used during inpatient rehabilitation. In general, lower admission FIM cognitive score groups were administered more of the medications under investigation compared with those with higher cognitive function at admission. Considerable site variation existed regarding medications administered. The current investigation provides baseline data for future studies of effectiveness.

Incidence of Neutropenia With Valproate and Quetiapine Combination Treatment in Subjects With Acquired Brain Injuries

OBJECTIVE

To investigate whether the incidence of neutropenia was higher in subjects who received a combination treatment with valproate and quetiapine than in those who were administered monotherapy.

DESIGN

Retrospective cohort study.

SETTING

Rehabilitation department of a university hospital.

PARTICIPANTS

Patients with acquired brain injuries who had taken valproate for seizures or quetiapine for delirium for >7 days (N=101). Data were extracted from electronic medical records of the hospital.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Incidence of neutropenia (absolute neutrophil count<2000 cells/μL) was elicited from the weekly complete blood cell records for 71.07±43.71 days of observation. The odds ratio for neutropenia development was calculated and adjusted for variables that showed significant differences between patients with or without neutropenia.

RESULTS

The incidence of neutropenia was significantly higher in the group receiving the combination treatment than in those receiving the monotherapy (32.26% vs 12.90%, adjusted P=.036), despite a lack of any differences in the daily doses of the medications. Coadministration of quetiapine and valproate was the predictor of neutropenia development when age, body weight, and underlying diseases were adjusted in the logistic regression model (odds ratio=3.749; 95% confidence interval, 1.161-12.099; P=.027).

CONCLUSIONS

Administration of quetiapine together with valproate in patients with acquired brain injury could increase the incidence of medication-induced neutropenia.

Sensitivity and Specificity of the Coma Recovery Scale--Revised Total Score in Detection of Conscious Awareness

OBJECTIVE

To describe the sensitivity and specificity of Coma Recovery Scale-Revised (CRS-R) total scores in detecting conscious awareness.

DESIGN

Data were retrospectively extracted from the medical records of patients enrolled in a specialized disorders of consciousness (DOC) program. Sensitivity and specificity analyses were completed using CRS-R-derived diagnoses of minimally conscious state (MCS) or emerged from minimally conscious state (EMCS) as the reference standard for conscious awareness and the total CRS-R score as the test criterion. A receiver operating characteristic curve was constructed to demonstrate the optimal CRS-R total cutoff score for maximizing sensitivity and specificity.

SETTING

Specialized DOC program.

PARTICIPANTS

Patients enrolled in the DOC program (N=252, 157 men; mean age, 49y; mean time from injury, 48d; traumatic etiology, n=127; nontraumatic etiology, n=125; diagnosis of coma or vegetative state, n=70; diagnosis of MCS or EMCS, n=182).

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Sensitivity and specificity of CRS-R total scores in detecting conscious awareness.

RESULTS

A CRS-R total score of 10 or higher yielded a sensitivity of .78 for correct identification of patients in MCS or EMCS, and a specificity of 1.00 for correct identification of patients who did not meet criteria for either of these diagnoses (ie, were diagnosed with vegetative state or coma). The area under the curve in the receiver operating characteristic curve analysis is .98.

CONCLUSIONS

A total CRS-R score of 10 or higher provides strong evidence of conscious awareness but resulted in a false-negative diagnostic error in 22% of patients who demonstrated conscious awareness based on CRS-R diagnostic criteria. A cutoff score of 8 provides the best balance between sensitivity and specificity, accurately classifying 93% of cases. The optimal total score cutoff will vary depending on the user's objective.

Management of Mild Traumatic Brain Injury Symptoms in a 31-Year-Old Woman Using Cervical Manipulation and Acupuncture: A Case Report

OBJECTIVE

The objective was to describe chiropractic and acupuncture care of a patient with acute mild traumatic brain injury (mTBI) symptoms.

CLINICAL FEATURES

A 31-year-old woman had acute neck pain, headache, dizziness, nausea, tinnitus, difficulty concentrating, and fatigue following a fall. She was diagnosed at an urgent care facility with mTBI immediately following the fall. Pharmaceutical intervention had been ineffective for her symptoms.

INTERVENTION AND OUTCOME

The patient was treated with chiropractic adjustments characterized as high velocity, low amplitude thrusts directed to the cervical spine and local acupuncture points in the cervical and cranial regions. The patient received care for a total of 8 visits over 2.5 weeks with resolution of concussive symptoms.

CONCLUSION

This patient with mTBI responded favorably to a conservative treatment protocol with the combination of chiropractic and acupuncture care.

A Role of Serum-Based Neuronal and Glial Markers as Potential Predictors for Distinguishing Severity and Related Outcomes in Traumatic Brain Injury

Objective

Optimal treatment decision and estimation of the prognosis in traumatic brain injury (TBI) is currently based on demographic and clinical predictors. But sometimes, there are limitations in these factors. In this study, we analyzed three central nervous system biomarkers in TBI patients, will discuss the roles and clinical applications of biomarkers in TBI.

Methods

From July on 2013 to August on 2014, a total of 45 patients were included. The serum was obtained at the time of hospital admission, and biomarkers were extracted with centrifugal process. It was analyzed for the level of S-100 beta (S100B), glial fibrillary acidic protein (GFAP), and ubiquitin carboxy-terminal hydrolase-L1 (UCH-L1).

Results

This study included 33 males and 12 females with a mean age of 58.5 (19-84) years. TBI patients were classified into two groups. Group A was severe TBI with Glasgow Coma Scale (GCS) score 3-5 and Group B was mild TBI with GCS score 13-15. The median serum concentration of S100B, GFAP, and UCH-L1 in severe TBI were raised 5.1 fold, 5.5 fold, and 439.1 fold compared to mild injury, respectively. The serum levels of these markers correlated significantly with the injury severity and clinical outcome (p<0.001). Increased level of markers was strongly predicted poor outcomes.

Conclusion

S100B, GFAP, and UCH-L1 serum level of were significantly increased in TBI according to severity and associated clinical outcomes. Biomarkers have potential utility as diagnostic, prognostic, and therapeutic adjuncts in the setting of TBI.

Ten-Year Employment Patterns of Working Age Individuals After Moderate to Severe Traumatic Brain Injury: A National Institute on Disability and Rehabilitation Research Traumatic Brain Injury Model Systems Study

OBJECTIVE

To describe the 10-year patterns of employment for individuals of working age discharged from a Traumatic Brain Injury Model Systems (TBIMS) center between 1989 and 2009.

DESIGN

Secondary data analysis.

SETTING

Inpatient rehabilitation centers.

PARTICIPANTS

Patients aged 16 to 55 years (N=3618) who were not retired at injury, received inpatient rehabilitation at a TBIMS center, were discharged alive between 1989 and 2009, and had at least 3 completed follow-up interviews at postinjury years 1, 2, 5, and 10.

INTERVENTIONS

Not applicable.

MAIN OUTCOMES MEASURE

Employment.

RESULTS

Patterns of employment were generated using a generalized linear mixed model, where these patterns were transformed into temporal trajectories of probability of employment via random effects modeling. Covariates demonstrating significant relations to growth parameters that govern the trajectory patterns were similar to those noted in previous cross-sectional research and included age, sex, race/ethnicity, education, preinjury substance misuse, preinjury vocational status, and days of posttraumatic amnesia. The calendar year in which the injury occurred also greatly influenced trajectories. An interactive tool was developed to provide visualization of all postemployment trajectories, with many showing decreasing probabilities of employment between 5 and 10 years postinjury.

CONCLUSIONS

These results highlight that postinjury employment after moderate to severe traumatic brain injury (TBI) is a dynamic process, with varied patterns of employment for individuals with specific characteristics. The overall decline in trajectories of probability of employment between 5 and 10 years postinjury suggests that moderate to severe TBI may have unfavorable chronic effects and that employment outcome is highly influenced by national labor market forces. Additional research targeting the underlying drivers of the decline between 5 and 10 years postinjury is recommended, as are interventions that target influencing factors.

Traumatic Brain Injury Patient, Injury, Therapy, and Ancillary Treatments Associated With Outcomes at Discharge and 9 Months Postdischarge

OBJECTIVE

To examine associations of patient and injury characteristics, inpatient rehabilitation therapy activities, and neurotropic medications with outcomes at discharge and 9 months postdischarge for patients with traumatic brain injury (TBI).

DESIGN

Prospective, longitudinal observational study.

SETTING

Inpatient rehabilitation centers.

PARTICIPANTS

Consecutive patients (N=2130) enrolled between 2008 and 2011, admitted for inpatient rehabilitation after an index TBI injury.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Rehabilitation length of stay, discharge to home, and FIM at discharge and 9 months postdischarge.

RESULTS

The admission FIM cognitive score was used to create 5 relatively homogeneous subgroups for subsequent analysis of treatment outcomes. Within each subgroup, significant associations were found between outcomes and patient and injury characteristics, time spent in therapy activities, and medications used. Patient and injury characteristics explained on average 35.7% of the variation in discharge outcomes and 22.3% in 9-month outcomes. Adding time spent and level of effort in therapy activities and percentage of stay using specific medications explained approximately 20% more variation for discharge outcomes and 12.9% for 9-month outcomes. After patient, injury, and treatment characteristics were used to predict outcomes, center differences added only approximately 1.9% additional variance explained.

CONCLUSIONS

At discharge, greater effort during therapy sessions, time spent in more complex therapy activities, and use of specific medications were associated with better outcomes for patients in all admission FIM cognitive subgroups. At 9 months postdischarge, similar but less pervasive associations were observed for therapy activities, but not classes of medications. Further research is warranted to examine more specific combinations of therapy activities and medications that are associated with better outcomes.

Occupational, Physical, and Speech Therapy Treatment Activities During Inpatient Rehabilitation for Traumatic Brain Injury

OBJECTIVE

To describe the use of occupational therapy (OT), physical therapy (PT), and speech therapy (ST) treatment activities throughout the acute rehabilitation stay of patients with traumatic brain injury.

DESIGN

Multisite prospective observational cohort study.

SETTING

Inpatient rehabilitation settings.

PARTICIPANTS

Patients (N=2130) admitted for initial acute rehabilitation after traumatic brain injury. Patients were categorized on the basis of admission FIM cognitive scores, resulting in 5 fairly homogeneous cognitive groups.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Percentage of patients engaged in specific activities and mean time patients engaged in these activities for each 10-hour block of time for OT, PT, and ST combined.

RESULTS

Therapy activities in OT, PT, and ST across all 5 cognitive groups had a primary focus on basic activities. Although advanced activities occurred in each discipline and within each cognitive group, these advanced activities occurred with fewer patients and usually only toward the end of the rehabilitation stay.

CONCLUSIONS

The pattern of activities engaged in was both similar to and different from patterns seen in previous practice-based evidence studies with different rehabilitation diagnostic groups.

Group Therapy Use and Its Impact on the Outcomes of Inpatient Rehabilitation After Traumatic Brain Injury: Data From Traumatic Brain Injury-Practice Based Evidence Project

OBJECTIVES

To describe the amount and content of group therapies provided during inpatient rehabilitation for traumatic brain injury (TBI), and to assess the relations of group therapy with patient, injury, and treatment factors and outcomes.

DESIGN

Prospective observational cohort.

SETTING

Inpatient rehabilitation.

PARTICIPANTS

Consecutive admissions (N=2130) for initial TBI rehabilitation at 10 inpatient rehabilitation facilities (9 in the United States, 1 in Canada) from October 2008 to September 2011.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Proportion of sessions that were group therapy (≥2 patients were treated simultaneously by ≥1 clinician); proportion of patients receiving group therapy; type of activity performed and amount of time spent in group therapy, by discipline; rehabilitation length of stay; discharge location; and FIM cognitive and motor scores at discharge.

RESULTS

Of the patients, 79% received at least 1 session of group therapy, with group therapy accounting for 13.7% of all therapy sessions and 15.8% of therapy hours. On average, patients spent 2.9h/wk in group therapy. The greatest proportion of treatment time in group format was in therapeutic recreation (25.6%), followed by speech therapy (16.2%), occupational therapy (10.4%), psychology (8.1%), and physical therapy (7.9%). Group therapy time and type of treatment activities varied among admission FIM cognitive subgroups and treatment sites. Several factors appear to be predictive of receiving group therapy, with the treatment site being a major influence. However, group therapy as a whole offered little explanation of differences in the outcomes studied.

CONCLUSIONS

Group therapy is commonly used in TBI rehabilitation, to varying degrees among disciplines, sites, and cognitive impairment subgroups. Various therapeutic activities take place in group therapy, indicating its perceived value in addressing many domains of functioning. Variation in outcomes is not explained well by overall percentage of therapy time delivered in groups.

Enteral Nutrition for Patients With Traumatic Brain Injury in the Rehabilitation Setting: Associations With Patient Preinjury and Injury Characteristics and Outcomes

OBJECTIVE

To determine the association of enteral nutrition (EN) with patient preinjury and injury characteristics and outcomes for patients receiving inpatient rehabilitation after traumatic brain injury (TBI).

DESIGN

Prospective observational study.

SETTING

Nine rehabilitation centers.

PARTICIPANTS

Patients (N=1701) admitted for first full inpatient rehabilitation after TBI.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

FIM at rehabilitation discharge, length of stay, weight loss, and various infections.

RESULTS

There were many significant differences in preinjury and injury characteristics between patients who received EN and patients who did not. After matching patients with a propensity score of >40% for the likely use of EN, patients receiving EN with either a standard or a high-protein formula (>20% of calories coming from protein) for >25% of their rehabilitation stay had higher FIM motor and cognitive scores at rehabilitation discharge and less weight loss than did patients with similar characteristics not receiving EN.

CONCLUSIONS

For patients receiving inpatient rehabilitation after TBI and matched on a propensity score of >40% for the likely use of EN, clinicians should strongly consider, when possible, EN for ≥25% of the rehabilitation stay and especially with a formula that contains at least 20% protein rather than a standard formula.

Traumatic Brain Injury-Practice Based Evidence Study: Design and Patients, Centers, Treatments, and Outcomes

OBJECTIVES

To describe study design, patients, centers, treatments, and outcomes of a traumatic brain injury (TBI) practice-based evidence (PBE) study and to evaluate the generalizability of the findings to the U.S. TBI inpatient rehabilitation population.

DESIGN

Prospective, longitudinal, observational study.

SETTING

Ten inpatient rehabilitation centers.

PARTICIPANTS

Patients (N=2130) enrolled between October 2008 and September 2011 and admitted for inpatient rehabilitation after an index TBI injury.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Return to acute care during rehabilitation, rehabilitation length of stay, FIM at discharge, residence at discharge, and 9 months postdischarge rehospitalization, FIM, participation, and subjective well-being.

RESULTS

The level of admission FIM cognitive score was found to create relatively homogeneous subgroups for the subsequent analysis of best treatment combinations. There were significant differences in patient and injury characteristics, treatments, rehabilitation course, and outcomes by admission FIM cognitive subgroups. TBI-PBE study patients were overall similar to U.S. national TBI inpatient rehabilitation populations.

CONCLUSIONS

This TBI-PBE study succeeded in capturing naturally occurring variation in patients and treatments, offering opportunities to study best treatments for specific patient impairments. Subsequent articles in this issue report differences between patients and treatments and associations with outcomes in greater detail.

Predictors for moderate to severe paediatric head injury derived from a surveillance registry in the emergency department

INTRODUCTION AND AIM

Head injuries are a common complaint among children presenting to the emergency department (ED). This study is part of an ongoing prospective surveillance of head injured children presenting to a paediatric ED. We aim to derive predictors for moderate to severe head injury in our population.

MATERIALS AND METHODS

We performed an unmatched case-control study. Cases were defined as those who presented to the ED with moderate to severe head injury, during the period from 2006 to 2014. Controls were obtained from the prospective surveillance head injury database and were children who presented to the ED with head injury but who remained well on follow up. We compared variables from demographics, mechanism of injury, history, and physical examination.

RESULTS

There were 39 cases and 1173 controls. In the prospective database, our event rate was 0.5% and our computed tomography (CT) rate was 1%. Among those with moderate to severe head injury, they were more likely to be involved in road traffic accidents, have a history of difficult arousal, confusion or disorientation and a history of seizure. On physical examination, cases were more likely to have the presence of altered mental status, base of skull fracture, scalp hematoma and anisocoria. On multivariable analysis, the following 4 predictors remained statistically significant: Involvement in road traffic accident (p<0.001), difficult arousal (p<0.001), vomiting (p=0.003) and signs of base of skull fracture (p<0.001). Using these 4 variables, the Area under Curve was 0.97 {Sensitivity 92.3% (79.1-98.4%), Specificity 93.0% (91.4-94.4%), positive predictive value 30.5% (22-40%), negative predictive value 99.7% (99.2-99.9%)}.

CONCLUSION

Involvement in road traffic accident, difficult arousal, base of skull fracture and vomiting are independent predictors for moderate to severe head injury in our paediatric population.

Functional independence after inpatient rehabilitation for traumatic brain injury among minority children and adolescents

OBJECTIVE

To compare motor and cognitive functional independence scores between Hispanic, non-Hispanic black (NHB), and non-Hispanic white (NHW) children with traumatic brain injury (TBI) after discharge from inpatient rehabilitation.

DESIGN

Retrospective cohort study using the Uniform Data System for Medical Rehabilitation national dataset from the years 2002 to 2012.

SETTING

Inpatient rehabilitation units.

PARTICIPANTS

Children (N=10,141) aged 6 months to 18 years who received inpatient rehabilitation for TBI.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Motor and cognitive functional independence after discharge from inpatient rehabilitation, adjusting for age, sex, admission function, length of stay, insurance, and region.

RESULTS

Inpatient rehabilitation therapy improved functional independence for all children. Younger age, lower admission functional independence scores, and Medicaid insurance were associated with lower functional independence at discharge. Hispanic and NHB children had lower discharge cognitive scores compared with NHW children; however, differences were small and were partially explained by insurance status and region. Children who received rehabilitation therapy at pediatric facilities had greater cognitive improvement.

CONCLUSIONS

While racial/ethnic disparities are small, minority children are more likely to be younger, to have Medicaid, and to be cared for at nonpediatric facilities, factors that increase their risk for lower functional outcomes.

Effect of Epidural Electrical Stimulation and Repetitive Transcranial Magnetic Stimulation in Rats With Diffuse Traumatic Brain Injury

OBJECTIVE

To evaluate the effects of epidural electrical stimulation (EES) and repetitive transcranial magnetic stimulation (rTMS) on motor recovery and brain activity in a rat model of diffuse traumatic brain injury (TBI) compared to the control group.

METHODS

Thirty rats weighing 270-285 g with diffuse TBI with 45 kg/cm(2) using a weight-drop model were assigned to one of three groups: the EES group (ES) (anodal electrical stimulation at 50 Hz), the rTMS group (MS) (magnetic stimulation at 10 Hz, 3-second stimulation with 6-second intervals, 4,000 total stimulations per day), and the sham-treated control group (sham) (no stimulation). They were pre-trained to perform a single-pellet reaching task (SPRT) and a rotarod test (RRT) for 14 days. Diffuse TBI was then induced and an electrode was implanted over the dominant motor cortex. The changes in SPRT success rate, RRT performance time rate and the expression of c-Fos after two weeks of EES or rTMS were tracked.

RESULTS

SPRT improved significantly from day 8 to day 12 in the ES group and from day 4 to day 14 in the MS group (p<0.05) compared to the sham group. RRT improved significantly from day 6 to day 11 in ES and from day 4 to day 9 in MS compared to the sham group. The ES and MS groups showed increased expression of c-Fos in the cerebral cortex compared to the sham group.

CONCLUSION

ES or MS in a rat model of diffuse TBI can be used to enhance motor recovery and brain activity.

S100B protein as a screening tool for computed tomography findings after mild traumatic brain injury: Systematic review and meta-analysis

PRIMARY OBJECTIVE

To determine whether S100B protein in serum can predict intracranial lesions on computed tomography (CT) scan after mild traumatic brain injury (MTBI).

RESEARCH DESIGN

Systematic review and meta-analysis Methods and procedures: A literature search was conducted using Medline, Embase, Cochrane, Google Scholar, CINAHL, SUMSearch, Bandolier, Trip databases, bibliographies from identified articles and review article references. Eligible articles were defined as observational studies including patients with MTBI who underwent post-traumatic head CT scan and assessing the screening role of S100B protein.

MAIN OUTCOMES AND RESULTS

There was a significant positive association between S100B protein concentration and positive CT scan (22 studies, SMD = 1.92, 95% CI = 1.29-2.45, I² = 100%; p < 0.001). The pooled sensitivity and specificity values for a cut-point range = 0.16-0.20 µg L^-1 were 98.65 (95% CI = 95.53-101.77; I² = 0.0%) and 50.69 (95% CI = 40.69-60.69; I² = 76.3%), respectively. The threshold for serum S100B protein with 99.63 (95% CI = 96.00-103.25; I² = 0.0%) sensitivity and 46.94 (95% CI = 39.01-54.87; I² = 95.5%) specificity was > 0.20 µg L^-1.

CONCLUSIONS

After MTBI, serum S100B protein levels are significantly associated with the presence of intracranial lesions on CT scan. Measuring the protein could be useful in screening high risk MTBI patients and decreasing unnecessary CT examinations.

A review of the neuro- and systemic inflammatory responses in post concussion symptoms: Introduction of the "post-inflammatory brain syndrome" PIBS

Post-concussion syndrome is an aggregate of symptoms that commonly present together after head injury. These symptoms, depending on definition, include headaches, dizziness, neuropsychiatric symptoms, and cognitive impairment. However, these symptoms are common, occurring frequently in non-head injured controls, leading some to question the existence of post-concussion syndrome as a unique syndrome. Therefore, some have attempted to explain post-concussion symptoms as post-traumatic stress disorder, as they share many similar symptoms and post-traumatic stress disorder does not require head injury. This explanation falls short as patients with post-concussion syndrome do not necessarily experience many key symptoms of post-traumatic stress disorder. Therefore, other explanations must be sought to explain the prevalence of post-concussion like symptoms in non-head injury patients. Many of the situations in which post-concussion syndrome like symptoms may be experienced such as infection and post-surgery are associated with systemic inflammatory responses, and even neuroinflammation. Post-concussion syndrome itself has a significant neuroinflammatory component. In this review we examine the evidence of neuroinflammation in post-concussion syndrome and the potential role systemic inflammation plays in post-concussion syndrome like symptoms. We conclude that given the overlap between these conditions and the role of inflammation in their etiologies, a new term, post-inflammatory brain syndromes (PIBS), is necessary to describe the common outcomes of many different inflammatory insults. The concept of post-concussion syndrome is in its evolution therefore, the new term post-inflammatory brain syndromes provides a better understanding of etiology of its wide-array of symptoms and the wide array of conditions they can be seen in.

Comparing the Neuropsychological Test Performance of Operation Enduring Freedom/Operation Iraqi Freedom (OEF/OIF) Veterans with and without Blast Exposure, Mild Traumatic Brain Injury, and Posttraumatic Stress Symptoms

To compare neuropsychological test performance of Veterans with and without mild traumatic brain injury (MTBI), blast exposure, and posttraumatic stress disorder (PTSD) symptoms. We compared the neuropsychological test performance of 49 Operation Enduring Freedom/Operation Iraqi Freedom (OEF/OIF) Veterans diagnosed with MTBI resulting from combat blast-exposure to that of 20 blast-exposed OEF/OIF Veterans without history of MTBI, 23 OEF/OIF Veterans with no blast exposure or MTBI history, and 40 matched civilian controls. Comparison of neuropsychological test performance across all four participant groups showed a complex pattern of mixed significant and mostly nonsignificant results, with omnibus tests significant for measures of attention, spatial abilities, and executive function. The most consistent pattern was the absence of significant differences between blast-exposed Veterans with MTBI history and blast-exposed Veterans without MTBI history. When blast-exposed Veteran groups with and without MTBI history were aggregated and compared to non-blast-exposed Veterans, there were significant differences for some measures of learning and memory, spatial abilities, and executive function. However, covariation for severity of PTSD symptoms eliminated all significant omnibus neuropsychological differences between Veteran groups. Our results suggest that, although some mild neurocognitive effects were associated with blast exposure, these neurocognitive effects might be better explained by PTSD symptom severity rather than blast exposure or MTBI history alone.

Gender Influences on Return to Work After Mild Traumatic Brain Injury

OBJECTIVE

To examine the influence of gender on the return to work experience of workers who sustained a work-related mild traumatic brain injury (TBI).

DESIGN

Qualitative study using in-depth telephone interviews.

SETTING

Community.

PARTICIPANTS

Purposive sampling was used to recruit participants. Participants were adults (N=12; males, n=6, females, n=6) with a diagnosis of mild TBI sustained through a workplace injury.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Not applicable.

RESULTS

Our findings suggest that gender impacts return to work experiences in multiple ways. Occupational and breadwinner roles were significant for both men and women after work-related mild TBI. Women in this study were more proactive than men in seeking and requesting medical and rehabilitation services; however, the workplace culture may contribute to whether and how health issues are discussed. Among our participants, those who worked in supportive, nurturing (eg, feminine) workplaces reported more positive return to work (RTW) experiences than participants employed in traditionally masculine work environments. For all participants, employer and coworker relations were critical elements in RTW outcomes.

CONCLUSIONS

The application of a gender analysis in this preliminary exploratory study revealed that gender is implicated in the RTW process on many levels for men and women alike. Further examination of the work reintegration processes that takes gender into account is necessary for the development of successful policy and practice for RTW after work-related MTBI.

Pediatric head injury: a pain for the emergency physician?

The prompt diagnosis and initial management of pediatric traumatic brain injury poses many challenges to the emergency department (ED) physician. In this review, we aim to appraise the literature on specific management issues faced in the ED, specifically: indications for neuroimaging, choice of sedatives, applicability of hyperventilation, utility of hyperosmolar agents, prophylactic anti-epileptics, and effect of hypothermia in traumatic brain injury. A comprehensive literature search of PubMed and Embase was performed in each specific area of focus corresponding to the relevant questions. The majority of the head injured patients presenting to the ED are mild and can be observed. Clinical prediction rules assist the ED physician in deciding if neuroimaging is warranted. In cases of major head injury, prompt airway control and careful use of sedation are necessary to minimize the chance of hypoxia, while avoiding hyperventilation. Hyperosmolar agents should be started in these cases and normothermia maintained. The majority of the evidence is derived from adult studies, and most treatment modalities are still controversial. Recent multicenter trials have highlighted the need to establish common platforms for further collaboration.

Predictors of longitudinal outcome and recovery of pragmatic language and its relation to externalizing behaviour after pediatric traumatic brain injury

The purpose of the present investigation was to evaluate the contribution of age-at-insult and brain pathology on longitudinal outcome and recovery of pragmatic language in a sample of children and adolescents with traumatic brain injury (TBI). Children and adolescents with mild to severe TBI (n=112) were categorized according to timing of brain insult: (i) Middle Childhood (5-9 years; n=41); (ii) Late Childhood (10-11 years; n=39); and (iii) Adolescence (12-15 years; n=32) and group-matched for age, gender and socio-economic status (SES) to a typically developing (TD) control group (n=43). Participants underwent magnetic resonance imaging (MRI) including a susceptibility weighted imaging (SWI) sequence 2-8 weeks after injury and were assessed on measures of pragmatic language and behavioural functioning at 6- and 24-months after injury. Children and adolescents with TBI of all severity levels demonstrated impairments in these domains at 6-months injury before returning to age-expected levels at 2-years post-TBI. However, while adolescent TBI was associated with post-acute disruption to skills that preceded recovery to age-expected levels by 2-years post injury, the middle childhood TBI group demonstrated impairments at 6-months post-injury that were maintained at 2-year follow up. Reduced pragmatic communication was associated with frontal, temporal and corpus callosum lesions, as well as more frequent externalizing behaviour at 24-months post injury. Findings show that persisting pragmatic language impairment after pediatric TBI is related to younger age at brain insult, as well as microhemorrhagic pathology in brain regions that contribute to the anatomically distributed social brain network. Relationships between reduced pragmatic communication and more frequent externalizing behavior underscore the need for context-sensitive rehabilitation programs that aim to increase interpersonal effectiveness and reduce risk for maladaptive behavior trajectories into the long-term post injury.