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Baig MR, Tapia RN, Meraj A, Pugh JA, Roache JD, Finley EP. Enhancing Access to Psychiatric Care for Posttraumatic Stress Disorder in Veterans with Mild Traumatic Brain Injury through Integrated Services. Psychiatr Q 2019; 90:815-827. [PMID: 31446544 DOI: 10.1007/s11126-019-09668-7] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
(i) To describe an integrated model of psychiatric care for the treatment of posttraumatic stress disorder (PTSD) in veterans with mild traumatic brain injury (mTBI). (ii) To evaluate access to and engagement in psychiatric care among veterans with comorbid PTSD and mTBI after implementation of an Integrated Care (IC) model compared to the previous Usual Care (UC). 100 randomly selected charts, 50 from each of UC and IC were reviewed in this non-concurrent case- control study. Polytrauma Network Site (PNS), an outpatient rehabilitation clinic, for veterans who suffered from brain and other traumatic injuries at an urban VA Polytrauma Rehabilitation Center. Veterans receiving treatment for mTBI symptoms by the rehabilitation team were referred for medication management for PTSD to UC and IC. Co-located access to psychiatric care for medication management as part of the interdisciplinary team with the goal of expediting rehabilitation and functional recovery. Number of consults for psychiatric care for medication management scheduled and completed within 30 days, and number of veterans offered, initiating, and completing evidence-based psychotherapies for PTSD in UC compared to IC. After implementation of IC there were significant improvements in timely completion of consults and patient engagement with a psychiatrist. There also were improvements in number of referrals, initiation, and completion of evidence-based psychotherapies for the treatment of PTSD. IC within the PNS shows promise as an effective care model for increasing access and engagement in care for veterans with comorbid PTSD/mTBI. Future research is needed to examine the utility of this model in other sites.
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Affiliation(s)
- Muhammad R Baig
- Mental Health, South Texas Veterans Healthcare System, Mail Code A116, 7400 Merton Minter Blvd., San Antonio, TX, 78229, USA. .,Polytrauma Rehabilitation Center, Mail Code A116, 7400 Merton Minter Blvd., San Antonio, TX, 78229, USA. .,Department of Psychiatry, University of Texas Health Science Center at San Antonio, Mail Code A116, 7400 Merton Minter Blvd., San Antonio, TX, 78229, USA.
| | - Rebecca N Tapia
- Polytrauma Rehabilitation Center, Mail Code A116, 7400 Merton Minter Blvd., San Antonio, TX, 78229, USA
| | - Adeel Meraj
- Mental Health, South Texas Veterans Healthcare System, Mail Code A116, 7400 Merton Minter Blvd., San Antonio, TX, 78229, USA
| | - Jacqueline A Pugh
- South Texas Veterans Health Care System, San Antonio, TX, USA.,Division of General/Hospital Medicine, Department of Medicine, University of Texas Health Science Center at San Antonio, San Antonio, TX, USA
| | - John D Roache
- Department of Psychiatry, University of Texas Health Science Center at San Antonio, Mail Code A116, 7400 Merton Minter Blvd., San Antonio, TX, 78229, USA
| | - Erin P Finley
- Department of Psychiatry, University of Texas Health Science Center at San Antonio, Mail Code A116, 7400 Merton Minter Blvd., San Antonio, TX, 78229, USA.,South Texas Veterans Health Care System, San Antonio, TX, USA.,Division of General/Hospital Medicine, Department of Medicine, University of Texas Health Science Center at San Antonio, San Antonio, TX, USA
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Patel P, Taylor D, Park MS. Characteristics of traumatic brain injury during Operation Enduring Freedom–Afghanistan: a retrospective case series. Neurosurg Focus 2019; 47:E13. [DOI: 10.3171/2019.8.focus19493] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2019] [Accepted: 08/20/2019] [Indexed: 11/06/2022]
Abstract
Traumatic brain injury (TBI) is a significant cause of morbidity and mortality, especially among members of the armed services. Injuries sustained in the battlefield are subject to different mechanisms than those sustained in civilian life, particularly blast and high-velocity injury. Due to the unique nature of these injuries and the challenges associated with battlefield medicine, surgical interventions play a key role in acute management of TBI. However, the burden of chronic disease posed by TBI is poorly understood and difficult to investigate, especially in the military setting. The authors report the case logs of a United States Navy neurosurgeon, detailing the acute management and outcomes of 156 patients sustaining TBI between November 2010 and May 2011 during the war in Afghanistan. By demographics, more than half of the patients treated were local nationals. By mechanism of injury, blunt trauma (40.4%) and explosive injury (37.2%) were the most common contributors to TBI. Decompressive craniectomies (24.0%) and clot evacuations (14.7%) were the procedures most commonly performed. Nearly one-quarter of patients were transferred to receive further care, yet only 3 patients were referred for rehabilitative services. Furthermore, the data suggest that patients sustaining comorbid injuries in addition to TBI may be predisposed to worse outcomes. Improvements in documentation of military patients may improve knowledge of TBI and further identify potential variables or treatments that may affect prognosis. The increased survivability from TBI also highlights the need for additional research expenditure in the field of neurorehabilitation specifically.
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Wang YS, Hsieh W, Chung JR, Lan TH, Wang Y. Repetitive mild traumatic brain injury alters diurnal locomotor activity and response to the light change in mice. Sci Rep 2019; 9:14067. [PMID: 31575951 PMCID: PMC6773703 DOI: 10.1038/s41598-019-50513-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2019] [Accepted: 09/13/2019] [Indexed: 12/14/2022] Open
Abstract
Mild traumatic brain injury (mTBI) is a common cause of brain damage with a high incidence of multiple mTBIs found among athletes and soldiers. The purpose of this study is to examine the diurnal behavioral changes after multiple mTBIs. Adult mice were anesthetized; mTBI was conducted by dropping a 30-g weight to the right temporal skull once (mTBI1) or three times (mTBI3) over 3-week. Open-field motor behavior was recorded for 3 days after the last mTBI. In the first 4-hour exploratory phase, mTBI1 or mTBI3 equally reduced locomotor activity. A significant reduction of locomotor activity was found in the dark cycle between 4–72 hour in mTBI1 or mTBI3 mice; higher motor activity was seen after mTBI3 compared to mTBI1. In the light cycle, mTBI3 mice demonstrated an earlier immobilization followed by hyperactivity. The response to light change significantly correlated with the number of impacts. The IBA1 and BAX protein levels were equally increased in the lesioned cortex after mTBI1 and mTBI3. mTBI3 selectively upregulated the expression of circadian clock gene Per1 in hypothalamus and hippocampus as well as iNOS expression in the lesioned side cortex. Our data suggest multiple mTBIs alter diurnal locomotor activity and response to the change of light, which may involve Per1 expression in the lesioned brain.
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Affiliation(s)
- Yu-Syuan Wang
- Center for Neuropsychiatric Research, National Health Research Institutes, Zhunan, Taiwan
| | - Wei Hsieh
- Center for Neuropsychiatric Research, National Health Research Institutes, Zhunan, Taiwan
| | - Jia-Ru Chung
- Center for Neuropsychiatric Research, National Health Research Institutes, Zhunan, Taiwan
| | - Tsuo-Hung Lan
- Center for Neuropsychiatric Research, National Health Research Institutes, Zhunan, Taiwan.,Department of Psychiatry, Taichung Veteran General Hospital, Taichung, Taiwan.,Department of Psychiatry, School of Medicine, National Yang-Ming University, Taipei, Taiwan
| | - Yun Wang
- Center for Neuropsychiatric Research, National Health Research Institutes, Zhunan, Taiwan.
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Buccellato KH, Nordstrom M, Murphy JM, Burdea GC, Polistico K, House G, Kim N, Grampurohit N, Sorensen J, Isaacson BM, Pasquina PF. A Randomized Feasibility Trial of a Novel, Integrative, and Intensive Virtual Rehabilitation Program for Service Members Post-Acquired Brain Injury. Mil Med 2019; 185:e203-e211. [DOI: 10.1093/milmed/usz150] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2019] [Revised: 05/10/2019] [Accepted: 06/05/2019] [Indexed: 11/13/2022] Open
Abstract
Abstract
Introduction
Acquired Brain Injury, whether resulting from Traumatic brain injury (TBI) or Cerebral Vascular Accident (CVA), represent major health concerns for the Department of Defense and the nation. TBI has been referred to as the “signature” injury of recent U.S. military conflicts in Iraq and Afghanistan – affecting approximately 380,000 service members from 2000 to 2017; whereas CVA has been estimated to effect 795,000 individuals each year in the United States. TBI and CVA often present with similar motor, cognitive, and emotional deficits; therefore the treatment interventions for both often overlap. The Defense Health Agency and Veterans Health Administration would benefit from enhanced rehabilitation solutions to treat deficits resulting from acquired brain injuries (ABI), including both TBI and CVA. The purpose of this study was to evaluate the feasibility of implementing a novel, integrative, and intensive virtual rehabilitation system for treating symptoms of ABI in an outpatient clinic. The secondary aim was to evaluate the system’s clinical effectiveness.
Materials and Methods
Military healthcare beneficiaries with ABI diagnoses completed a 6-week randomized feasibility study of the BrightBrainer Virtual Rehabilitation (BBVR) system in an outpatient military hospital clinic. Twenty-six candidates were screened, consented and randomized, 21 of whom completed the study. The BBVR system is an experimental adjunct ABI therapy program which utilizes virtual reality and repetitive bilateral upper extremity training. Four self-report questionnaires measured participant and provider acceptance of the system. Seven clinical outcomes included the Fugl-Meyer Assessment of Upper Extremity, Box and Blocks Test, Jebsen-Taylor Hand Function Test, Automated Neuropsychological Assessment Metrics, Neurobehavioral Symptom Inventory, Quick Inventory of Depressive Symptomatology-Self-Report, and Post Traumatic Stress Disorder Checklist- Civilian Version. The statistical analyses used bootstrapping, non-parametric statistics, and multilevel/hierarchical modeling as appropriate. This research was approved by the Walter Reed National Military Medical Center and Uniformed Services University of the Health Sciences Institutional Review Boards.
Results
All of the participants and providers reported moderate to high levels of utility, ease of use and satisfaction with the BBVR system (x̄ = 73–86%). Adjunct therapy with the BBVR system trended towards statistical significance for the measure of cognitive function (ANAM [x̄ = −1.07, 95% CI −2.27 to 0.13, p = 0.074]); however, none of the other effects approached significance.
Conclusion
This research provides evidence for the feasibility of implementing the BBVR system into an outpatient military setting for treatment of ABI symptoms. It is believed these data justify conducting a larger, randomized trial of the clinical effectiveness of the BBVR system.
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Affiliation(s)
- Kiara H Buccellato
- The Henry M. Jackson Foundation for the Advancement of Military Medicine, 6720 A Rockledge Dr, Bethesda, MD
- The Center for Rehabilitation Sciences Research 4301 Jones Bridge Rd, Bethesda, MD
| | - Michelle Nordstrom
- The Henry M. Jackson Foundation for the Advancement of Military Medicine, 6720 A Rockledge Dr, Bethesda, MD
- The Center for Rehabilitation Sciences Research 4301 Jones Bridge Rd, Bethesda, MD
- Department of Rehabilitation Medicine, Uniformed Services University of Health Sciences, 4301 Jones Bridge Rd, Bethesda, MD
- Department of Rehabilitation Medicine, Walter Reed National Military Medical Center, 8901 Rockville Pike, Bethesda, MD
| | - Justin M Murphy
- The Henry M. Jackson Foundation for the Advancement of Military Medicine, 6720 A Rockledge Dr, Bethesda, MD
- The Center for Rehabilitation Sciences Research 4301 Jones Bridge Rd, Bethesda, MD
| | - Grigore C Burdea
- Bright Cloud International Corp, 675 US Hwy 1, North Brunswick, NJ
| | - Kevin Polistico
- Bright Cloud International Corp, 675 US Hwy 1, North Brunswick, NJ
| | - Gregory House
- Bright Cloud International Corp, 675 US Hwy 1, North Brunswick, NJ
| | - Nam Kim
- Bright Cloud International Corp, 675 US Hwy 1, North Brunswick, NJ
| | | | - Jeff Sorensen
- The Henry M. Jackson Foundation for the Advancement of Military Medicine, 6720 A Rockledge Dr, Bethesda, MD
- The Center for Rehabilitation Sciences Research 4301 Jones Bridge Rd, Bethesda, MD
| | - Brad M Isaacson
- The Center for Rehabilitation Sciences Research 4301 Jones Bridge Rd, Bethesda, MD
- Department of Rehabilitation Medicine, Uniformed Services University of Health Sciences, 4301 Jones Bridge Rd, Bethesda, MD
- The Geneva Foundation, 917 Pacific Ave, Tacoma, WA
| | - Paul F Pasquina
- Department of Rehabilitation Medicine, Uniformed Services University of Health Sciences, 4301 Jones Bridge Rd, Bethesda, MD
- Department of Rehabilitation Medicine, Walter Reed National Military Medical Center, 8901 Rockville Pike, Bethesda, MD
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Baig MR, Wilson JL, Lemmer JA, Beck RD, Peterson AL, Roache JD. Enhancing Completion of Cognitive Processing Therapy for Posttraumatic Stress Disorder with Quetiapine in Veterans with Mild Traumatic Brain Injury: a Case Series. Psychiatr Q 2019; 90:431-445. [PMID: 31054021 DOI: 10.1007/s11126-019-09638-z] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
To evaluate the outcomes of the antiarousal medications valproate, risperidone, and quetiapine on completion of treatment of cognitive processing therapy (CPT) for PTSD. A case series of fifty treatment-seeking adult (≥18 years) veterans with mild traumatic brain injury and combat-related PTSD who had unsuccessful trials of 2 or more first-line agents and previously declined treatment with trauma-focused therapy, seen at the psychiatric outpatient services of the local Polytrauma Rehabilitation Center from January 1, 2014, through December 31, 2017. Patients were prescribed valproate (n = 8), risperidone (n = 17), or quetiapine (n = 25) and were referred for individual weekly treatment with CPT. Outcome measurements of interest were measures of engagement and completion rate of CPT, PTSD Checklist total score (range, 0-80; higher scores indicate greater PTSD severity) and arousal subscale score (range, 0-24; higher scores indicate greater arousal severity), and clinical observations of sleep variables. Of the 50 patients included in the study, 48 (96%) were men; mean (SD) age was 36 (8) years. Eighteen (86%) patients initially receiving quetiapine and none taking valproate or risperidone became adequately engaged in and completed CPT. Among patients who completed CPT, the mean decrease in the PTSD Checklist score was 25 [95% CI, 30 to 20] and 9 (50%) patients no longer met criteria for PTSD. These preliminary findings support quetiapine as an adjunctive medication to facilitate CPT. A pragmatic trial is needed to evaluate the efficacy, safety, and feasibility of quetiapine to improve engagement in and completion rate of CPT.
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Affiliation(s)
- Muhammad R Baig
- Mental Health, South Texas Veterans Healthcare System, San Antonio, TX, USA. .,Polytrauma Rehabilitation Center, South Texas Veterans Healthcare System, San Antonio, TX, USA. .,Department of Psychiatry, University of Texas Health Science Center at San Antonio, San Antonio, TX, USA.
| | - Jennifer L Wilson
- Mental Health, South Texas Veterans Healthcare System, San Antonio, TX, USA.,Polytrauma Rehabilitation Center, South Texas Veterans Healthcare System, San Antonio, TX, USA
| | - Jennifer A Lemmer
- Mental Health, South Texas Veterans Healthcare System, San Antonio, TX, USA.,Polytrauma Rehabilitation Center, South Texas Veterans Healthcare System, San Antonio, TX, USA
| | - Robert D Beck
- Mental Health, South Texas Veterans Healthcare System, San Antonio, TX, USA.,Polytrauma Rehabilitation Center, South Texas Veterans Healthcare System, San Antonio, TX, USA
| | - Alan L Peterson
- Mental Health, South Texas Veterans Healthcare System, San Antonio, TX, USA.,Department of Psychiatry, University of Texas Health Science Center at San Antonio, San Antonio, TX, USA.,Department of Psychology, University of Texas at San Antonio, San Antonio, TX, USA
| | - John D Roache
- Department of Psychiatry, University of Texas Health Science Center at San Antonio, San Antonio, TX, USA.,Department of Pharmacology, University of Texas Health San Antonio, San Antonio, TX, USA
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Malgras B, Aoun O, Pauleau G, Boddaert G, Hornez E, Dulou R, Delmas JM, Haen P, Laversanne S, Crambert A, Balandraud P. Deployment of the Surgical Life-saving Module (SLM) in 2017: Lessons learned in setting up and training operational surgical units. Injury 2019; 50:1133-1137. [PMID: 30851979 DOI: 10.1016/j.injury.2019.03.001] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/25/2018] [Revised: 01/13/2019] [Accepted: 03/02/2019] [Indexed: 02/02/2023]
Abstract
INTRODUCTION The military operations carried out by the French armed forces, occasionally require the use of the Surgical Life-saving Module (SLM), to ensure the surgical support of its soldiers. Due to its extreme mobility and capacity of fast deployment, SLM is particularly useful in small-scale military operations, such as Special Forces missions. In 2017, the French SLM was for the first time used to ensure surgical support of allied forces, which were lacking forward surgical capabilities. MATERIALS AND METHODS the SLM is a mobile, heliborne, airborne, surgical structure with parachuting capability onto land or sea, therefore essentially focused on life-saving procedures, also known as "damage control" surgery. Due to the need for mobility and rapid implementation, the SLM is limited to a maximum of 5 interventions or, in terms of injuries, to 1 or 2 seriously injured patients. RESULTS Over a period of 2 months, 5 medical teams were successively deployed with the SLM. A total of 157 casualties were treated. The most common injuries were caused by shrapnel 561%), followed by firearms (36%), and blunt trauma (2.5%). Injuries included the limbs (56%), thorax (18%), abdomen (13%), head (11%), and neck (2%). The average ISS was 8.5 (1-25) with 26 patients presenting with an ISS greater than or equal to 15. The average NISS was 10.8 (1-75) with 34 casualties having an NISS equal to or greater than 15. The surgical procedures were broken down as follows: 126 dressings, 16 laparotomies, 7 thoracotomies, 12 isolated thoracic drains (without thoracotomy), 1 cervicotomy, 12 amputations, 7 limb splints, 2 limb fasciotomies, 2 external fixators and 1 femoral fracture traction. CONCLUSIONS The numerous SLM deployments in larger operations highlighted its ability to adapt both in terms of equipment and personnel. Continuous management of equipment logistics, robust personnel training, and appropriate organization of the evacuation procedures, were the key elements for optimizing combat casualty care. As a consequence, the SLM appears to be an operational surgical unit of choice during deployments.
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Affiliation(s)
- Brice Malgras
- Department of Digestive Surgery, Begin Military Teaching Hospital, Saint Mandé, France.
| | - Olivier Aoun
- 5th Armed Forces Medical Center, Strasbourg, France
| | - Ghislain Pauleau
- Department of Gastrointestinal Surgery, Laveran Military Teaching Hospital, Marseille, France
| | - Guillaume Boddaert
- Department of Gastrointestinal, Thoracic and Vascular Surgery, Percy Military Teaching Hospital, Clamart, France
| | - Emmanuel Hornez
- Department of Gastrointestinal, Thoracic and Vascular Surgery, Percy Military Teaching Hospital, Clamart, France
| | - Renaud Dulou
- Department of Neurosurgery, Percy Military Teaching Hospital, Clamart, France
| | - Jean-Marc Delmas
- Department of Neurosurgery, Percy Military Teaching Hospital, Clamart, France
| | - Pierre Haen
- Departmet of Maxillofacial Surgery, Laveran Military Teaching Hospital, Marseille, France
| | - Sophie Laversanne
- Departmet of Maxillofacial Surgery, Laveran Military Teaching Hospital, Marseille, France
| | - Anna Crambert
- Department of Otorhinolaryngology, Percy Military Teaching Hospital, Clamart, France
| | - Paul Balandraud
- Department of Gastrointestinal Surgery, Saint-Anne Military Teaching Hospital, Toulon, France
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Vest V, Bernardo-Colón A, Watkins D, Kim B, Rex TS. Rapid Repeat Exposure to Subthreshold Trauma Causes Synergistic Axonal Damage and Functional Deficits in the Visual Pathway in a Mouse Model. J Neurotrauma 2019; 36:1646-1654. [PMID: 30451083 DOI: 10.1089/neu.2018.6046] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
We examined the effect of repeat exposure to a non-damaging insult on central nervous system axons using the optic projection as a model. The optic projection is attractive because its axons are spatially separated from the cell bodies, it is easily accessible, it is composed of long axons, and its function can be measured. We performed closed-system ocular neurotrauma in C57Bl/6 mice using bursts of 15 or 26-psi (pounds per square inch) overpressure air that caused no gross damage. We quantified the visual evoked potential (VEP) and total and degenerative axons in the optic nerve. Repeat exposure to a 15-psi air blast caused more axon damage and vision loss than a single exposure to a 26-psi air blast. However, an increased VEP latency was detected in both groups. Exposure to three 15-psi air blasts separated by 0.5 sec caused 15% axon degeneration at 2 weeks. In contrast, no axon degeneration above sham levels was detected when the interinjury interval was increased to 10 min. Exposure to 15-psi air blasts once a day for 6 consecutive days caused 3% axon degeneration. Therefore, repeat mild trauma within an interinjury interval of 1 min or less causes synergistic axon damage, whereas mild trauma repeated at a longer interinjury interval causes additive, cumulative damage. The synergistic damage may underlie the high incidence of traumatic brain injury and traumatic optic neuropathy in blast-injured service members given that explosive blasts are multiple injury events that occur in a very short time span. This study also supports the use of the VEP as a biomarker for traumatic optic neuropathy.
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Affiliation(s)
- Victoria Vest
- 1 Vanderbilt Eye Institute, Vanderbilt University Medical Center, Nashville, Tennessee
| | | | - Dexter Watkins
- 3 Department of Mechanical Engineering, Vanderbilt University, Nashville, Tennessee
| | - Bohan Kim
- 2 Department of Ophthalmology & Visual Sciences, Vanderbilt University School of Medicine, Nashville, Tennessee
| | - Tonia S Rex
- 1 Vanderbilt Eye Institute, Vanderbilt University Medical Center, Nashville, Tennessee.,2 Department of Ophthalmology & Visual Sciences, Vanderbilt University School of Medicine, Nashville, Tennessee
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Sharma A, Muresanu DF, Ozkizilcik A, Tian ZR, Lafuente JV, Manzhulo I, Mössler H, Sharma HS. Sleep deprivation exacerbates concussive head injury induced brain pathology: Neuroprotective effects of nanowired delivery of cerebrolysin with α-melanocyte-stimulating hormone. PROGRESS IN BRAIN RESEARCH 2019; 245:1-55. [DOI: 10.1016/bs.pbr.2019.03.002] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
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Armstrong M, Champagne J, Mortimer DS. Department of Veterans Affairs Polytrauma Rehabilitation Centers: Inpatient Rehabilitation Management of Combat-Related Polytrauma. Phys Med Rehabil Clin N Am 2018; 30:13-27. [PMID: 30470417 DOI: 10.1016/j.pmr.2018.08.013] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Abstract
Traumatic brain injury (TBI) is one of the signature injuries of Operation Iraqi Freedom and Operation Enduring Freedom. To ensure that rehabilitation care needs of veterans and active duty servicemembers with TBI and polytrauma injuries were met, the Department of Veterans Affairs (VA) established the Polytrauma System of Care (PSC) in 2005. The 5 VA Polytrauma Rehabilitation Centers provide tertiary, acute inpatient rehabilitation for the PSC. Interdisciplinary treatment teams of multiple rehabilitation disciplines provide the complex, patient-centered care to achieve maximum benefit. After discharge, veterans and servicemembers with TBI and polytrauma receive lifelong support and care through the PSC.
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Affiliation(s)
- Michael Armstrong
- Department of Physical Medicine and Rehabilitation, Minneapolis VA Health Care System, University of Minnesota, 1 Veterans Drive (117), Minneapolis, MN 55417, USA.
| | - Julie Champagne
- Polytrauma Transitional Rehabilitation, Minneapolis VA Health Care System, 1 Veterans Drive (117), Minneapolis, MN 55417, USA
| | - Diane Schretzman Mortimer
- Department of Physical Medicine and Rehabilitation, Polytrauma Network Site, Minneapolis VA Health Care System, 1 Veterans Drive (117), Minneapolis, MN 55417, USA
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Koehmstedt C, Lydick SE, Patel D, Cai X, Garfinkel S, Weinstein AA. Health status, difficulties, and desired health information and services for veterans with traumatic brain injuries and their caregivers: A qualitative investigation. PLoS One 2018; 13:e0203804. [PMID: 30208083 PMCID: PMC6135487 DOI: 10.1371/journal.pone.0203804] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2017] [Accepted: 08/25/2018] [Indexed: 01/22/2023] Open
Abstract
Traumatic brain injury (TBI) is considered the signature injury among military service member and Veterans who served in Operation Iraqi Freedom and Operation Enduring Freedom with over 360,000 individuals sustaining a first-time TBI in the military. These service members and Veterans, and their caregiver(s), must navigate multiple health systems and find experts across many fields of expertise to recover and optimize functionality. Twenty-two individuals, 10 caregivers of Veterans with TBI, 12 Veterans with TBI, participated in semi-structured interviews. Responses were coded using NVivo. Participants from both groups reported difficulties finding community supportive services (support groups) in local communities. Most participants identified the need for an advocate or point-person to help guide them to needed services and provide ongoing support in the post-acute health care recovery phase. Caregivers and Veterans desired a more personalized recovery plan from their medical professionals. When describing their ideal health information and services model most identified interactivity and twenty-four-hour availability as essential components. To provide Veterans and caregivers with optimal support and resources to navigate a complicated health services system, advocates and personalized care plans are needed. Future research should examine the feasibility and cost-effectiveness of these services.
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Affiliation(s)
- Christine Koehmstedt
- Center for the Study of Chronic Illness and Disability, College of Health and Human Services, George Mason University, Fairfax, Virginia, United States of America
| | - Susan E. Lydick
- Center for the Study of Chronic Illness and Disability, College of Health and Human Services, George Mason University, Fairfax, Virginia, United States of America
| | - Drasti Patel
- Center for the Study of Chronic Illness and Disability, College of Health and Human Services, George Mason University, Fairfax, Virginia, United States of America
| | - Xinsheng Cai
- American Institutes for Research, Washington, DC, United States of America
| | - Steven Garfinkel
- American Institutes for Research, Washington, DC, United States of America
| | - Ali A. Weinstein
- Center for the Study of Chronic Illness and Disability, College of Health and Human Services, George Mason University, Fairfax, Virginia, United States of America
- * E-mail:
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Moradi Moghadam O, Nematollahi N, Shiri Malek Abad E, Hasani V, Tabibkhooei A, Sheikhvatan M, Niakan Lahiji M. Effect of Modafinil Administration on the Level of Consciousness in Patients with Brain Injuries of Moderate Severity. Trauma Mon 2018; 24. [DOI: 10.5812/traumamon.61505] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2017] [Revised: 12/24/2017] [Accepted: 01/09/2018] [Indexed: 07/04/2024] Open
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Agoston DV. Modeling the Long-Term Consequences of Repeated Blast-Induced Mild Traumatic Brain Injuries. J Neurotrauma 2018; 34:S44-S52. [PMID: 28937952 DOI: 10.1089/neu.2017.5317] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
Repeated mild traumatic brain injury (rmTBI) caused by playing collision sports or by exposure to blasts during military operations can lead to late onset, chronic diseases such as chronic traumatic encephalopathy (CTE), a progressive neurodegenerative condition that manifests in increasingly severe neuropsychiatric abnormalities years after the last injury. Currently, because of the heterogeneity of the clinical presentation, confirmation of a CTE diagnosis requires post-mortem examination of the brain. The hallmarks of CTE are abnormal accumulation of phosphorylated tau protein, TDP-43 immunoreactive neuronal cytoplasmic inclusions, and astroglial abnormalities, but the pathomechanism leading to these terminal findings remains unknown. Animal modeling can play an important role in the identification of CTE pathomechanisms, the development of early stage diagnostic and prognostic biomarkers, and pharmacological interventions. Modeling the long-term consequences of blast rmTBI in animals is especially challenging because of the complexities of blast physics and animal-to-human scaling issues. This review summarizes current knowledge about the pathobiologies of CTE and rmbTBI and discusses problems as well as potential solutions related to high-fidelity modeling of rmbTBI and determining its long-term consequences.
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Affiliation(s)
- Denes V Agoston
- Department of Anatomy, Physiology and Genetics, Uniformed Services University , Bethesda, Maryland; Department of Neuroscience, Karolinska Institute, Stockholm, Sweden
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63
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Symptom Reporting and Management of Chronic Post-Concussive Symptoms in Military Service Members and Veterans. CURRENT PHYSICAL MEDICINE AND REHABILITATION REPORTS 2018. [DOI: 10.1007/s40141-018-0173-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
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Greer K, Chen J, Brickler T, Gourdie R, Theus MH. Modulation of gap junction-associated Cx43 in neural stem/progenitor cells following traumatic brain injury. Brain Res Bull 2017; 134:38-46. [PMID: 28648814 PMCID: PMC5597487 DOI: 10.1016/j.brainresbull.2017.06.016] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2017] [Revised: 06/12/2017] [Accepted: 06/20/2017] [Indexed: 12/17/2022]
Abstract
Restoration of learning and memory deficits following traumatic brain injury (TBI) is attributed, in part, to enhanced neural stem/progenitor cell (NSPCs) function. Recent findings suggest gap junction (GJ)-associated connexin 43 (Cx43) plays a key role in the cell cycle regulation and function of NSPCs and is modulated following TBI. Here, we demonstrate that Cx43 is up-regulated in the dentate gyrus following TBI and is expressed on vimentin-positive cells in the subgranular zone. To test the role of Cx43 on NSPCs, we exposed primary cultures to the α-connexin Carboxyl Terminal (αCT1) peptide which selectively modulates GJ-associated Cx43. Treatment with αCT1 substantially reduced proliferation and increased caspase 3/7 expression on NSPCs in a dose-dependent manner. αCT1 exposure also reduced overall expression of Cx43 and phospho (p)-Serine368. These findings demonstrate that Cx43 positively regulates adult NPSCs; the modulation of which may influence changes in the dentate gyrus following TBI.
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Affiliation(s)
- Kisha Greer
- The Department of Biomedical Sciences and Pathobiology, Virginia-Maryland Regional College of Veterinary Medicine, 215 Duck Pond Drive, Blacksburg, VA 24061, USA
| | - Jiang Chen
- The Department of Biomedical Sciences and Pathobiology, Virginia-Maryland Regional College of Veterinary Medicine, 215 Duck Pond Drive, Blacksburg, VA 24061, USA
| | - Thomas Brickler
- The Department of Biomedical Sciences and Pathobiology, Virginia-Maryland Regional College of Veterinary Medicine, 215 Duck Pond Drive, Blacksburg, VA 24061, USA
| | - Robert Gourdie
- Virgnia Tech Carillion Research Institute, College of Medicine, 2 Riverside Circle, Roanoke, VA 24016, USA
| | - Michelle H Theus
- The Department of Biomedical Sciences and Pathobiology, Virginia-Maryland Regional College of Veterinary Medicine, 215 Duck Pond Drive, Blacksburg, VA 24061, USA.
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Wang Y, Sawyer TW, Tse YC, Fan C, Hennes G, Barnes J, Josey T, Weiss T, Nelson P, Wong TP. Primary Blast-Induced Changes in Akt and GSK 3β Phosphorylation in Rat Hippocampus. Front Neurol 2017; 8:413. [PMID: 28868045 PMCID: PMC5563325 DOI: 10.3389/fneur.2017.00413] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2017] [Accepted: 07/31/2017] [Indexed: 12/30/2022] Open
Abstract
Traumatic brain injury (TBI) due to blast from improvised explosive devices has been a leading cause of morbidity and mortality in recent conflicts in Iraq and Afghanistan. However, the mechanisms of primary blast-induced TBI are not well understood. The Akt signal transduction pathway has been implicated in various brain pathologies including TBI. In the present study, the effects of simulated primary blast waves on the phosphorylation status of Akt and its downstream effector kinase, glycogen synthase kinase 3β (GSK3β), in rat hippocampus, were investigated. Male Sprague-Dawley (SD) rats (350–400 g) were exposed to a single pulse shock wave (25 psi; ~7 ms duration) and sacrificed 1 day, 1 week, or 6 weeks after exposure. Total and phosphorylated Akt, as well as phosphorylation of its downstream effector kinase GSK3β (at serine 9), were detected with western blot analysis and immunohistochemistry. Results showed that Akt phosphorylation at both serine 473 and threonine 308 was increased 1 day after blast on the ipsilateral side of the hippocampus, and this elevation persisted until at least 6 weeks postexposure. Similarly, phosphorylation of GSK3β at serine 9, which inhibits GSK3β activity, was also increased starting at 1 day and persisted until at least 6 weeks after primary blast on the ipsilateral side. In contrast, p-Akt was increased at 1 and 6 weeks on the contralateral side, while p-GSK3β was increased 1 day and 1 week after primary blast exposure. No significant changes in total protein levels of Akt and GSK were observed on either side of the hippocampus at any time points. Immunohistochemical results showed that increased p-Akt was mainly of neuronal origin in the CA1 region of the hippocampus and once phosphorylated, the majority was translocated to the dendritic and plasma membranes. Finally, electrophysiological data showed that evoked synaptic N-methyl-d-aspartate (NMDA) receptor activity was significantly increased 6 weeks after primary blast, suggesting that increased Akt phosphorylation may enhance synaptic NMDA receptor activation, or that enhanced synaptic NMDA receptor activation may increase Akt phosphorylation.
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Affiliation(s)
- Yushan Wang
- Defence Research and Development Canada, Suffield Research Centre, Medicine Hat, AB, Canada
| | - Thomas W Sawyer
- Defence Research and Development Canada, Suffield Research Centre, Medicine Hat, AB, Canada
| | - Yiu Chung Tse
- Department of Psychiatry, Douglas Mental Health University Institute, McGill University, Montreal, QC, Canada
| | - Changyang Fan
- Defence Research and Development Canada, Suffield Research Centre, Medicine Hat, AB, Canada
| | - Grant Hennes
- Defence Research and Development Canada, Suffield Research Centre, Medicine Hat, AB, Canada
| | - Julia Barnes
- Defence Research and Development Canada, Suffield Research Centre, Medicine Hat, AB, Canada
| | - Tyson Josey
- Defence Research and Development Canada, Suffield Research Centre, Medicine Hat, AB, Canada
| | - Tracy Weiss
- Defence Research and Development Canada, Suffield Research Centre, Medicine Hat, AB, Canada
| | - Peggy Nelson
- Defence Research and Development Canada, Suffield Research Centre, Medicine Hat, AB, Canada
| | - Tak Pan Wong
- Department of Psychiatry, Douglas Mental Health University Institute, McGill University, Montreal, QC, Canada
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