Blood-Based Biomarkers in Traumatic Brain Injury: A Narrative Review With Implications for the Legal System

Traumatic brain injury (TBI) is an increasingly recognized diagnosis with significant, and often costly, associated consequences. Yet, despite their increased recognition, TBIs remain underdiagnosed. This issue is especially prominent in the context of mild TBI (mTBI), where there often exists little to no objective evidence of brain injury. In recent years, considerable effort has been made to better define and interpret known objective markers of TBI, as well as identify and explore new ones. An area of particular interest has focused on research related to blood-based biomarkers of TBI. Advancements in our understanding of TBI-related biomarkers can make it possible to characterize the severity of TBI with greater accuracy, improve our understanding of staging within both the injury process and the recovery process, and help us develop quantifiable metrics representative of reversal and recovery from a brain injury following trauma. Proteomic and non-proteomic blood-based biomarkers are being studied extensively and have shown promise for these purposes. Developments in this realm have significant implications not only for clinical care but also for legislation, as well as civil and criminal litigation. Despite their substantial potential, most of these biomarkers are not yet ready for use within the clinical setting, and therefore, are not appropriate for use within the legal or policy-making systems at this time. Given that existing standardization for the accurate and reliable use of TBI biomarkers is currently insufficient for use within either the clinical or legal realms, such data can be vulnerable to misuse and can even result in the abuse of the legal system for unwarranted gain. Courts will need to carefully evaluate the information presented in their role as gatekeepers of the admissibility of scientific evidence within the legal process. Ultimately, the development of biomarkers should lead to improved clinical care following TBI exposure, coherent and informed laws surrounding TBI, and more accurate and just results in litigation surrounding TBI-related sequelae.

Surge of Miller Fisher variant and Guillain-Barré syndrome in two downtown Los Angeles community teaching hospitals

Guillain-Barré syndrome (GBS) and Miller Fisher variant (MFv) cases spiked threefold in Los Angeles, with a high proportion of MFv cases. MFv is underdiagnosed when accompanying neurological symptoms are mild. This report emphasizes the seasonality of GBS and its relation to ganglioside antibodies.

Epidemiology of War-Related Spinal Cord Injury Among Combatants: A Systematic Review

STUDY DESIGN

Systematic review.

OBJECTIVES

War-related spinal cord injuries (SCIs) are commonly more severe and complex than traumatic SCIs among civilians. This systematic review, for the first time, synthesized and critically appraised the literature on the epidemiology of war-related SCIs. This review aimed to identify distinct features from the civilian SCIs that can have an impact on the management of military and civilian SCIs.

METHODS

Medline, EMBASE, and PsycINFO databases were searched for articles on epidemiology of war-related SCI among combatants, published from 1946 to December 20, 2017. This review included only original publications on epidemiological aspects of SCIs that occur during an act of war. The STROBE statement was used to examine the quality of the publications.

RESULTS

The literature search identified 1594 publications, of which 25 articles fulfilled the inclusion and exclusion criteria. The studies were classified into the following topics: 17 articles reported demographics, level and severity of SCI, mechanism of injury and/or associated bodily injuries; 5 articles reported the incidence of war-related SCI; and 6 articles reported the frequency of SCI among other war-related bodily injuries. Overall, military personnel with war-related SCI were typically young, white men, with predominantly thoracic or lumbar level, complete (American Spinal Injury Association [ASIA] Impairment Scale A) SCI due to gunshot or explosion and often associated with other bodily injuries. Marines appear to be at a greater risk of war-related SCI than the military personal in the Army, Navy, and Air Force.

CONCLUSIONS

The war-related SCIs among soldiers are distinct from the traumatic SCI in the general population. The majority of the current literature is based on the American experiences in most recent wars.

Traumatic spinal cord injury in military personnel versus civilians: a propensity score-matched cohort study

INTRODUCTION

Military personnel are exposed to mechanisms of bodily injuries that may differ from civilians. A retrospective cohort study (RCS) and a propensity score-matched cohort study (PSMCS) were undertaken to examine the potential differences in injury epidemiology, management and outcomes after spinal cord injury (SCI) between military personnel and civilians.

METHODS

Using a Canadian multicentre SCI database, data of all individuals with sufficient data from October 2013 to January 2017 were included in the RCS (n=1043). In the PSMCS, a group of 50 military personnel with SCI was compared with a group of 50 civilians with SCI who were matched regarding sex, age, and level, severity and mechanism of SCI.

RESULTS

In the RCS, military personnel with SCI (n=61) were significantly older and predominantl males when compared with civilians with SCI (n=982). However, the study groups were not statistically different with regards to their: level, severity and mechanisms of SCI; frequency of associated bodily injuries; and need for mechanical ventilation after SCI. In the PSMCS, the group of military individuals with SCI (n=50) was similar to the group of civilians with SCI (n=50) regarding pre-existing medical comorbidities, degree of motor impairment at admission, initial treatment for SCI and clinical and neurological outcomes after SCI.

CONCLUSIONS

The results of these studies suggest that military SCI group has disproportionally older men at the time of injury compared with civilians with SCI. However, the military and civilian SCI groups had similar outcomes of alike initial treatment when both groups were matched regarding their demographic profile and injury characteristics.

Gabrielle Lévy and the Roussy-Lévy syndrome

In 1934, Gabrielle Lévy died at the age of 48. She became well known for an article she published on a hereditary polyneuropathy in cooperation with Gustav Roussy, resulting in the eponym Roussy-Lévy syndrome. Not much is known about this extraordinary neurologist/neuropathologist. Her family declared that she died from the disease she was studying. She was a pupil of Pierre Marie, with whom she worked at the Salpêtrière in Paris and wrote on war neurology. In cooperation with Marie, she published a number of articles on postencephalitic syndromes, which also became the subject of her 1922 thesis. Three years later, she became associate physician at the Paul-Brousse Hospital in Paris, where the study of brain tumors became one of the subjects of her scientific work. Remarkably, Lévy was first author in a few of her many articles, although Roussy confirmed that she often initiated the study and even wrote the main part. In this article her career is considered in the context of the struggle of women physicians to improve their position during the early-twentieth century. She probably died from a brain tumor or a postencephalitic syndrome.

The right tool and the right place for the job: the importance of the field in experimental neurophysiology, 1880-1945

This paper seeks to contribute to understandings of practice and place in the history of early American neurophysiology by exploring research with jellyfish at marine stations. Jellyfish became a particularly important research tool to experimental physiologists studying neurological subjects at the turn of the twentieth century. But their enthusiasm for the potential of this organism was constrained by its delicacy in captivity. The discovery of hardier species made experimentation at the shore possible and resulted in two epicenters of neurophysiological research on the American East Coast: the Marine Biological Laboratory and the Carnegie Institution's Dry Tortugas Laboratory. Work done in these locations had impacts on a wide range of physiological questions. These centers were short lived-researchers at the MBL eventually focused on the squid giant axon and the Tortugas lab closed after the death of Mayer-but the development of basic requirements and best practices to sustain these organisms paints an important picture of early experimental neurophysiology. Marine organisms and locations have played an integral role in the development of experimental life sciences in America. By understanding the earliest experimental research done at these locations, and the organisms that lured researchers from the campus to the coastline, we can begin to integrate marine stations into the larger historical narrative of American physiology.

Impact of World War I on brain mapping

Although much tragedy was experienced during World War I (WWI), the nature of the war and the advancements of weaponry led to a change in the quality and quantity of injuries which were conducive for study. This paper discusses how trauma during WWI led to advances in brain mapping from occipital injuries. Gordon Holmes was a British neurologist who was able to create a retinotopic map of the visual cortex from studying more than 400 cases of occipital injuries; his work has contributed immensely to our understanding of visual processing. There have been many extensions from Holmes' work in regard to how we analyze other sensory modalities and in researching how the brain processes complex stimuli such as faces. Aside from the scholastic benefit, brain mapping also has functional use and can be used for neurosurgical planning to preserve important structures. With the advent of more advanced modalities for analyzing the brain, there have been initiatives in total brain mapping which has added significantly to the body of work started by Holmes during WWI. This paper reviews the history during WWI that led to advances in brain mapping, the lasting scholastic and functional impact from these advancements, and future improvements.

Retrospective analysis of Guillain-Barré syndrome and Fisher syndrome after the Great East Japan Earthquake

Guillain-Barré syndrome (GBS) and Fisher syndrome (FS) are immune-mediated peripheral neuropathies, and most of these cases were known to be associated with a preceding infection. Recent reports evidenced an increase in the number of infectious disease cases after the earthquake. The aim of this report is to investigate the incidence and clinical features of GBS and FS after the Great East Japan Earthquake. We found GBS and FS patients had markedly increased in 2011, the year of the earthquake. In regard to an antecedent illness, gastrointestinal infection was significantly increased in GBS patients after the earthquake. These results suggest environmental factors including infectious agents and stress caused by the earthquake might have been involved in the outbreak of the diseases.

The influence of war on the development of neurosurgery

The treatment of craniospinal war wounds proved to be a significant driving force in the early growth of neurosurgery as a specialty. This publication explores the historical relationship between the evolution of combat methodology from antiquity through modern conflicts as it dovetails with and drives corresponding advancements in the field of neurosurgery. Whether it's the basic management principles for intracranial projectile wounds derived from World War I experiences, the drastic improvement in the outcomes and management of spinal cord injuries observed in World War II, or the fact that both of these wars played a crucial role in the development of a training system that is the origin of modern residency programs, the influence of wartime experiences is pervasive.

Eduard Hitzig's experiences in the Franco-Prussian War (1870-1871): the case of Joseph Masseau

It is well known that Fritsch and Hitzig published the results of their experiments on cortical stimulation in 1870, the year in which the Franco-Prussian War (FPW) broke out. Several tall stories are found about Hitzig's role in the FPW; stories that have not been well documented. During this war, he worked at the military hospital in Nancy, where he was allowed to admit to his ward soldiers with head wounds. He made a close observation of the 20-year-old French soldier Joseph Masseau, who suffered from a right-sided cerebral abscess following a gunshot wound sustained during the Loire campaign on December 10, 1870 and was looked after in the military hospital of Nancy in January and February 1871. Hitzig related the clinical and autopsy observations to his recent experimental findings. A translation into English of part of the case report is provided.

Stem cell applications in military medicine

There are many similarities between health issues affecting military and civilian patient populations, with the exception of the relatively small but vital segment of active soldiers who experience high-energy blast injuries during combat. A rising incidence of major injuries from explosive devices in recent campaigns has further complicated treatment and recovery, highlighting the need for tissue regenerative options and intensifying interest in the possible role of stem cells for military medicine. In this review we outline the array of tissue-specific injuries typically seen in modern combat - as well as address a few complications unique to soldiers - and discuss the state of current stem cell research in addressing each area. Embryonic, induced-pluripotent and adult stem cell sources are defined, along with advantages and disadvantages unique to each cell type. More detailed stem cell sources are described in the context of each tissue of interest, including neural, cardiopulmonary, musculoskeletal and sensory tissues, with brief discussion of their potential role in regenerative medicine moving forward. Additional commentary is given to military stem cell applications aside from regenerative medicine, such as blood pharming, immunomodulation and drug screening, with an overview of stem cell banking and the unique opportunity provided by the military and civilian overlap of stem cell research.