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Weppner J, Senol S, Larick R, Jackson S. Diagnostic Accuracy of the Yale Swallow Protocol in Moderate-to-Severe Traumatic Brain Injury: A Prospective Blinded Videofluoroscopic Investigation. J Head Trauma Rehabil 2024:00001199-990000000-00130. [PMID: 38453631 DOI: 10.1097/htr.0000000000000929] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/09/2024]
Abstract
OBJECTIVE The study aimed to assess the accuracy of the Yale Swallow Protocol (YSP) in screening aspiration in adults with acute moderate-to-severe traumatic brain injury (TBI) by comparing the YSP with a videofluoroscopic swallow study (VFSS). SETTING Level 1 academic trauma center. PARTICIPANTS The study involved a cohort of 50 consecutive adults with a history of acute moderate-to-severe TBI. DESIGN The prospective cohort study was conducted between July 2020 and June 2021. Participants underwent the YSP to assess aspiration risk, followed by a VFSS within 5 to 10 minutes after the YSP, to assess the accuracy of the YSP compared with the VFSS. MAIN MEASURE The accuracy of the YSP in identifying aspiration in adults with acute moderate-to-severe TBI. RESULTS The interrater agreement for identifying aspiration on the VFSS and the YSP was excellent, as well as 100% agreement between the speech-language pathologists and the radiologist and between the 2 speech-language pathologists, respectively. Of the 50 participants, 16 passed the YSP, while 34 failed. Among those who failed, 30 were confirmed to have aspirated on the VFSS (true-positives) and 4 did not show aspiration on the VFSS (false-positives). The YSP demonstrated a high sensitivity of 96.8%, a specificity of 78.9%, a positive predictive value of 88.2%, and a negative predictive value of 93.8% in identification of aspiration in this cohort. CONCLUSIONS To date, no dedicated prospective studies have been conducted to assess the utility of the YSP as a screening tool for identifying aspiration risk in persons with moderate-to-severe TBI. The results of this study conclude that the YSP is an effective screening tool for prediction of aspiration in acute care patients with moderate-to-severe TBI due to its high sensitivity and negative predictive value. These factors aid in identification of individuals at risk for aspiration and facilitate timely interventions to prevent complications.
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Affiliation(s)
- Justin Weppner
- Author Affiliations: Department of Internal Medicine, Virginia Tech Carilion School of Medicine, Roanoke (Dr Weppner); Department of Internal Medicine, Edward Via College of Osteopathic Medicine, Blacksburg, Virginia (Dr Weppner); Department of Internal Medicine, Carilion Clinic, Roanoke, Virginia (Dr Weppner and Ms Jackson); and Department of Physical Medicine and Rehabilitation (Dr Senol), Eastern Virginia Medical School (Mr Larick), Norfolk, Virginia
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Curl CC, Leija RG, Arevalo JA, Osmond AD, Duong JJ, Kaufer D, Horning MA, Brooks GA. Underfeeding Alters Brain Tissue Synthesis Rate in a Rat Brain Injury Model. Int J Mol Sci 2023; 24:13195. [PMID: 37686002 PMCID: PMC10487942 DOI: 10.3390/ijms241713195] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2023] [Revised: 08/21/2023] [Accepted: 08/23/2023] [Indexed: 09/10/2023] Open
Abstract
Brain injuries (BI) are highly disruptive, often having long lasting effects. Inadequate standard of care (SOC) energy support in the hospital leads to dietary energy deficiencies in BI patients. However, it is unclear how underfeeding (UF) affects protein synthesis post-BI. Therefore, in a rat model, we addressed the issue of UF on the protein fractional synthesis rate (fSR) post-BI. Compared to ad libitum (AL)-fed animals, we found that UF decreased protein synthesis in hind-limb skeletal muscle and cortical mitochondrial and structural proteins (p ≤ 0.05). BI significantly increased protein synthesis in the left and right cortices (p ≤ 0.05), but suppressed protein synthesis in the cerebellum (p ≤ 0.05) as compared to non-injured sham animals. Compared to underfeeding alone, UF in conjunction with BI (UF+BI) caused increased protein synthesis rates in mitochondrial, cytosolic, and whole-tissue proteins of the cortical brain regions. The increased rates of protein synthesis found in the UF+BI group were mitigated by AL feeding, demonstrating that caloric adequacy alleviates the effects of BI on protein dynamics in cortical and cerebellar brain regions. This research provides evidence that underfeeding has a negative impact on brain healing post-BI and that protein reserves in uninjured tissues are mobilized to support cortical tissue repair following BI.
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Affiliation(s)
| | | | | | | | | | | | | | - George A. Brooks
- Department of Integrative Biology, University of California at Berkeley, Berkeley, CA 94720-3140, USA; (C.C.C.); (R.G.L.); (J.A.A.); (A.D.O.); (D.K.)
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Jeong H, Kim JH, Choo YH, Kim M, Lee S, Ha EJ, Oh J. Nutrition Therapy for Patients With Traumatic Brain Injury: A Narrative Review. Korean J Neurotrauma 2023; 19:177-184. [PMID: 37431366 PMCID: PMC10329886 DOI: 10.13004/kjnt.2023.19.e31] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2023] [Revised: 06/15/2023] [Accepted: 06/18/2023] [Indexed: 07/12/2023] Open
Abstract
Traumatic brain injury (TBI) is a global health and socio-economic problem, resulting in significant disability and mortality. Malnutrition is common in TBI patients and is associated with increased vulnerability to infection, higher morbidity and mortality rates, as well as longer stays in the intensive care unit and hospital. Following TBI, various pathophysiological mechanisms, such as hypermetabolism and hypercatabolism, affect patient outcomes. It is crucial to provide adequate nutrition therapy to prevent secondary brain damage and promote optimal recovery. This review includes a literature review and discusses the challenges encountered in clinical practice regarding nutrition in TBI patients. The focus is on determining energy requirements, timing and methods of nutrition delivery, promoting enteral tolerance, providing enteral nutrition to patients receiving vasopressors, and implementing trophic enteral nutrition. Enhancing our understanding of the current evidence regarding appropriate nutrition practices will contribute to improving overall outcomes for TBI patients.
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Affiliation(s)
- Heewon Jeong
- Department of Neurosurgery, Chungnam National University Hospital, Daejeon, Korea
| | - Jae Hyun Kim
- Department of Neurosurgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Yoon-Hee Choo
- Department of Neurosurgery, Seoul St. Mary’s Hospital, The Catholic University of Korea, Seoul, Korea
| | - Moinay Kim
- Department of Neurosurgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Seungioo Lee
- Department of Neurosurgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Eun Jin Ha
- Department of Critical Care Medicine, Seoul National University Hospital, Seoul, Korea
| | - Jiwoong Oh
- Division of Neurotrauma & Neurocritical Care Medicine, Department of Neurosurgery, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
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Fractional Gluconeogenesis: A Biomarker of Dietary Energy Adequacy in a Rat Brain Injury Model. Metabolites 2022; 12:metabo12121163. [PMID: 36557201 PMCID: PMC9781857 DOI: 10.3390/metabo12121163] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2022] [Revised: 11/15/2022] [Accepted: 11/19/2022] [Indexed: 11/24/2022] Open
Abstract
Patients treated for traumatic brain injury (TBI) are in metabolic crises because of the trauma and underfeeding. We utilized fractional gluconeogenesis (fGNG) to assess nutritional adequacy in ad libitum-fed and calorically-restricted rats following TBI. Male Sprague-Dawley individually housed rats 49 days of age were randomly assigned into four groups: ad libitum (AL) fed control (AL-Con, sham), AL plus TBI (AL+TBI), caloric restriction (CR) control (CR-Con, sham), and CR plus TBI (CR+TBI). From days 1-7 animals were given AL access to food and water containing 6% deuterium oxide (D2O). On day 8, a pre-intervention blood sample was drawn from each animal, and TBI, sham injury, and CR protocols were initiated. On day 22, the animals were euthanized, and blood was collected to measure fGNG. Pre-intervention, there was no significant difference in fGNG among groups (p ≥ 0.05). There was a significant increase in fGNG due to caloric restriction, independent of TBI (p ≤ 0.05). In addition, fGNG may provide a real-time, personalized biomarker for assessing patient dietary caloric needs.
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Arora P, Singh K, Kumari M, Trivedi R. Temporal profile of serum metabolites and inflammation following closed head injury in rats is associated with HPA axis hyperactivity. Metabolomics 2022; 18:28. [PMID: 35486220 DOI: 10.1007/s11306-022-01886-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/01/2021] [Accepted: 04/06/2022] [Indexed: 10/18/2022]
Abstract
INTRODUCTION Closed head injury (CHI) causes neurological disability along with systemic alterations that can activate neuro-endocrine response through hypothalamic-pituitary-adrenal (HPA) axis activation. A dysregulated HPA axis function can lead to relocation of energy substrates and alteration in metabolic pathways and inflammation at the systemic level. OBJECTIVES Assessment of time-dependent changes in serum metabolites and inflammation after both mild and moderate CHI. Along with this, serum corticosterone levels and hypothalamic microglial response were observed. METHODS Rats underwent mild and moderate weight-drop injury and their serum and hypothalamus were assessed at acute, sub-acute and chronic timepoints. Changes in serum metabolomics were determined using high resolution NMR spectroscopy. Serum inflammatory cytokine, corticosterone levels and hypothalamic microglia were assessed at all timepoints. RESULTS Metabolites including lactate, choline and branched chain amino acids were found as the classifiers that helped distinguish between control and injured rats during acute, sub-acute and chronic timepoints. While, increased αglucose: βglucose and TMAO: choline ratios after acute and sub-acute timepoints of mild injury differentiated from moderate injured rats. The injured rats also showed distinct inflammatory profile where IL-1β and TNF-α levels were upregulated in moderate injured rats while IL-10 levels were downregulated in mild injured rats. Furthermore, injury specific alterations in serum metabolic and immunologic profile were found to be associated with hyperactive HPA axis, with consistent increase in serum corticosterone concentration post injury. The hypothalamic microglia showed a characteristic activated de-ramified cellular morphology in both mild and moderate injured rats. CONCLUSION The study suggests that HPA axis hyperactivity along with hypothalamic microglial activation led to temporal changes in the systemic metabolism and inflammation. These time dependent changes in the metabolite profile of rats can further strengthen the knowledge of diagnostic markers and help distinguish injury related outcomes after TBI.
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Affiliation(s)
- Palkin Arora
- Radiological, Nuclear and Imaging Sciences (RNAIS), Institute of Nuclear Medicine and Allied Sciences (INMAS), DRDO, Delhi, 110054, India
- Department of Biochemistry, Panjab University, Chandigarh, 160014, India
| | - Kavita Singh
- Radiological, Nuclear and Imaging Sciences (RNAIS), Institute of Nuclear Medicine and Allied Sciences (INMAS), DRDO, Delhi, 110054, India
- Athinoula A. Martinos Center for Biomedical Imaging, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
| | - Megha Kumari
- Radiological, Nuclear and Imaging Sciences (RNAIS), Institute of Nuclear Medicine and Allied Sciences (INMAS), DRDO, Delhi, 110054, India
- Department of Biotechnology, Delhi Technological University (DTU), Delhi, 110042, India
| | - Richa Trivedi
- Radiological, Nuclear and Imaging Sciences (RNAIS), Institute of Nuclear Medicine and Allied Sciences (INMAS), DRDO, Delhi, 110054, India.
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Joosten KFM, Eveleens RD, Verbruggen SCAT. Nutritional support in the recovery phase of critically ill children. Curr Opin Clin Nutr Metab Care 2019; 22:152-158. [PMID: 30585805 DOI: 10.1097/mco.0000000000000549] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
PURPOSE OF REVIEW The metabolic stress response of a critically ill child evolves over time and thus it seems reasonable that nutritional requirements change during their course of illness as well. This review proposes strategies and considerations for nutritional support during the recovery phase to gain optimal (catch-up) growth with preservation of lean body mass. RECENT FINDINGS Critical illness impairs nutritional status, muscle mass and function, and neurocognition, but early and high intakes of artificial nutrition during the acute phase cannot resolve this. Although (parenteral) nutrient restriction during the acute phase appears to be beneficial, persistent nutrient restriction, when the metabolic stress response resolves, has short-term and long-term detrimental consequences. Requirements increase markedly during the recovery phase to enable recovery and catch-up growth. Such large amounts of intake demand for alternate approach, especially when intestinal problems constitute a barrier for full enteral feeding. As part of the nutritional recovery, mobilization and exercise are essential to achieve catch-up growth with an optimal body composition. SUMMARY During the recovery phase of paediatric critical illness (catch-up) growth and muscle recovery require nutritional intakes at least two times the resting energy expenditure.
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Affiliation(s)
- Koen F M Joosten
- Paediatric Intensive Care, Department of Paediatrics and Paediatric Surgery, Erasmus MC - Sophia Children's Hospital, Rotterdam, the Netherlands
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Nie C, Wang T, Yu H, Wang X, Zeng X, Wei Z, Shi X. The blood parameters and liver function changed inconsistently among children between burns and traumatic injuries. PeerJ 2019; 7:e6415. [PMID: 30775182 PMCID: PMC6375254 DOI: 10.7717/peerj.6415] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2018] [Accepted: 01/08/2019] [Indexed: 11/20/2022] Open
Abstract
Objective Burn and traumatic injury are two kinds of injury by modality. They cause acute phase response and lead to a series of pathological and physiological changes. In this study, we explored whether there are differences in routine blood parameters and liver enzyme levels between burned and traumatically injured children. Methods Patients under 18 years old with injuries were recruited. Their demographic and clinical data were recorded. Collected clinical data included routine blood parameters (white blood cell count (WBC), red blood cell count (RBC), platelets (PLT), hemoglobin (HB)), serological enzyme levels (alanine aminotransferase (ALT), aspartate transaminase (AST), glutamyltransferase (GGT), alkaline phosphatase (ALP), cholinesterase (CHE)), and total protein (TP) levels (albumin (ALB), globulin (GLB)). A generalized linear model and multivariate analysis of variance were used to conduct comparisons. Results A total of 162 children (109 with burns and 53 with traumatic injuries) with a mean age of 4.36 ± 4.29 years were enrolled in the study. Burned children had higher levels of RBC, HB, WBC, AST and lower levels of TP, CHE, ALB than traumatically injured children (P < 0.05). Moreover, the concentration of WBC and HB was higher in males compared to females (P < 0.001). Conversely, the level of AST and TP in males was lower, AST levels were significantly lower in males (P = 0.005). Age positively correlated with the levels of HB, AST and TP (P < 0.001), and negatively correlated with WBC (P < 0.001). With decreasing body mass index (BMI), the levels of WBC, HB, AST and TP significantly increased in both groups of injured children (P < 0.001). In addition, ISS was positively correlated with WBC and HB levels (P < 0.001), but negatively correlated with AST and TP levels (P < 0.001). Conclusions Children with burn injuries suffered a greater acute response and liver damage than traumatically injured children. This may in part underlie clinical observations of differences in children morbidity and mortality in response to different injury types.
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Affiliation(s)
- Chan Nie
- Department of Epidemiology and Health Statistics, School of Public Health, Zunyi Medical University, Zunyi, Guizhou, China
| | - Tao Wang
- Department of Epidemiology and Health Statistics, School of Public Health, Zunyi Medical University, Zunyi, Guizhou, China
| | - Huiting Yu
- Department of Epidemiology and Health Statistics, School of Public Health, Zunyi Medical University, Zunyi, Guizhou, China
| | - Xue Wang
- Department of Epidemiology and Health Statistics, School of Public Health, Zunyi Medical University, Zunyi, Guizhou, China
| | - Xueqin Zeng
- Burns & Plastic Surgery, Affiliated Hospital of Zunyi Medical University, Zunyi Medical University, Zunyi, Guizhou, China
| | - Zairong Wei
- Burns & Plastic Surgery, Affiliated Hospital of Zunyi Medical University, Zunyi Medical University, Zunyi, Guizhou, China
| | - Xiuquan Shi
- Department of Epidemiology and Health Statistics, School of Public Health, Zunyi Medical University, Zunyi, Guizhou, China.,Center for Injury Research and Policy & Center for Pediatric Trauma Research, The Research Institute at Nationwide Children's Hospital, The Ohio State University College of Medicine, Columbus, OH, United States of America
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Vaickus M, Hsieh T, Kintsurashvili E, Kim J, Kirsch D, Kasotakis G, Remick DG. Mild Traumatic Brain Injury in Mice Beneficially Alters Lung NK1R and Structural Protein Expression to Enhance Survival after Pseudomonas aeruginosa Infection. THE AMERICAN JOURNAL OF PATHOLOGY 2018; 189:295-307. [PMID: 30472211 DOI: 10.1016/j.ajpath.2018.10.019] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/03/2018] [Revised: 09/04/2018] [Accepted: 10/23/2018] [Indexed: 12/11/2022]
Abstract
Mild traumatic brain injury (mTBI) in a murine model increases survival to a bacterial pulmonary challenge compared with blunt tail trauma (TT). We hypothesize substance P and its receptor, the neurokinin 1 receptor (NK1R; official name TACR1), play a role in the increased survival of mTBI mice. Mice were subjected to mTBI or TT, and 48 hours after trauma, the levels of NK1R mRNA and protein were significantly up-regulated in mTBI lungs. Examination of the lung 48 hours after injury by microarray showed significant differences in the expression of 433 gene sets between groups, most notably genes related to intercellular proteins. Despite down-regulated gene expression of connective proteins, the presence of an intact pulmonary vasculature was supported by normal histology and bronchoalveolar lavage protein levels. To determine whether these mTBI-induced lung changes benefited in vivo responses, two chemotactic stimuli (a CXCL1 chemokine and a live Pseudomonas aeruginosa infection) were administered 48 hours after trauma. For both stimuli, mTBI mice recruited more neutrophils to the lung 4 hours after instillation (CXCL1: mTBI = 6.3 ± 1.3 versus TT = 3.3 ± 0.7 neutrophils/mL; Pseudomonas aeruginosa: mTBI = 9.4 ± 1.4 versus TT = 5.3 ± 1.1 neutrophils/mL). This study demonstrates that the downstream consequences of mTBI on lung NK1R levels and connective protein expression enhance neutrophil recruitment to a stimulus that may contribute to increased survival.
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Affiliation(s)
- Max Vaickus
- Department of Pathology and Laboratory Medicine, Boston University School of Medicine, Boston, Massachusetts
| | - Terry Hsieh
- Department of Pathology and Laboratory Medicine, Boston University School of Medicine, Boston, Massachusetts
| | - Ekaterina Kintsurashvili
- Department of Pathology and Laboratory Medicine, Boston University School of Medicine, Boston, Massachusetts
| | - Jiyoun Kim
- Department of Pathology and Laboratory Medicine, Boston University School of Medicine, Boston, Massachusetts
| | - Daniel Kirsch
- Department of Pathology and Laboratory Medicine, Boston University School of Medicine, Boston, Massachusetts
| | - George Kasotakis
- Department of Pathology and Laboratory Medicine, Boston University School of Medicine, Boston, Massachusetts
| | - Daniel G Remick
- Department of Pathology and Laboratory Medicine, Boston University School of Medicine, Boston, Massachusetts.
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Re: Enteral nutrition in traumatic brain injury. J Trauma Acute Care Surg 2018; 82:650-651. [PMID: 28030498 DOI: 10.1097/ta.0000000000001344] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Abstract
BACKGROUND Brain Trauma Foundation guidelines recommend the early use of enteral nutrition to optimize recovery following traumatic brain injury (TBI). Our aim was to examine the effect of early feeds (≤24 hours) on clinical outcomes after TBI. METHODS We performed a 3-year retrospective study of patients with severe TBI (Glasgow Coma Scale score <8) who were intubated, admitted to the intensive care unit (ICU), and received tube feeds. Early tube feeds (early TF) were defined as initiation of tube feeds within 24 hours, whereas late tube feeds (late TF) were defined as initiation of tube feeds after 24 hours. Outcome measures included pneumonia rates, days on ventilator, hospital and ICU stay, and mortality rates. RESULTS A total of 90 patients (early TF: 58, late TF: 32) were included, of which 73.3% were male, mean age was 42 (SD, 20) years, and median head Abbreviated Injury Scale score was 4 (range, 3-5). There was no difference in age (p = 0.1), head Abbreviated Injury Scale score (p = 0.5), or admission Glasgow Coma Scale score (p = 0.9) between the two groups. Patients with early TF were associated with higher number of ICU days (p = 0.03) and higher pneumonia rates (p = 0.04), but there was no significant difference in mortality (p = 0.44) as compared with those who underwent late TF. CONCLUSIONS Although early tube feeds are known to improve outcomes in TBI patients, our data suggest that early feeds in TBI patients are associated with higher rates of pneumonia and greater hospital resource utilization. LEVEL OF EVIDENCE Therapeutic study, level IV.
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Affiliation(s)
- Julie Ay Cichero
- Honorary Senior Fellow, School of Pharmacy, The University of Queensland, Brisbane, Australia, and Co-Chair of the International Dysphagia Diet Standardisation Initiative
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Bochicchio GV, Bochicchio K, Nehman S, Casey C, Andrews P, Scalea TM. Tolerance and Efficacy of Enteral Nutrition in Traumatic Brain–Injured Patients Induced Into Barbiturate Coma. JPEN J Parenter Enteral Nutr 2017; 30:503-6. [PMID: 17047175 DOI: 10.1177/0148607106030006503] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND There is a paucity of data evaluating the efficacy of nutrition support in traumatic brain-injured patients induced into barbiturate coma for refractory intracranial hypertension. Our objective was to evaluate the efficacy of enteral nutrition in a select group of trauma patients. METHODS Prospective data were collected on severe traumatic brain-injured patients over a 4-year period. Patients were stratified by whether or not they were induced into a barbiturate coma. Barbiturate coma was defined as per American Association of Neurological Surgeons (AANS) guidelines. All patients were initially fed via the enteral route via a nasogastric feeding tube. Patients who did not tolerate feedings within 48 hours started receiving prokinetic agents. Feeding tolerance was defined as ability to tolerate enteral feedings with <150 mL of gastric residuals every 6 hours for >72 hours. RESULTS Fifty-seven patients were induced into a barbiturate coma. All were victims of blunt-force trauma. Forty-two of 57 (74%) patients were men, with a mean age of 37+/-12 years and a mean injury severity score of 24+/-10. Thirty-eight of the 57 (67%) patients had an isolated traumatic brain injury. All 57 patients failed enteral nutrition via the nasogastric route after the first 48 hours of nutrition initiation after barbiturate coma was fully achieved by protocol criteria. Prokinetic agents demonstrated no improvement in feeding tolerance after the subsequent 48-72 hours. Of the 12 patients who had a postpyloric feeding tube placed, only 25% tolerated enteral nutrition for >48 hours. CONCLUSIONS Patients with traumatic brain injury induced into barbiturate coma develop a significant ileus that is refractory to prokinetic agents. Only a marginal improvement is seen when the postpyloric route is obtained. Early parenteral nutrition should be considered in this patient population.
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Affiliation(s)
- Grant V Bochicchio
- R. Adams Cowley Shock Trauma Center, Division of Clinical and Outcomes Research, University of Maryland School of Medicine, Baltimore, Maryland 21201, USA.
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Abstract
Traumatic brain injury (TBI) is a common injury among children. Most TBIs are mild and do not require hospitalization. However, whether or not the patients require acute hospitalization, TBIs may have long-lasting consequences. There is little research on the nutrient needs of these patients, and recommendations are frequently based on data from adults with TBI. It is clear that calorie and protein needs are elevated with acute TBI. However, calorie needs are also decreased by therapies such as sedation, chemical paralysis, and barbiturate coma. Long-term calorie needs may be lower for "comatose" patients. Enteral feeding is preferred and possible for patients with TBI, though gastric feeding may be problematic in some patients. In the acute phase, patients with TBI can also have dysregulation of fluid and electrolyte balance, which may require alterations in nutrition care. Dysphagia is common after moderately severe TBI and requires a multidisciplinary approach for treatment. Future opportunities for research on pediatric TBI are numerous and may include ongoing clarification of macronutrient needs, as well as investigation into the roles of specific nutrients such as zinc, antioxidants, and anti-inflammatory compounds.
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Affiliation(s)
- Carrie Redmond
- Strong Memorial Hospital, 601 Elmwood Avenue, Box 667, Rochester, NY 14642, USA.
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Abstract
Clinical and political responses to the worldwide epidemic of traumatic brain injury (TBI) need to recognize that the quality of outcome depends on both phases of treatment: acute care and rehabilitation. The growing scientific evidence for neural repair and regeneration has supported growing interest about what rehabilitation can offer to restore function and independence to disabled individuals. Clinicians who treat acutely head-injured patients should develop some understanding of the reality and potential of rehabilitation, to put their own work into perspective. This article reviews the common problems that follow TBI, unpacks the rehabilitation box to see what can be done about them, and considers the scientific evidence for the efficacy of the rehabilitation process.
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Affiliation(s)
- Douglas Gentleman
- Centre for Brain Injury Rehabilitation, Royal Victoria Hospital, Dundee, UK
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The Aetiology of Reduced Cardiorespiratory Fitness Among Adults with Severe Traumatic Brain Injury and the Relationship with Physical Activity: A Narrative Review. BRAIN IMPAIR 2015. [DOI: 10.1017/brimp.2015.28] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Reduced cardiorespiratory fitness or cardiorespiratory deconditioning is a secondary physical impairment commonly reported to affect people after traumatic brain injury (TBI), both in the short- and long-term. Eleven studies have measured peak oxygen uptake${\rm ({\dot V}O}_{{\rm 2peak}} )$to evaluate fitness in this population. The mean (SD)${\rm \dot VO}_{{\rm 2peak}}$from these studies was 27.2 (6.7) mL.kg−1·min−1, which is markedly below the average fitness level of age-matched healthy individuals. The aetiology of cardiorespiratory deconditioning has not been well evaluated among people with TBI; however, studies on prolonged bed rest and studies on the acute consequences of TBI inform our current understanding. The primary aim of this paper is to present a model to describe the physiological factors contributing to the development of cardiorespiratory deconditioning among people with severe TBI. We propose that both central and peripheral factors contribute to reduced fitness, and that these changes occur because of both the initial brain damage and trauma sustained and the prolonged and initially extreme physical inactivity that is commonly experienced after this type of injury. Reduced fitness can significantly affect the ability to return to pre-injury activities. Given that reintegration into the community is a key goal of rehabilitation among people with TBI, interventions that can prevent or reverse reduced fitness need to be implemented.
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Horn SD, Kinikini M, Moore LW, Hammond FM, Brandstater ME, Smout RJ, Barrett RS. Enteral Nutrition for Patients With Traumatic Brain Injury in the Rehabilitation Setting: Associations With Patient Preinjury and Injury Characteristics and Outcomes. Arch Phys Med Rehabil 2015; 96:S245-55. [PMID: 26212401 PMCID: PMC4545614 DOI: 10.1016/j.apmr.2014.06.024] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2014] [Revised: 05/21/2014] [Accepted: 06/26/2014] [Indexed: 10/23/2022]
Abstract
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.
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Affiliation(s)
- Susan D Horn
- Institute for Clinical Outcomes Research, International Severity Information Systems, Inc, Salt Lake City, UT.
| | - Merin Kinikini
- Neuro Specialty Rehabilitation Unit, Intermountain Medical Center, Salt Lake City, UT
| | | | - Flora M Hammond
- Carolinas Rehabilitation, Charlotte, NC; Indiana University, Indianapolis, IN
| | | | - Randall J Smout
- Institute for Clinical Outcomes Research, International Severity Information Systems, Inc, Salt Lake City, UT
| | - Ryan S Barrett
- Institute for Clinical Outcomes Research, International Severity Information Systems, Inc, Salt Lake City, UT
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El-Masri MM, Hammad TA, McLeskey SW, Joshi M, Korniewicz DM. Predictors of Nosocomial Bloodstream Infections Among Critically Ill Adult Trauma Patients. Infect Control Hosp Epidemiol 2015; 25:656-63. [PMID: 15357157 DOI: 10.1086/502457] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
AbstractObjective:To identify the independent predictors of nosocomial bloodstream infections (BSIs) among critically ill adult trauma patients.Design:A prospective, cohort design was used to study patients who met predetermined inclusion criteria. Basic descriptive and univariate statistical analyses were performed to identify unadjusted predictors. A forward stepwise multivariate logistic regression analysis was then conducted to identify independent predictors of nosocomial BSI.Setting:Level I university-affiliated shock trauma center.Patients:Three hundred sixty-one critically ill adult trauma patients, 55 of whom developed nosocomial BSIs (15.2%).Results:Data analysis of 45 variables indicated that only 9 were independent predictors of nosocomial BSI: presence of a chest tube, use of immunosuppressive agents, presence of microbial resistance, length of stay, presence of preexisting infection, percentage change of serum albumin levels, patient disposition, transfusion of 10 or more units of blood, and number of central venous catheters (CVCs) for patients who had 4 or more. The classification index of the final regression model at a cut-off point of 0.5 had a specificity of 97.4%, a sensitivity of 60%, a positive predictive value of 76.7%, a negative predictive value of 93%, and an overall precision of 91%.Conclusion:In this study, only 9 variables were independent predictors of nosocomial BSI. Our findings are specific to critically ill adult trauma patients and should be interpreted within the context of this particular population.
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Affiliation(s)
- Maher M El-Masri
- University of Windsor, Faculty of Nursing, 401 Sunset, CHN Room G110, Windsor, Ontario, Canada N9B 3P4
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Predictors of Nosocomial Bloodstream Infections Among Critically Ill Adult Trauma Patients. Infect Control Hosp Epidemiol 2015. [DOI: 10.1017/s0195941700079959] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
AbstractObjective:To identify the independent predictors of nosocomial bloodstream infections (BSIs) among critically ill adult trauma patients.Design:A prospective, cohort design was used to study patients who met predetermined inclusion criteria. Basic descriptive and univariate statistical analyses were performed to identify unadjusted predictors. A forward stepwise multivariate logistic regression analysis was then conducted to identify independent predictors of nosocomial BSI.Setting:Level I university-affiliated shock trauma center.Patients:Three hundred sixty-one critically ill adult trauma patients, 55 of whom developed nosocomial BSIs (15.2%).Results:Data analysis of 45 variables indicated that only 9 were independent predictors of nosocomial BSI: presence of a chest tube, use of immunosuppressive agents, presence of microbial resistance, length of stay, presence of preexisting infection, percentage change of serum albumin levels, patient disposition, transfusion of 10 or more units of blood, and number of central venous catheters (CVCs) for patients who had 4 or more. The classification index of the final regression model at a cut-off point of 0.5 had a specificity of 97.4%, a sensitivity of 60%, a positive predictive value of 76.7%, a negative predictive value of 93%, and an overall precision of 91%.Conclusion:In this study, only 9 variables were independent predictors of nosocomial BSI. Our findings are specific to critically ill adult trauma patients and should be interpreted within the context of this particular population.
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Park YG, Yoon YH, Jung KJ, Choi JH. Nutritional Status of Patients with Brain Disorder during the First Six Months. BRAIN & NEUROREHABILITATION 2015. [DOI: 10.12786/bn.2015.8.1.53] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022] Open
Affiliation(s)
- Yoon Ghil Park
- Department of Rehabilitation Medicine and Rehabilitation Institute of Neuromuscular Disease, Yonsei University College of Medicine, Korea
| | - Yeo Hoon Yoon
- Department of Rehabilitation Medicine and Rehabilitation Institute of Neuromuscular Disease, Yonsei University College of Medicine, Korea
| | - Kang Jae Jung
- Department of Rehabilitation Medicine and Rehabilitation Institute of Neuromuscular Disease, Yonsei University College of Medicine, Korea
| | - Jung Hwa Choi
- Yonsei University Graduate School of Medicine, Korea
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Tamási P. [Neurological diseases and nutrition -- what can we do?]. Orv Hetil 2014; 155:2041-7. [PMID: 25497154 DOI: 10.1556/oh.2014.30052] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
Neurological diseases and nutrition are in complex relationship. In the first part of this review the nutritional consequences of acute neurological diseases is presented, with special emphasis on traumatic injuries of the nervous system and stroke. Nutritional therapy of these patients is described in detail. In addition, chronic, degenerative neurological pathological conditions are also discussed, including nutritional consequences and possibilities of therapy. Some ethical and legal issues are also considered. The second part of this review article describes neurological consequences of nutritional problems, both deficits of macro- and micronutrients and toxic effects.
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Affiliation(s)
- Péter Tamási
- Péterfy Sándor Utcai Kórház-Rendelőintézet és Baleseti Központ Központi Aneszteziológiai és Intenzív Terápiás Osztály Budapest Péterfy S. u. 8-14. 1076
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Nutrition therapy in the optimisation of health outcomes in adult patients with moderate to severe traumatic brain injury: findings from a scoping review. Injury 2014; 45:1834-41. [PMID: 24996574 DOI: 10.1016/j.injury.2014.06.004] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/12/2014] [Revised: 06/04/2014] [Accepted: 06/06/2014] [Indexed: 02/02/2023]
Abstract
INTRODUCTION Patients who have sustained traumatic brain injury (TBI) have increased nutritional requirements yet are often unable to eat normally, and adequate nutritional therapy is needed to optimise recovery. The aim of the current scoping review was to describe the existing evidence for improved outcomes with optimal nutrition therapy in adult patients with moderate to severe TBI, and to identify gaps in the literature to inform future research. METHODS Using an exploratory scoping study approach, Medline, Cinahl, Embase, CENTRAL, the Neurotrauma reviews in the Global Evidence Mapping (GEM) Initiative, and Evidence Reviews in Acquired Brain Injury (ERABI) were searched from 2003 to 14 November 2013 using variations of the search terms 'traumatic brain injury' and 'nutrition'. Articles were included if they reported mortality, morbidity, or length of stay outcomes, and were classified according to the nature of nutrition intervention and study design. RESULTS Twenty relevant articles were identified of which: 12 were original research articles; two were systematic reviews; one a meta-analysis; and five were narrative reviews. Of these, eleven explored timing of feed provision, eight explored route of administration of feeding, nine examined the provision of specific nutrients, and none examined feeding environment. Some explored more than one intervention. Three sets of guidelines which contain feeding recommendations were also identified. DISCUSSION Inconsistency within nutrition intervention methods and outcome measures means that the present evidence base is inadequate for the construction of best practice guidelines for nutrition and TBI. Further research is necessary to elucidate the optimal nutrition therapy for adults with TBI with respect to the timing, route of administration, nutrient provision and feeding environment. A consensus on the ideal outcome measure and the most appropriate method and timing of its measurement is required as a foundation for this evidence base.
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Osuka A, Uno T, Nakanishi J, Hinokiyama H, Takahashi Y, Matsuoka T. Energy expenditure in patients with severe head injury: controlled normothermia with sedation and neuromuscular blockade. J Crit Care 2012; 28:218.e9-13. [PMID: 22835423 DOI: 10.1016/j.jcrc.2012.05.012] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2012] [Revised: 05/22/2012] [Accepted: 05/23/2012] [Indexed: 10/28/2022]
Abstract
OBJECTIVES Providing optimal caloric intake is important for patients with severe traumatic brain injury. Insufficient nutrition worsens prognosis, and excessive nutrition may lead to complications such as weaning delay from mechanical ventilation. However, using controlled normothermia with sedation and neuromuscular blockade for patients with anticipated severe brain edema, the optimal caloric intake is still unclear. METHODS Ten patients with severe traumatic brain injury were studied. All patients received midazolam and vecuronium or pancuronium to control body temperature to 36.0°C. Energy expenditure was measured using indirect calorimetry. Age, body height, body weight, heart rate, blood pressure, body temperature, and minute ventilation volume were evaluated at the time of the study. Differences between the mean measured energy expenditures (MEEs) and predicted basal energy expenditures (PEEs from the Harris-Benedict equation) were analyzed using paired t test. Furthermore, the relationships between these variables and MEEs were analyzed with multiple regression analysis. RESULTS The result of MEE was 1279±244 kcal/d. When compared with PEE, MEE/PEE was 87.2% ± 10%. Multiple regression analysis showed that age, body height, body weight, heart rate, and minute ventilation volume were related with MEE. CONCLUSIONS Energy expenditure in patients with severe traumatic brain injury who need mechanical ventilation and have received controlled normothermia with sedation and neuromuscular blockade was 13% less than predicted basal levels. Energy expenditure might be obtained from age, body height, body weight, heart rate, and minute ventilation.
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Affiliation(s)
- Akinori Osuka
- Osaka Prefectural Senshu Critical Care Medical Centre, Izumisano, Osaka 598-0048, Japan.
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Abstract
OBJECTIVE Adequate nutrition support is considered important to recovery after pediatric traumatic brain injury. The 2003 Pediatric Guidelines recommend initiation of nutrition within 72 hrs after traumatic brain injury. We examined our local experience with nutritional support in severe pediatric traumatic brain injury patients (cases) and non-traumatic brain injury patients (controls). DESIGN A retrospective review of pediatric patients with severe traumatic brain injury over an 11-yr period (1997-2009) and without traumatic brain injury over a 3-yr period (2007-2009). SETTING Level I pediatric trauma center pediatric intensive care unit. PATIENTS Patients with severe pediatric traumatic brain injury (age <15 yrs, Glasgow Coma Scale score of <9) and admitted to the pediatric intensive care unit for >7 days and patients without traumatic brain injury (age <15 yrs, head Abbreviated Injury Scale score of 0) and admitted to pediatric intensive care unit. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Data from 101 severe traumatic brain injury and 92 non-traumatic brain injury patients were analyzed. Traumatic brain injury patients: All received enteral nutrition while 13 (12%) also received parenteral nutrition. Nutrition was started 53 ± 20 hrs (range 12-162) after pediatric intensive care unit admission. Fifty patients (52%) received nutrition within the first 48 hrs, and 83 (82%) received nutrition support within the first 72 hrs. Caloric and protein intakes were 47% and 40% of the goals on pediatric intensive care unit day 7 and 76% and 70% of the goals on pediatric intensive care unit day 14. Caloric and protein goals were met in 26% ± 16% and 18% ± 19% of pediatric intensive care unit stay, respectively. Patients whose intake met nutritional goals on pediatric intensive care unit day 7 had earlier initiation of nutrition support at admission than patients who never met the goals (calorie goal met vs. unmet by day 7, 44 ± 23 hrs vs. 67 ± 31 hrs; p < .001; protein goal met vs. unmet by day 7, 43 ± 17 hrs vs. 65 ± 29 hrs; p = .001). Patients gained 0.6% ± 11% weight by pediatric intensive care unit day 7 and lost 7% ± 11% weight by pediatric intensive care unit day 14. Non-traumatic brain injury patients: The time to start of nutrition for the non-traumatic brain injury group was earlier only for patients with isolated orthopedic injuries (24 ± 6 hrs; p = .02). The average caloric and protein intakes were less for the traumatic brain injury (n = 20) group (caloric 52% ± 16% of goal and protein 42% ± 18% of goal) than for the non-traumatic brain injury (n = 23) group (65% ± 11% of goal and protein 51% ± 20% of goal; both p < .01) for pediatric intensive care unit days 0-7. For pediatric intensive care unit days 8-14, there was no difference in average caloric (82% ± 22% vs. 79% ± 18% of goal) or protein (77% ± 6% vs. 79% ± 7% of goal) between the traumatic brain injury (n = 12) and non-traumatic brain injury (n = 10) groups. Addition of a nutritionist was associated with earlier time to nutrition start (p = .02). CONCLUSIONS Nutritional support was initiated in most patients within 72 hrs of pediatric intensive care unit admission. Although daily caloric and protein goals were not achieved in the first 2 wks of pediatric intensive care unit stay and nutritional deficiencies were common, earlier start of nutritional support was associated with involvement of a nutritionist and with meeting both caloric and protein goals by pediatric intensive care unit day 7.
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Chiang YH, Chao DP, Chu SF, Lin HW, Huang SY, Yeh YS, Lui TN, Binns CW, Chiu WT. Early enteral nutrition and clinical outcomes of severe traumatic brain injury patients in acute stage: a multi-center cohort study. J Neurotrauma 2011; 29:75-80. [PMID: 21534720 DOI: 10.1089/neu.2011.1801] [Citation(s) in RCA: 47] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023] Open
Abstract
Guidelines for patients with severe traumatic brain injury (sTBI) published in 2007 recommend providing early nutrition after trauma. Early enteral nutrition (EN) started within 48 h post-injury reduces clinical malnutrition, prevents bacterial translocation from the gastrointestinal tract, and improves outcome in sTBI patients sustaining hypermetabolism and hypercatabolism. The aim of this study was to examine the effect of early EN support on survival rate, Glasgow Coma Scale (GCS) score, and clinical outcome of sTBI patients. Medical records of sTBI patients with GCS scores 4-8 were recruited from 18 hospitals in Taiwan, excluding patients with GCS scores ≤3. During 2002-2010, data from 145 EN patients receiving appropriate calories and nutrients within 48 h post-trauma were collected and compared with 152 non-EN controls matched for gender, age, body weight, initial GCS score, and operative status. The EN patients had a greater survival rate and GCS score on the 7th day in the intensive care unit (ICU), and a better outcome at 1 month post-injury. After adjusting for age, gender, initial GCS score, and recruitment period, the non-EN patients had a hazard ratio of 14.63 (95% CI 8.58-24.91) compared with EN patients. The GCS score during the first 7 ICU days was significantly improved among EN patients with GCS scores of 6-8 compared with EN patients with GCS scores of 4-5 and non-EN patients with GCS scores of 6-8. This finding demonstrates that EN within 48 h post-injury is associated with better survival, GCS recovery, and outcome among sTBI patients, particularly in those with a GCS score of 6-8.
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Affiliation(s)
- Yung-Hsiao Chiang
- Department of Neurosurgery, Taipei Medical University Hospital, Taipei, Taiwan
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Abstract
Of all the interventions available to aid recovery of the injured child, few have the power of proper nutritional support. Healing after trauma depends not only on restoration of oxygen delivery, but on "substrate delivery," or provision of calories to support metabolic power and specific nutrients to allow rebuilding of injured tissue. Failure to deliver adequate substrate to the cells is revealed as another form of shock. Nutritional interventions after trauma are most effective when informed by the specific ways that children diverge physiologically (metabolic rate, biomechanics, physiological response to trauma) from adults. This review describes these responses and outlines a general strategy for safely delivering energy and specific substrates to protect and heal injured children, regardless of body size and type of injury.
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Affiliation(s)
- Robin C Cook
- Department of Clinical Nutrition, The Children's Hospital of Philadelphia, 34th St. and Civic Center Blvd., Philadelphia, PA 19104, USA
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Sickness behaviors following medial frontal cortical contusions in male rats. Behav Brain Res 2010; 217:202-8. [PMID: 20933021 DOI: 10.1016/j.bbr.2010.09.029] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2008] [Revised: 09/02/2010] [Accepted: 09/24/2010] [Indexed: 11/21/2022]
Abstract
Behaviors associated with sickness (food consumption, weight maintenance, exploratory activity and grooming frequency) were examined on post-surgical days 1, 3, 5, 7 and 9 in male rats treated with progesterone (4 mg/kg) and/or vehicle. Rats with medial frontal cortex contusions showed reduced food consumption on days 1 and 3 (p < 0.01), reduced weight maintenance on days 1, 3, 5, 7 and 9 (p < 0.01), reduced grooming frequency on day 1 (p < .01), and reduced exploratory activity on day 1 (p < 0.01), after injury compared to sham rats. Contusion induced behaviors were not attenuated with 5 days of progesterone treatment (p > 0.05). Progesterone did reduce lesion size at 9 days after injury (p < 0.05). Our results suggest sickness behaviors occur after traumatic brain injury and that they might not respond to some neurosteroidal agents.
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Nutritional support in head injury. Nutrition 2010; 27:129-32. [PMID: 20579845 DOI: 10.1016/j.nut.2010.05.004] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2009] [Revised: 05/03/2010] [Accepted: 05/03/2010] [Indexed: 12/30/2022]
Abstract
Nutritional support is imperative to the recovery of head-injury patients. Hypermetabolism and hypercatabolism place this patient population at increased risk for weight loss, muscle wasting, and malnutrition. Nutrition management may be further complicated by alterations in gastrointestinal motility. Resting energy expenditure should be measured using indirect calorimetry and protein status measured using urine urea nitrogen. Providing early enteral nutrition within 72 hours of injury may decrease infection rates and overall complications. Establishing standards of practice and nutrition protocols will assure patients receive optimal nutrition assessment and intervention in a timely manner.
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Kim CT, Moberg-Wolff E, Trovato M, Kim H, Murphy N. Pediatric rehabilitation: 1. Common medical conditions in children with disabilities. PM R 2010; 2:S3-S11. [PMID: 20359677 DOI: 10.1016/j.pmrj.2009.12.004] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2009] [Accepted: 12/09/2009] [Indexed: 11/18/2022]
Abstract
OBJECTIVE This self-directed learning module focuses on the physiatric management of the common morbidities associated with pediatric traumatic brain injury and cerebral palsy. It is part of the study guide on pediatric rehabilitation in the Self-Directed Physiatric Education Program for practitioners and trainees in physical medicine and rehabilitation and pediatric medicine. The goal of this article is to enhance the learner's knowledge regarding current physiatric management of complications related with pediatric traumatic brain injury and cerebral palsy.
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Affiliation(s)
- Chong Tae Kim
- Department of PM&R, University of Pennsylvania, School of Medicine, 3405 Civic Center Boulevard, Philadelphia, PA 19096, USA.
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Arun P, Ariyannur PS, Moffett JR, Xing G, Hamilton K, Grunberg NE, Ives JA, Namboodiri AMA. Metabolic acetate therapy for the treatment of traumatic brain injury. J Neurotrauma 2010; 27:293-8. [PMID: 19803785 DOI: 10.1089/neu.2009.0994] [Citation(s) in RCA: 48] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
Patients suffering from traumatic brain injury (TBI) have decreased markers of energy metabolism, including N-acetylaspartate (NAA) and ATP. In the nervous system, NAA-derived acetate provides acetyl-CoA required for myelin lipid synthesis. Acetate can also be oxidized in mitochondria for the derivation of metabolic energy. In the current study, using the controlled cortical impact model of TBI in rats, we investigated the effects of the hydrophobic acetate precursor, glyceryltriacetate (GTA), as a method of delivering metabolizable acetate to the injured brain. We found that GTA administration significantly increased the levels of both NAA and ATP in the injured hemisphere 4 and 6 days after injury, and also resulted in significantly improved motor performance in rats 3 days after injury.
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Affiliation(s)
- Peethambaran Arun
- Department of Anatomy, Physiology and Genetics, Uniformed Services University of the Health Sciences, Bethesda, Maryland 20814, USA
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Cook AM, Peppard A, Magnuson B. Nutrition Considerations in Traumatic Brain Injury. Nutr Clin Pract 2008; 23:608-20. [DOI: 10.1177/0884533608326060] [Citation(s) in RCA: 89] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023] Open
Affiliation(s)
- Aaron M. Cook
- From the University of Kentucky Healthcare, Lexington
| | - Amy Peppard
- From the University of Kentucky Healthcare, Lexington
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Foley N, Marshall S, Pikul J, Salter K, Teasell R. Hypermetabolism following Moderate to Severe Traumatic Acute Brain Injury: A Systematic Review. J Neurotrauma 2008; 25:1415-31. [DOI: 10.1089/neu.2008.0628] [Citation(s) in RCA: 73] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023] Open
Affiliation(s)
- Norine Foley
- Aging, Rehabilitation & Geriatric Care Program, Lawson Health Research Institute, Parkwood Hospital, London, Ontario, Canada
| | - Shawn Marshall
- Department of Medicine, University of Ottawa, The Ottawa Hospital Rehabilitation Centre, Ottawa, Ontario, Canada
| | - Jill Pikul
- Critical Care, Trauma and Transplant Program, London Health Sciences Centre, University Campus, London, Ontario, Canada
| | - Katherine Salter
- Aging, Rehabilitation & Geriatric Care Program, Lawson Health Research Institute, Parkwood Hospital, London, Ontario, Canada
| | - Robert Teasell
- Department of Physical Medicine and Rehabilitation, Parkwood Hospital, London, Ontario, Canada
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Davis LM, Pauly JR, Readnower RD, Rho JM, Sullivan PG. Fasting is neuroprotective following traumatic brain injury. J Neurosci Res 2008; 86:1812-22. [DOI: 10.1002/jnr.21628] [Citation(s) in RCA: 130] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
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Sun J, Wang L, Shen J, Wang Z, Qian Y. Effect of propofol on mucous permeability and inflammatory mediators expression in the intestine following traumatic brain injury in rats. Cytokine 2007; 40:151-6. [DOI: 10.1016/j.cyto.2007.09.003] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2007] [Revised: 08/06/2007] [Accepted: 09/06/2007] [Indexed: 10/22/2022]
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Mestecky AM. Metabolic responses after severe head injury and how to optimize nutrition: A literature review. ACTA ACUST UNITED AC 2006. [DOI: 10.12968/bjnn.2006.2.2.20916] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
- Ann-Marie Mestecky
- Florence Nightingale School of Nursing and Midwifery, King's College London, 57 Waterloo Road, London SE1 8WA
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Eilander HJ, Wijnen VJM, Scheirs JGM, de Kort PLM, Prevo AJH. Children and young adults in a prolonged unconscious state due to severe brain injury: outcome after an early intensive neurorehabilitation programme. Brain Inj 2006; 19:425-36. [PMID: 16101265 DOI: 10.1080/02699050400025299] [Citation(s) in RCA: 59] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
PRIMARY OBJECTIVE The Rehabilitation Centre Leijpark in The Netherlands provides an Early Intensive Neurorehabilitation Programme (EINP) to children and young adults in a prolonged unconscious state after severe brain injury. In an extensive research project the effects of EINP were studied. This part of the project focused on the outcome in terms of level of consciousness (LOC) in relation to the specific characteristics of a retrospectively studied cohort. RESEARCH DESIGN This study was executed according to a one-group archived pre-test-post-test design. SUBJECTS Subjects were all consecutively admitted patients (n=145, 72% male) between December 1987-January 2001. Inclusion criteria were: age 0-25 years, within 6 months after injury, LOC at admission vegetative state (VS) or minimally conscious state (MCS). One hundred and four patients (72%) suffered a traumatic injury and 41 patients (28%) a non-traumatic injury. METHODS AND PROCEDURES All patients had received EINP until they reached consciousness or until it was concluded that no progress was achieved during 3 months after the start of EINP. Medical files were investigated to collect the patients' characteristics and injury data, to determine the LOC at admission and at discharge and to determine the discharge destination. RESULTS Almost two-thirds of the patients reached full consciousness. LOC at admission, aetiology and interval since injury were found to be significant prognostic factors. Traumatic patients had a much better outcome than non-traumatic patients. A comparison with earlier outcome studies showed a more favourable outcome than expected. It is argued that a multi-centre study is needed to confirm possible effects of EINP.
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Affiliation(s)
- H J Eilander
- Rehabilitation Centre Leijpark, Division Research, Project VLB-NAH, Tilburg, The Netherlands.
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Annette H, Wenström Y. Implementing clinical guidelines for nutrition in a neurosurgical intensive care unit. Nurs Health Sci 2005; 7:266-72. [PMID: 16271133 DOI: 10.1111/j.1442-2018.2005.00246.x] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Patients in neurosurgical intensive care have individual needs concerning nutrition because of their conditions. An important therapeutic goal is to prevent the development of malnutrition as it contributes to an increase in mortality and enhances the risk of complications in these patients. The health-care team has a mutual responsibility for this, although it is a complex task and a correct assessment of patients' nutritional needs is vital. Multidisciplinary clinical guidelines focused on nutrition might help the health-care staff in decision-making and allowing individualized treatment for patients. The aim of this study was to evaluate the implementation and use of such a guideline. The results show that the guideline is used in varying degrees by the health-care team. Areas that focused on more practical aspects of nutritional support seemed to have a unified approach, whereas areas on nutritional assessment and routine nutrition orders demonstrated both a lack of knowledge and unclear role responsibilities. The results reveal how different professional groups in health care perceive the implementation of a clinical guideline. Some areas need further clarification, there needs to be continuing development of nutritional guidelines, and education of staff is needed in order to enhance the nutritional care of patients.
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Affiliation(s)
- Hansson Annette
- Neurosurgical Intensive Care Unit, Karolinska Hospital, Stockholm, Sweden
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Aydin S, Ulusoy H, Usul H, Yulug E, Cobanoglu U, Aydin K, Yenilmez E, Kutun S. Effects of Early Versus Delayed Nutrition on Intestinal Mucosal Apoptosis and Atrophy After Traumatic Brain Injury. Surg Today 2005; 35:751-9. [PMID: 16133670 DOI: 10.1007/s00595-005-3034-3] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2004] [Accepted: 11/16/2004] [Indexed: 10/25/2022]
Abstract
PURPOSE To determine the optimal time to start nutritional support after traumatic brain injury (TBI). METHODS Rats were divided into six groups of seven. All but one of these groups were subjected to moderate closed head trauma under general anesthesia. Groups Ia and Ib were commenced on immunonutrition and standard enteral nutrition, respectively, 8 h later; groups IIa and IIb were commenced on immunonutrition and standard enteral nutrition, respectively, 72 h later; and group III was commenced on a parenteral saline infusion 8 h later. Group IV was a control group fed a laboratory diet and not subjected to trauma. The rats were killed 7 days later, and ileal segments were examined using light and electron microscopy. We used the deoxynucleotidyl transferase-mediated deoxyuridine triphosphate nick end labeling (TUNEL) technique to detect intestinal mucosal apoptosis. RESULTS Group III had a lower body weight than the other groups (P < 0.005). The mean villous height was highest in groups Ia and IV and lowest in group III. The villi count was lower in groups Ib, IIa, IIb, and III than in group IV (P < 0.005). The apoptotic index counts were higher in groups IIa, IIb, and III than in group IV (P < 0.005). CONCLUSIONS The addition of enriching immunonutrients to early enteral feeding helps preserve an almost normal gut mucosa.
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Affiliation(s)
- Sevim Aydin
- Department of Histology, Karadeniz Technical University, Farabi Hospital, Anabilim Dali, 61080, Trabzon, Turkey
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Bhambhani Y, Rowland G, Farag M. Effects of circuit training on body composition and peak cardiorespiratory responses in patients with moderate to severe traumatic brain injury. Arch Phys Med Rehabil 2005; 86:268-76. [PMID: 15706553 DOI: 10.1016/j.apmr.2004.04.022] [Citation(s) in RCA: 34] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
OBJECTIVE To examine the time course of the changes in body composition and peak cardiorespiratory fitness resulting from routine brain injury rehabilitation program (BIRP) activities and circuit training in patients with moderate to severe traumatic brain injury (TBI). DESIGN Time-series design spanning 18 weeks. Trials T1 and T2 were completed in weeks 1 and 2, respectively, to establish reliability of the measurements, followed by trial 3 (T3) 4 weeks later to evaluate changes resulting from the BIRP. SETTING A BIRP in a community rehabilitation hospital. PARTICIPANTS Fourteen inpatients with moderate to severe acquired TBI (Glasgow Coma Scale score, 4.6+/-1.4; time since injury, 17.2+/-17 mo). INTERVENTIONS Twelve-week circuit-training program designed to enhance muscular strength and endurance and aerobic fitness. Subjects were tested midway (T4) through the program and at the end (T5) of 12 weeks. The patients completed an average of 32 supervised sessions, each lasting 1 hour. MAIN OUTCOME MEASURES Changes in body composition and peak cardiorespiratory responses. RESULTS No significant changes were observed in the body mass or percentage body fat during the study. The peak values of power output, oxygen uptake, and ventilation rate increased significantly as a result of training, with no concomitant increases in peak heart rate or blood lactate (T5>T3, T2, T1; P <.05). No significant changes were evident midway through training. CONCLUSIONS In a heterogeneous sample of patients with moderate to severe TBI, (1) body composition and peak cardiorespiratory responses remained fairly stable during 6 weeks of BIRP activities, (2) improvements in peak cardiorespiratory fitness required more than 6 weeks of circuit training, and (3) a 12-week course of circuit training without controlling caloric intake was not effective in reducing body weight or percentage body fat.
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Affiliation(s)
- Yagesh Bhambhani
- Faculty of Rehabilitation Medicine, University of Alberta, Edmonton, Canada.
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Hang CH, Shi JX, Li JS, Wu W, Yin HX. Alterations of intestinal mucosa structure and barrier function following traumatic brain injury in rats. World J Gastroenterol 2003; 9:2776-81. [PMID: 14669332 PMCID: PMC4612051 DOI: 10.3748/wjg.v9.i12.2776] [Citation(s) in RCA: 133] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
AIM: Gastrointestinal dysfunction is a common complication in patients with traumatic brain injury (TBI). However, the effect of traumatic brain injury on intestinal mucosa has not been studied previously. The aim of the current study was to explore the alterations of intestinal mucosa morphology and barrier function, and to determine how rapidly the impairment of gut barrier function occurs and how long it persists following traumatic brain injury.
METHODS: Male Wistar rats were randomly divided into six groups (6 rats each group) including controls without brain injury and traumatic brain injury groups at hours 3, 12, 24, and 72, and on day 7. The intestinal mucosa structure was detected by histopathological examination and electron microscopy. Gut barrier dysfunction was evaluated by detecting serum endotoxin and intestinal permeability. The level of serum endotoxin and intestinal permeability was measured by using chromogenic limulus amebocyte lysate and lactulose/mannitol (L/M) ratio, respectively.
RESULTS: After traumatic brain injury, the histopathological alterations of gut mucosa occurred rapidly as early as 3 hours and progressed to a serious state, including shedding of epithelial cells, fracture of villi, focal ulcer, fusion of adjacent villi, dilation of central chyle duct, mucosal atrophy, and vascular dilation, congestion and edema in the villous interstitium and lamina propria. Apoptosis of epithelial cells, fracture and sparseness of microvilli, loss of tight junction between enterocytes, damage of mitochondria and endoplasm, were found by electron microscopy. The villous height, crypt depth and surface area in jejunum decreased progressively with the time of brain injury. As compared with that of control group (183.7 ± 41.8 EU/L), serum endotoxin level was significantly increased at 3, 12, and 24 hours following TBI (434.8 ± 54.9 EU/L, 324.2 ± 61.7 EU/L and 303.3 ± 60.2 EU/L, respectively), and peaked at 72 hours (560.5 ± 76.2 EU/L), then declined on day 7 (306.7 ± 62.4 EU/L, P < 0.01). Two peaks of serum endotoxin level were found at hours 3 and 72 following TBI. L/M ratio was also significantly higher in TBI groups than that in control group (control, 0.0172 ± 0.0009; 12 h, 0.0303 ± 0.0013; 24 h, 0.0354 ± 0.0025; 72 h, 0.0736 ± 0.0105; 7 d, 0.0588 ± 0.0083; P < 0.01).
CONCLUSION: Traumatic brain injury can induce significant damages of gut structure and impairment of barrier function which occur rapidly as early as 3 hours following brain injury and lasts for more than 7 days with marked mucosal atrophy.
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Affiliation(s)
- Chun-Hua Hang
- Medical College of Nanjing University, Nanjing 210002, Jiangsu Province, China.
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Pohl M, Rückriem S, Strik H, Hörtinger B, Meissner D, Mehrholz J, Pause M. Treatment of pressure ulcers by serial casting in patients with severe spasticity of cerebral origin. Arch Phys Med Rehabil 2002; 83:35-9. [PMID: 11782830 DOI: 10.1053/apmr.2002.27474] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
OBJECTIVE To assess the effectiveness of serial casting in the treatment of pressure ulcers caused by severe spasticity. DESIGN Case series. SETTING A clinic for the rehabilitation of persons with neurologic disorders. PATIENTS Nine patients with 11 pressure ulcers resulting from severe cerebral spasticity, the ulcers being intractable to conventional management because of repeated friction and/or inaccessibility. INTERVENTION Serial casting of the limb(s) with the pressure ulcer(s), with either fenestration or a cast arch providing access to the wound. MAIN OUTCOME MEASURES Improved healing of pressure ulcers, as quantified with the National Pressure Ulcer Advisory Panel classification system. RESULTS Within a mean of 4.6 weeks, 7 ulcers healed completely and 4 improved markedly. The casting caused no complications. Moreover, extension deficits improved markedly in all patients (105 degrees +/- 27 degrees to 17 degrees +/- 10 degrees ). CONCLUSION Serial casting may be a valuable tool in the treatment of pressure ulcers at the extremities of patients with severe cerebral spasticity.
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Affiliation(s)
- Marcus Pohl
- Department of Neurological Rehabilitation, Bavaria-Klinik, Kreischa, Germany.
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Martindale RG, Cresci GA. The use of immune enhancing diet in head injury. JPEN J Parenter Enteral Nutr 2001; 25:S27-8; discussion S28-9. [PMID: 11288919 DOI: 10.1177/014860710102500207] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- R G Martindale
- Department of Surgery, Medical College of Georgia, Augusta 30912-4000, USA.
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