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Sunny A, James RR, Menon SR, Rayaroth S, Daniel A, Thompson NA, Tharakan B. Matrix Metalloproteinase-9 inhibitors as therapeutic drugs for traumatic brain injury. Neurochem Int 2024; 172:105642. [PMID: 38008261 DOI: 10.1016/j.neuint.2023.105642] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2023] [Revised: 11/04/2023] [Accepted: 11/09/2023] [Indexed: 11/28/2023]
Abstract
Traumatic brain injury (TBI) is one of the leading causes of morbidity and mortality among young adults and the elderly. In the United States, TBI is responsible for around 30 percent of all injuries brought on by injuries in general. Vasogenic cerebral edema due to blood-brain barrier (BBB) dysfunction and the associated elevation of intracranial pressure (ICP) are some of the major causes of secondary injuries following traumatic brain injury. Matrix metalloproteinase-9 (MMP-9) is a therapeutic target for being an enzyme that degrades the proteins that make up a part of the microvascular basal lamina as well as inter-endothelial tight junctions of the blood-brain barrier. MMP-9-mediated BBB dysfunctions and the compromise of the BBB is a major pathway that leads the development of vasogenic cerebral edema, elevation of ICP, poor cerebral perfusion and brain herniation following traumatic brain injury. That makes MMP-9 an effective therapeutic target and endogenous or exogenous MMP-9 inhibitors as therapeutic drugs for preventing secondary brain damage after traumatic brain injury. Although our understanding of the mechanisms that underlie the primary and secondary stages of damage following a TBI has significantly improved in recent years, such information has not yet resulted in the successful development of novel pharmacological treatment options for traumatic brain injury. Recent pre-clinical and/or clinical studies have demonstrated that there are several compounds with specific or non-specific MMP-9 inhibitory properties either directly binding and inhibiting MMP-9 or by indirectly inhibiting MMP-9, with potential as therapeutic agents for traumatic brain injury. This article reviews the efficacy of several such medications and potential agents that include endogenous and exogeneous compounds that are at various levels of research and development. MMP-9-based therapeutic drug development has enormous potential in the pharmacological treatment of cerebral edema and/or neuronal injury resulting from traumatic brain injury.
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Affiliation(s)
- Angel Sunny
- Icahn School of Medicine at Mount Sinai, Elmhurst, NY, USA
| | | | | | | | - Abhijith Daniel
- Pushpagiri Institute of Medical Sciences and Research Centre, Thiruvalla, India
| | - Namita Ann Thompson
- Pushpagiri Institute of Medical Sciences and Research Centre, Thiruvalla, India
| | - Binu Tharakan
- Department of Surgery, Morehouse School of Medicine, Atlanta, GA, USA.
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Stein A, Vinh To X, Nasrallah FA, Barlow KM. Evidence of Ongoing Cerebral Microstructural Reorganization in Children With Persisting Symptoms Following Mild Traumatic Brain Injury: A NODDI DTI Analysis. J Neurotrauma 2024; 41:41-58. [PMID: 37885245 DOI: 10.1089/neu.2023.0196] [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] [Indexed: 10/28/2023] Open
Abstract
Approximately 300-550 children per 100,000 sustain a mild traumatic brain injury (mTBI) each year, of whom ∼25-30% have long-term cognitive problems. Following mTBI, free water (FW) accumulation occurs in white matter (WM) tracts. Diffusion tensor imaging (DTI) can be used to investigate structural integrity following mTBI. Compared with conventional DTI, neurite orientation dispersion and density imaging (NODDI) orientation dispersion index (ODI) and fraction of isolated free water (FISO) metrics may allow a more advanced insight into microstructural damage following pediatric mTBI. In this longitudinal study, we used NODDI to explore whole-brain and tract-specific differences in ODI and FISO in children with persistent symptoms after mTBI (n = 80) and in children displaying clinical recovery (n = 32) at 1 and 2-3 months post-mTBI compared with healthy controls (HCs) (n = 21). Two-way repeated measures analysis of variance (ANOVA) and voxelwise two-sample t tests were conducted to compare whole-brain and tract-specific diffusion across groups. All results were corrected at positive false discovery rate (pFDR) <0.05. We also examined the association between NODDI metrics and clinical outcomes, using logistical regression to investigate the value of NODDI metrics in predicting future recovery from mTBI. Whole-brain ODI was significantly increased in symptomatic participants compared with HCs at both 1 and 2 months post-injury, where the uncinate fasciculus (UF) and inferior fronto-occipital fasciculus (IFOF) were particularly implicated. Using region of interest (ROI) analysis in significant WM, bilateral IFOF and UF voxels, symptomatic participants had the highest ODI in all ROIs. ODI was lower in asymptomatic participants, and HCs had the lowest ODI in all ROIs. No changes in FISO were found across groups or over time. WM ODI was moderately correlated with a higher youth-reported post-concussion symptom inventory (PCSI) score. With 87% predictive power, ODI (1 month post-injury) and clinical predictors (age, sex, PCSI score, attention scores) were a more sensitive predictor of recovery at 2-3 months post-injury than fractional anisotropy (FA) and clinical predictors, or clinical predictors alone. FISO could not predict recovery at 2-3 months post-injury. Therefore, we found that ODI was significantly increased in symptomatic children following mTBI compared with HCs at 1 month post-injury, and progressively decreased over time alongside clinical recovery. We found no significant differences in FISO between groups or over time. WM ODI at 1 month was a more sensitive predictor of clinical recovery at 2-3 months post-injury than FA, FISO, or clinical measures alone. Our results show evidence of ongoing microstructural reorganization or neuroinflammation between 1 and 2-3 months post-injury, further supporting delayed return to play in children who remain symptomatic. We recommend future research examining the clinical utility of NODDI following mTBI to predict recovery or persistence of post-concussion symptoms and thereby inform management of mTBI.
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Affiliation(s)
- Athena Stein
- Acquired Brain Injury in Children Research Group, The University of Queensland, South Brisbane, Queensland, Australia
| | - Xuan Vinh To
- Queensland Brain Institute, The University of Queensland, South Brisbane, Queensland, Australia
| | - Fatima A Nasrallah
- Queensland Brain Institute, The University of Queensland, South Brisbane, Queensland, Australia
| | - Karen M Barlow
- Acquired Brain Injury in Children Research Group, The University of Queensland, South Brisbane, Queensland, Australia
- Queensland Pediatric Rehabilitation Service, Queensland Children's Hospital, South Brisbane, Queensland, Australia
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Zou X, Zhang X, Qiang T, Hu X, Zhang L. Melatonin attenuates sevoflurane-induced hippocampal damage and cognitive deficits in neonatal mice by suppressing CypD in parvalbumin neurons. Brain Res Bull 2023; 204:110809. [PMID: 37931809 DOI: 10.1016/j.brainresbull.2023.110809] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2023] [Revised: 10/27/2023] [Accepted: 11/03/2023] [Indexed: 11/08/2023]
Abstract
BACKGROUND Sevoflurane, a commonly administered inhaled anesthetic, is found to induce synaptic and mitochondrial damage in neonatal mice. Mitochondrial membrane potential (MMP) changes, mediated by Cyclophilin D (CypD), are implicated in mitochondrial function. Melatonin, known for its significant neuroprotective properties, was investigated in this study to elucidate its mechanisms in mitigating the cognitive impairment caused by sevoflurane. METHODS The mice were categorized into several groups, including the control, vehicle, sevoflurane, vehicle plus sevoflurane, and melatonin plus sevoflurane groups. From postnatal day 6 to day 8, the mice were administered inhaled sevoflurane or intraperitoneal melatonin. MMP and reactive oxygen species (ROS) were measured using appropriate detection kits. The protein expression levels of PSD95, Synapsin Ⅰ, and CypD in the hippocampus were analyzed through western blotting in acute and prolonged terms. Immunofluorescence staining was used to assess the co-localizations of PSD95 or CypD in parvalbumin (PV) neurons. Cognitive ability was evaluated through novel object recognition, social interaction experiment, and the Morris water maze. RESULTS The findings revealed that repeated exposure to sevoflurane in neonatal mice resulted in cognitive and synaptic impairment. Furthermore, melatonin administration suppressed the ROS and CypD protein expression, enhanced the MMP in mitochondria and synaptic protein expression in PV neurons, and ameliorated cognitive deficits. CONCLUSION Melatonin alleviated sevoflurane-induced cognitive deficits by suppressing CypD and promoting synaptic development in hippocampal PV neurons. These results provide valuable insights into a promising therapeutic approach for preventing neurotoxic injuries caused by general anesthetics.
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Affiliation(s)
- Xuezhu Zou
- Department of Anesthesiology and Perioperative Medicine, The Second Affiliated Hospital of Anhui Medical University, 678 Furong Road, Hefei 230061, Anhui Province, China; Key Laboratory of Anesthesiology and Perioperative Medicine of Anhui Higher Education Institutes, Anhui Medical University, Hefei, China
| | - Xiaoyuan Zhang
- Department of Anesthesiology and Perioperative Medicine, The Second Affiliated Hospital of Anhui Medical University, 678 Furong Road, Hefei 230061, Anhui Province, China; Key Laboratory of Anesthesiology and Perioperative Medicine of Anhui Higher Education Institutes, Anhui Medical University, Hefei, China
| | - Tingting Qiang
- Department of Anesthesiology, The First Affiliated Hospital of Anhui Medical University, 218 Jixi Road, Hefei 230061, Anhui Province, China
| | - Xianwen Hu
- Department of Anesthesiology and Perioperative Medicine, The Second Affiliated Hospital of Anhui Medical University, 678 Furong Road, Hefei 230061, Anhui Province, China; Key Laboratory of Anesthesiology and Perioperative Medicine of Anhui Higher Education Institutes, Anhui Medical University, Hefei, China.
| | - Li Zhang
- Department of Anesthesiology and Perioperative Medicine, The Second Affiliated Hospital of Anhui Medical University, 678 Furong Road, Hefei 230061, Anhui Province, China; Key Laboratory of Anesthesiology and Perioperative Medicine of Anhui Higher Education Institutes, Anhui Medical University, Hefei, China.
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Bell A, Hewins B, Bishop C, Fortin A, Wang J, Creamer JL, Collen J, Werner JK. Traumatic Brain Injury, Sleep, and Melatonin-Intrinsic Changes with Therapeutic Potential. Clocks Sleep 2023; 5:177-203. [PMID: 37092428 PMCID: PMC10123665 DOI: 10.3390/clockssleep5020016] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2023] [Revised: 03/27/2023] [Accepted: 03/30/2023] [Indexed: 04/25/2023] Open
Abstract
Traumatic brain injury (TBI) is one of the most prevalent causes of morbidity in the United States and is associated with numerous chronic sequelae long after the point of injury. One of the most common long-term complaints in patients with TBI is sleep dysfunction. It is reported that alterations in melatonin follow TBI and may be linked with various sleep and circadian disorders directly (via cellular signaling) or indirectly (via free radicals and inflammatory signaling). Work over the past two decades has contributed to our understanding of the role of melatonin as a sleep regulator and neuroprotective anti-inflammatory agent. Although there is increasing interest in the treatment of insomnia following TBI, a lack of standardization and rigor in melatonin research has left behind a trail of non-generalizable data and ambiguous treatment recommendations. This narrative review describes the underlying biochemical properties of melatonin as they are relevant to TBI. We also discuss potential benefits and a path forward regarding the therapeutic management of TBI with melatonin treatment, including its role as a neuroprotectant, a somnogen, and a modulator of the circadian rhythm.
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Affiliation(s)
- Allen Bell
- Walter Reed National Military Medical Center, Bethesda, MD 20814, USA
| | - Bryson Hewins
- School of Medicine, Uniformed Services University of the Health Sciences, Bethesda, MD 20814, USA; (B.H.)
| | - Courtney Bishop
- School of Medicine, Uniformed Services University of the Health Sciences, Bethesda, MD 20814, USA; (B.H.)
| | - Amanda Fortin
- School of Medicine, Uniformed Services University of the Health Sciences, Bethesda, MD 20814, USA; (B.H.)
| | - Jonathan Wang
- School of Medicine, Uniformed Services University of the Health Sciences, Bethesda, MD 20814, USA; (B.H.)
| | | | - Jacob Collen
- Walter Reed National Military Medical Center, Bethesda, MD 20814, USA
- School of Medicine, Uniformed Services University of the Health Sciences, Bethesda, MD 20814, USA; (B.H.)
| | - J. Kent Werner
- Walter Reed National Military Medical Center, Bethesda, MD 20814, USA
- School of Medicine, Uniformed Services University of the Health Sciences, Bethesda, MD 20814, USA; (B.H.)
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Jacquens A, Needham EJ, Zanier ER, Degos V, Gressens P, Menon D. Neuro-Inflammation Modulation and Post-Traumatic Brain Injury Lesions: From Bench to Bed-Side. Int J Mol Sci 2022; 23:ijms231911193. [PMID: 36232495 PMCID: PMC9570205 DOI: 10.3390/ijms231911193] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2022] [Revised: 09/14/2022] [Accepted: 09/15/2022] [Indexed: 11/16/2022] Open
Abstract
Head trauma is the most common cause of disability in young adults. Known as a silent epidemic, it can cause a mosaic of symptoms, whether neurological (sensory-motor deficits), psychiatric (depressive and anxiety symptoms), or somatic (vertigo, tinnitus, phosphenes). Furthermore, cranial trauma (CT) in children presents several particularities in terms of epidemiology, mechanism, and physiopathology-notably linked to the attack of an immature organ. As in adults, head trauma in children can have lifelong repercussions and can cause social and family isolation, difficulties at school, and, later, socio-professional adversity. Improving management of the pre-hospital and rehabilitation course of these patients reduces secondary morbidity and mortality, but often not without long-term disability. One hypothesized contributor to this process is chronic neuroinflammation, which could accompany primary lesions and facilitate their development into tertiary lesions. Neuroinflammation is a complex process involving different actors such as glial cells (astrocytes, microglia, oligodendrocytes), the permeability of the blood-brain barrier, excitotoxicity, production of oxygen derivatives, cytokine release, tissue damage, and neuronal death. Several studies have investigated the effect of various treatments on the neuroinflammatory response in traumatic brain injury in vitro and in animal and human models. The aim of this review is to examine the various anti-inflammatory therapies that have been implemented.
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Affiliation(s)
- Alice Jacquens
- Unité de Neuroanesthésie-Réanimation, Hôpital de la Pitié Salpêtrière 43-87, Boulevard de l’Hôpital, F-75013 Paris, France
- Inserm, Maladies Neurodéveloppementales et Neurovasculaires, Université Paris Cité, F-75019 Paris, France
- Correspondence: ; Tel.: +33-1-42-16-00-00
| | - Edward J. Needham
- Division of Anaesthesia, Addenbrooke’s Hospital, University of Cambridge, Box 93, Hills Road, Cambridge CB2 2QQ, UK
| | - Elisa R. Zanier
- Department of Neuroscience, Istituto di Ricerche Farmacologiche Mario Negri IRCCS, 20156 Milan, Italy
| | - Vincent Degos
- Unité de Neuroanesthésie-Réanimation, Hôpital de la Pitié Salpêtrière 43-87, Boulevard de l’Hôpital, F-75013 Paris, France
- Inserm, Maladies Neurodéveloppementales et Neurovasculaires, Université Paris Cité, F-75019 Paris, France
| | - Pierre Gressens
- Inserm, Maladies Neurodéveloppementales et Neurovasculaires, Université Paris Cité, F-75019 Paris, France
| | - David Menon
- Division of Anaesthesia, Addenbrooke’s Hospital, University of Cambridge, Box 93, Hills Road, Cambridge CB2 2QQ, UK
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MohanMarugaRaja MK, Devarajan A, Dhote VV. Dietary supplementation for traumatic brain injury. DIAGNOSIS AND TREATMENT OF TRAUMATIC BRAIN INJURY 2022:485-494. [DOI: 10.1016/b978-0-12-823347-4.00038-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/16/2023]
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Sleep Problems and Melatonin Prescription After Concussion Among Youth Athletes. Clin J Sport Med 2021; 31:475-480. [PMID: 33055498 DOI: 10.1097/jsm.0000000000000803] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/25/2019] [Accepted: 10/02/2019] [Indexed: 02/02/2023]
Abstract
OBJECTIVES To examine the effect of sleep disturbances on concussion symptom recovery and to examine the effect of melatonin prescription on symptom improvement among concussed adolescents with sleep problems. DESIGN Longitudinal test-retest. SETTING Sports medicine clinic. PARTICIPANTS Patients aged 8 to 18 years, diagnosed with a concussion, evaluated within 14 days after injury, and evaluated again 15 to 35 days after injury. INDEPENDENT VARIABLES We grouped patients based on whether they reported sleep disturbances within 14 days of injury. MAIN OUTCOME MEASURES Outcome measures included symptom severity, headache severity, melatonin prescription, and the change in symptom severity between visits. RESULTS Two hundred twenty-five patients were included: 36% who reported sleep problems (44% female; age = 14.4 ± 2.0 years; evaluated 7.3 ± 3.8 and 23.2 ± 5.4 days after injury) and 64% who did not (32% female; age = 14.6 ± 2.3 years; evaluated 7.2 ± 3.4 and 23.0 ± 5.3 days after injury). Those with sleep problems reported higher symptom severity than those without across the 2 visits (22.1 ± 14.3 vs 14.6 ± 12.5; P < 0.001). There was no significant difference in the change in symptom severity between visits among those who received [median = 9-point improvement; interquartile range (IQR) = 1-14] and did not (median = 9, IQR = 2-18) receive a melatonin prescription (P = 0.80). CONCLUSIONS Sleep problems among pediatric patients within 2 weeks of concussion are associated with more severe symptoms. Melatonin prescription was not associated with faster symptom recovery.
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Stein A, Iyer KK, Khetani AM, Barlow KM. Changes in working memory-related cortical responses following pediatric mild traumatic brain injury: A longitudinal fMRI study. JOURNAL OF CONCUSSION 2021. [DOI: 10.1177/20597002211006541] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023] Open
Abstract
Persistent post-concussion symptoms (PPCS) lasting longer than 4 weeks affect 25% of children with mild traumatic brain injury (mTBI) or concussion. Working memory (WM) problems are a common complaint in children with PPCS. Despite normal function on traditional neuropsychological tests, these children exhibit aberrant cortical responses within the dorsolateral prefrontal cortex (dlPFC) and default mode network (DMN) regions – both of which are implicated in WM. Using a prospective, longitudinal cohort study design, we investigated changes in cortical fMRI responses within the dlPFC and DMN during an nback WM task at two timepoints: one and two months post-injury. Across these timepoints, the primary outcome was change in cortical activations (increase in BOLD) and deactivations (decrease in BOLD) of both dlPFC and DMN. Twenty-nine children (mean age 15.49 ± 2.15; 48.3% male) with fMRI scans at both timepoints were included, following data quality control. Student’s t-tests were used to examine cortical activations across time and task difficulty. ANCOVA F-tests examined cortical responses after removal of baseline across time, task difficulty and recovery. Volumes of interest (5 mm sphere) were placed in peak voxel regions of the DMN and dlPFC to compare cortical responses between recovered and unrecovered participants over time (one-way ANOVA). Between one and two months post-injury, we found significant increases in dlPFC activations and significant activations and deactivations in the DMN with increasing task difficulty, alongside improved task performance. Cortical responses of the DMN and bilateral dlPFC displayed increased intensity in recovered participants, together with improved attention and behavioural symptoms. Overall, our findings suggest evidence of neural compensation and ongoing cognitive recovery from pediatric TBI over time between one and two months post injury in children with PPCS. These results highlight the wider and persisting implications of mTBI in children, whose maturing brains are particularly vulnerable to TBI.
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Affiliation(s)
- Athena Stein
- Acquired Brain Injury in Children Research Program, Child Health Research Centre, Faculty of Medicine, The University of Queensland, Brisbane, Australia
| | - Kartik K Iyer
- Acquired Brain Injury in Children Research Program, Child Health Research Centre, Faculty of Medicine, The University of Queensland, Brisbane, Australia
| | - Aneesh M Khetani
- Department of Pediatrics, University of Calgary, Calgary, Canada
| | - Karen M Barlow
- Acquired Brain Injury in Children Research Program, Child Health Research Centre, Faculty of Medicine, The University of Queensland, Brisbane, Australia
- Department of Pediatrics, University of Calgary, Calgary, Canada
- Queensland Pediatric Rehabilitation Service, Queensland Children's Hospital, Brisbane, Australia
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B Juengst S, Kajankova M, Wright B, Terhorst L. Factor analysis of the adolescent version of the behavioural assessment screening tool (BAST-A) in adolescents with concussion. Brain Inj 2020; 35:130-137. [PMID: 33372810 DOI: 10.1080/02699052.2020.1857838] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
Objective: Develop and validate the Behavioral Assessment Screening Tool for Adolescents with brain injury.Setting: Concussion clinicsParticipants: Adolescents with mild traumatic brain injury 3 months after initial concussion clinic visit (n = 138).Design: Assessment development and validation (cross-sectional cohort) studyMain Measures: Behavioral Assessment Screening Tool - AdolescentResults: Expert panel members added or modified items specific to adolescents to the original Behavioral Assessment Screening Tool for adults. The Content Validity Index was 97.2%. Exploratory factor analysis of the Behavioral Assessment Screening Tool - Adolescent reduced the initial 70 items to 46 primary items with a 3-factor solution: Negative Affect & Fatigue, Executive & Social Function, and Risk Behaviors. Internal consistency reliabilities ranged from good to excellent for all factors (Cronbach's α =.80-.95). We retained four secondary maladaptive coping items (from an initial six), though these require further modification and testing (Cronbach's α =.67).Conclusion: The Behavioral Assessment Screening Tool for Adolescents, a measure of neurobehavioral symptoms after mild traumatic brain injury in adolescents, has a multidimensional factor structure with evidence of good internal consistency reliabilities. Future work will further evaluate its convergent and discriminant validity and employ item response theory analyses for validation in a new sample of adolescents with concussion.
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Affiliation(s)
- Shannon B Juengst
- Department of Physical Medicine & Rehabilitation, University of Texas Southwestern Medical Center, Dallas, Texas, USA.,Department of Rehabilitation Counseling, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Maria Kajankova
- Department of Rehabilitation and Human Performance, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Brittany Wright
- Department of Applied Clinical Research, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Lauren Terhorst
- Department of Occupational Therapy, University of Pittsburgh, Pittsburgh, Pennsylvania, USA.,Center for Clinical and Translational Science Institute, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
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Barlow KM, Kirk V, Brooks B, Esser MJ, Yeates KO, Zemek R, Kirton A, Mikrogianakis A, MacMaster F, Nettel-Aguirre A, Hutchison J, Turley B, Cameron C, Hill M, Boyd R, Dewey D. Efficacy of Melatonin for Sleep Disturbance in Children with Persistent Post-Concussion Symptoms: Secondary Analysis of a Randomized Controlled Trial. J Neurotrauma 2020; 38:950-959. [PMID: 32988292 DOI: 10.1089/neu.2020.7154] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023] Open
Abstract
Sleep disturbances are commonly reported in children with persistent post-concussion symptoms (PPCS). Melatonin treatment is often recommended, yet supporting evidence is scarce. We aimed to evaluate the efficacy of treatment with melatonin for sleep disturbance in youth with PPCS following mild traumatic brain injury (mTBI). This article is a secondary analysis of a clinical trial of melatonin compared with placebo to treat PPCS. Youth (8-18 years of age) with PPCS and significant sleep-related problems (SRPs) at 4-6 weeks post-injury were eligible. Exclusion criteria: significant medical/psychiatric history; previous concussion/mTBI within 3 months. Treatment groups were: placebo, melatonin 3 mg, or melatonin 10 mg. Primary outcome was change in SRPs measured using the Post-Concussion Symptom Inventory (PCSI) after 2 weeks of treatment. Secondary outcomes included change in actigraphy sleep efficiency, duration, onset latency, and wake-after-sleep-onset. Behavior was measured using Behaviour Assessment for Children (2nd edition). Seventy-two participants (mean age 14.0, standard deviation [SD] = 2.6) years; 60% female) with PPCS and significant sleep disturbance were included in the secondary analysis: placebo (n = 22); melatonin 3 mg (n = 25); melatonin 10 mg (n = 25). Sixty-four participants had actigraphy data. SRPs decreased across all groups over time with a significant effect of melatonin 3 mg (3.7; 95% confidence interval [CI]: 2.1, 5.4) compared with placebo (7.4; 95% CI: 4.2, 10.6) and melatonin 10 mg (6.4; 95% CI: 3.6, 9.2). Sleep duration increased in the melatonin 3 mg (43 min; 95% CI: 6, 93) and melatonin 10 mg groups (55 min; 95% CI: 5, 104) compared with placebo. A per protocol analysis demonstrated improved sleep efficiency in the melatonin 10 mg group (p = 0.029). No serious adverse events were reported. Depressive symptoms significantly decreased with melatonin 3 mg (-4.7; 95% CI: -9.2, -.2) but not with melatonin 10 mg (-1.4, 95% CI: -5.9, 3.2) treatment compared with placebo. Changes in cognition or behavior were otherwise not significantly different between treatment groups. Short-term melatonin is a well-tolerated treatment for sleep disturbance in youth with PPCS following mTBI. In this context, it may also be associated with a reduction in depressive symptoms.
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Affiliation(s)
- Karen Maria Barlow
- Child Health Research Centre, University of Queensland Faculty of Medicine and Biomedical Sciences, South Brisbane, Queensland, Australia.,Department of Paediatrics, University of Calgary Cumming School of Medicine, Calgary, Alberta, Canada
| | - Valerie Kirk
- Department of Paediatrics, University of Calgary Cumming School of Medicine, Calgary, Alberta, Canada
| | - Brian Brooks
- Department of Pediatrics, Clinical Neurosciences, and Psychology, Alberta Children's Hospital and University of Calgary, Calgary, Alberta, Canada
| | | | - Keith Owen Yeates
- Department of Psychology and University of Calgary, Calgary, Alberta, Canada
| | - Roger Zemek
- Clinical Research Unit, Children's Hospital of Eastern Ontario, Ottawa, Ontario, Canada
| | - Adam Kirton
- Department of Paediatrics, University of Calgary Cumming School of Medicine, Calgary, Alberta, Canada
| | | | - Frank MacMaster
- Department of Psychiatry and Pediatrics, University of Calgary, Calgary, Alberta, Canada
| | - Alberto Nettel-Aguirre
- Department of Paediatrics, University of Calgary Cumming School of Medicine, Calgary, Alberta, Canada
| | - James Hutchison
- Critical Care Medicine and Pediatrics, Hospital for Sick Children, Toronto, Ontario, Canada
| | - Brenda Turley
- Department of Pediatrics, Clinical Neurosciences, and Psychology, Alberta Children's Hospital and University of Calgary, Calgary, Alberta, Canada
| | - Candice Cameron
- Research Pharmacy, Alberta Health Services, Calgary, Alberta, Canada
| | - Michael Hill
- Department of Clinical Neurosciences, University of Calgary Cumming School of Medicine, Calgary, Alberta, Canada
| | - Roslyn Boyd
- Children's Health Research Centre, University of Queensland, South Brisbane, Queensland, Australia
| | - Deborah Dewey
- Department of Paediatrics, University of Calgary Cumming School of Medicine, Calgary, Alberta, Canada
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Revisiting Traumatic Brain Injury: From Molecular Mechanisms to Therapeutic Interventions. Biomedicines 2020; 8:biomedicines8100389. [PMID: 33003373 PMCID: PMC7601301 DOI: 10.3390/biomedicines8100389] [Citation(s) in RCA: 82] [Impact Index Per Article: 20.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2020] [Revised: 09/25/2020] [Accepted: 09/26/2020] [Indexed: 12/15/2022] Open
Abstract
Studying the complex molecular mechanisms involved in traumatic brain injury (TBI) is crucial for developing new therapies for TBI. Current treatments for TBI are primarily focused on patient stabilization and symptom mitigation. However, the field lacks defined therapies to prevent cell death, oxidative stress, and inflammatory cascades which lead to chronic pathology. Little can be done to treat the mechanical damage that occurs during the primary insult of a TBI; however, secondary injury mechanisms, such as inflammation, blood-brain barrier (BBB) breakdown, edema formation, excitotoxicity, oxidative stress, and cell death, can be targeted by therapeutic interventions. Elucidating the many mechanisms underlying secondary injury and studying targets of neuroprotective therapeutic agents is critical for developing new treatments. Therefore, we present a review on the molecular events following TBI from inflammation to programmed cell death and discuss current research and the latest therapeutic strategies to help understand TBI-mediated secondary injury.
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12
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Kim K, Priefer R. Evaluation of current post-concussion protocols. Biomed Pharmacother 2020; 129:110406. [PMID: 32768934 DOI: 10.1016/j.biopha.2020.110406] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2020] [Revised: 06/10/2020] [Accepted: 06/14/2020] [Indexed: 10/23/2022] Open
Abstract
The growing number of concussions and mild traumatic brain injuries (mTBI) with the lack of evidence-based treatment options is a continuous health concern. This creates problems when evaluating and providing efficacious symptom management to patients suffering from post-concussion syndrome (PCS). Numerous pharmacological and non-pharmacological agents have been utilized in an attempt to treat PCS. Some of these approaches include physical therapy, analgesics, antidepressants, and nutraceuticals. Although these treatments have had some success, there has been inconsistent outcomes, with some examples of patients' symptoms worsening. Among pharmaceutical agents, fluoxetine has been a popular choice for the symptom management of PCS. Although some patients have had symptom resolution with the use of fluoxetine, there is still a lack of conclusive data. Of the several biochemical changes that occur in a patient's brain following a concussion, an increase in reactive oxygen species (ROS) is of particular concern. In order to counteract the responses of the brain, antioxidants, such as ascorbic acid, have been utilized to reverse the damaging cellular effects. However, this may inadvertently cause an increase in ROS, rather than a reduction. Although there is a lack of consistency in exactly when each treatment was used in the post-injury interval, it is important that we analyze the strengths and weaknesses of the most commonly used agents due to the lack of a set protocol. The studies were chosen in a non-exhaustive manner and were not consistent in patients' post-injury intervals, in addition to other baseline characteristics. However, over-arching claims that some treatments may benefit more than others can be made. This review evaluates both the pharmaceutical and non-pharmaceutical protocols that are most commonly utilized in post-concussive patients for their efficacy in treatment of post-concussive syndrome (PCS).
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Affiliation(s)
- Kristin Kim
- Massachusetts College of Pharmacy and Health Sciences University, Boston, MA, United States
| | - Ronny Priefer
- Massachusetts College of Pharmacy and Health Sciences University, Boston, MA, United States.
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Brooks BL, Virani S, Khetani A, Carlson H, Jadavji Z, Mauthner M, Low TA, Plourde V, MacMaster FP, Bray S, Harris AD, Lebel C, Lebel RM, Esser MJ, Yeates KO, Barlow KM. Functional magnetic resonance imaging study of working memory several years after pediatric concussion. Brain Inj 2020; 34:895-904. [PMID: 32396403 DOI: 10.1080/02699052.2020.1753240] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
PRIMARY OBJECTIVE The neurophysiological effects of pediatric concussion several years after injury remain inadequately characterized. The objective of this study was to determine if a history of concussion was associated with BOLD response differences during an n-back working memory task in youth. RESEARCH DESIGN Observational, cross-sectional. METHODS AND PROCEDURES Participants include 52 children and adolescents (M = 15.1 years, 95%CI = 14.4-15.8, range = 9-19) with past concussion (n = 33) or orthopedic injury (OI; n = 19). Mean time since injury was 2.5 years (95%CI = 2.0-3.0). Measures included postconcussion symptom ratings, neuropsychological testing, and blood-oxygen-dependent-level (BOLD) functional magnetic resonance imaging (fMRI) during an n-back working memory task. MAIN OUTCOMES AND RESULTS Groups did not differ on accuracy or speed during the three n-back conditions. They also did not differ in BOLD signal change for the 1- vs. 0-back or 2- vs. 0-back contrasts (controlling for task performance). CONCLUSIONS This study does not support group differences in BOLD response during an n-back working memory task in youth who are on average 2.5 years post-concussion. The findings are encouraging from the perspective of understanding recovery after pediatric concussion.
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Affiliation(s)
- Brian L Brooks
- Neurosciences Program, Alberta Children's Hospital , Calgary, Alberta, Canada.,Alberta Children's Hospital Research Institute, University of Calgary , Calgary, Alberta, Canada.,Departments of Paediatrics, Clinical Neurosciences, and Psychology, University of Calgary , Calgary, Alberta, Canada
| | - Shane Virani
- Sport Injury Prevention Research Centre, Faculty of Kinesiology, University of Calgary , Calgary, Alberta, Canada.,Vi Riddell Pain and Rehabilitation Program, Alberta Children's Hospital Research Institute , Calgary, Alberta, Canada
| | - Aneesh Khetani
- Department of Neurosciences, University of Calgary , Calgary, Alberta, Canada
| | - Helen Carlson
- Alberta Children's Hospital Research Institute, University of Calgary , Calgary, Alberta, Canada.,Department of Pediatrics, University of Calgary , Calgary, Alberta, Canada.,Hotchkiss Brain Institute, University of Calgary , Calgary, Alberta, Canada
| | - Zeanna Jadavji
- Alberta Children's Hospital Research Institute, University of Calgary , Calgary, Alberta, Canada.,Department of Neurosciences, University of Calgary , Calgary, Alberta, Canada
| | - Micaela Mauthner
- Department of Neurosciences, University of Calgary , Calgary, Alberta, Canada
| | - Trevor A Low
- Department of Neurosciences, University of Calgary , Calgary, Alberta, Canada
| | - Vickie Plourde
- École de Psychologie, Faculté des sciences de la santé et des services communautaires, Université de Moncton, Monton, New Brunswick, Canada; Faculty Saint-Jean, University of Alberta , Edmonton, AB, Canada
| | - Frank P MacMaster
- Alberta Children's Hospital Research Institute, University of Calgary , Calgary, Alberta, Canada.,Departments of Psychiatry and Paediatrics, University of Calgary , Calgary, Alberta, Canada.,Mathison Centre for Mental Health Research and Education, Hotchkiss Brain Institute , Calgary, Alberta, Canada.,Strategic Clinical Network for Addictions and Mental Health, Alberta Health Services , Edmonton, Alberta, Canada
| | - Signe Bray
- Alberta Children's Hospital Research Institute, University of Calgary , Calgary, Alberta, Canada.,Hotchkiss Brain Institute, University of Calgary , Calgary, Alberta, Canada
| | - Ashley D Harris
- Alberta Children's Hospital Research Institute, University of Calgary , Calgary, Alberta, Canada.,Department of Radiology, University of Calgary , Calgary, Alberta, Canada
| | - Catherine Lebel
- Alberta Children's Hospital Research Institute, University of Calgary , Calgary, Alberta, Canada.,Hotchkiss Brain Institute, University of Calgary , Calgary, Alberta, Canada.,Department of Radiology, University of Calgary , Calgary, Alberta, Canada
| | - R Marc Lebel
- Alberta Children's Hospital Research Institute, University of Calgary , Calgary, Alberta, Canada.,Departments of Radiology and Biomedical Engineering, University of Calgary , Calgary, Alberta, Canada.,MR Applications and Workflow, GE Healthcare , Calgary, Alberta, Canada
| | - Michael J Esser
- Alberta Children's Hospital Research Institute, University of Calgary , Calgary, Alberta, Canada.,Department of Pediatrics, University of Calgary , Calgary, Alberta, Canada.,Hotchkiss Brain Institute, University of Calgary , Calgary, Alberta, Canada
| | - Keith Owen Yeates
- Alberta Children's Hospital Research Institute, University of Calgary , Calgary, Alberta, Canada.,Departments of Paediatrics, Clinical Neurosciences, and Psychology, University of Calgary , Calgary, Alberta, Canada.,Hotchkiss Brain Institute, University of Calgary , Calgary, Alberta, Canada
| | - Karen M Barlow
- Departments of Paediatrics and Clinical Neurosciences, University of Calgary , Calgary, Alberta, Canada.,Faculty of Medicine, University of Queensland , Brisbane, Australia
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14
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Saleem GT, Slomine BS, Suskauer SJ. Sleep Symptoms Predict School Attendance After Pediatric Concussion. Clin Pediatr (Phila) 2020; 59:580-587. [PMID: 32297793 DOI: 10.1177/0009922820913960] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
This study examined the relationship between postconcussive symptom domain and school attendance. Retrospective chart review was completed for 88 children aged 6 to 18 years who were evaluated within 30 days postinjury. Hierarchical multiple regression was used to assess the association of physical, cognitive, emotional, and sleep symptoms with extent of school attendance. A subgroup multiple regression analysis was conducted to evaluate whether age affected the relationship of symptoms to school attendance. After controlling for demographic variables and total number of symptoms, a higher number of postconcussive sleep symptoms strongly predicted less school attendance. Specifically, older children (≥14 years old) with more sleep symptoms demonstrated less school attendance. For children presenting for specialty care after concussion, sleep symptoms are unfavorably associated with return to school. Future work aimed at optimizing sleep regulation following concussion may assist with early reengagement in school as recommended by current concussion management guidelines.
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Affiliation(s)
- Ghazala T Saleem
- Kennedy Krieger Institute, Baltimore, MD, USA.,Johns Hopkins University, Baltimore, MD, USA
| | - Beth S Slomine
- Kennedy Krieger Institute, Baltimore, MD, USA.,Johns Hopkins University, Baltimore, MD, USA
| | - Stacy J Suskauer
- Kennedy Krieger Institute, Baltimore, MD, USA.,Johns Hopkins University, Baltimore, MD, USA
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15
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Barlow KM, Brooks BL, Esser MJ, Kirton A, Mikrogianakis A, Zemek RL, MacMaster FP, Nettel-Aguirre A, Yeates KO, Kirk V, Hutchison JS, Crawford S, Turley B, Cameron C, Hill MD, Samuel T, Buchhalter J, Richer L, Platt R, Boyd R, Dewey D. Efficacy of Melatonin in Children With Postconcussive Symptoms: A Randomized Clinical Trial. Pediatrics 2020; 145:peds.2019-2812. [PMID: 32217739 DOI: 10.1542/peds.2019-2812] [Citation(s) in RCA: 25] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/09/2020] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND Approximately 25% of children with concussion have persistent postconcussive symptoms (PPCS) with resultant significant impacts on quality of life. Melatonin has significant neuroprotective properties, and promising preclinical data suggest its potential to improve outcomes after traumatic brain injury. We hypothesized that treatment with melatonin would result in a greater decrease in PPCS symptoms when compared with a placebo. METHODS We conducted a randomized, double-blind trial of 3 or 10 mg of melatonin compared with a placebo (NCT01874847). We included youth (ages 8-18 years) with PPCS at 4 to 6 weeks after mild traumatic brain injury. Those with significant medical or psychiatric histories or a previous concussion within the last 3 months were excluded. The primary outcome was change in the total youth self-reported Post-Concussion Symptom Inventory score measured after 28 days of treatment. Secondary outcomes included change in health-related quality of life, cognition, and sleep. RESULTS Ninety-nine children (mean age: 13.8 years; SD = 2.6 years; 58% girls) were randomly assigned. Symptoms improved over time with a median Post-Concussion Symptom Inventory change score of -21 (95% confidence interval [CI]: -16 to -27). There was no significant effect of melatonin when compared with a placebo in the intention-to-treat analysis (3 mg melatonin, -2 [95% CI: -13 to 6]; 10 mg melatonin, 4 [95% CI: -7 to 14]). No significant group differences in secondary outcomes were observed. Side effects were mild and similar to the placebo. CONCLUSIONS Children with PPCS had significant impairment in their quality of life. Seventy-eight percent demonstrated significant recovery between 1 and 3 months postinjury. This clinical trial does not support the use of melatonin for the treatment of pediatric PPCS.
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Affiliation(s)
- Karen M Barlow
- Department of Pediatrics, Alberta Children's Hospital Research Institute and .,Clinical Neurosciences, Cumming School of Medicine and.,Child Health Research Centre, The University of Queensland, Brisbane, Australia
| | - Brian L Brooks
- Department of Pediatrics, Alberta Children's Hospital Research Institute and.,Clinical Neurosciences, Cumming School of Medicine and.,Psychology, University of Calgary, Calgary, Alberta, Canada.,Neuroscience Program, Alberta Children's Hospital, Calgary, Alberta, Canada
| | - Michael J Esser
- Department of Pediatrics, Alberta Children's Hospital Research Institute and.,Clinical Neurosciences, Cumming School of Medicine and
| | - Adam Kirton
- Department of Pediatrics, Alberta Children's Hospital Research Institute and.,Radiology.,Clinical Neurosciences, Cumming School of Medicine and
| | - Angelo Mikrogianakis
- Department of Pediatrics, Alberta Children's Hospital Research Institute and.,Emergency Medicine, and
| | - Roger L Zemek
- Departments of Pediatrics and Emergency Medicine and Research Institute, Children's Hospital of Eastern Ontario and University of Ottawa, Ottawa, Ontario, Canada
| | - Frank P MacMaster
- Department of Pediatrics, Alberta Children's Hospital Research Institute and.,Departments of Psychiatry, Paediatrics, and
| | - Alberto Nettel-Aguirre
- Department of Pediatrics, Alberta Children's Hospital Research Institute and.,Departments of Community Health Sciences
| | - Keith Owen Yeates
- Department of Pediatrics, Alberta Children's Hospital Research Institute and.,Clinical Neurosciences, Cumming School of Medicine and.,Psychology, University of Calgary, Calgary, Alberta, Canada
| | - Valerie Kirk
- Department of Pediatrics, Alberta Children's Hospital Research Institute and
| | - James S Hutchison
- Neurosciences and Mental Health Research Program, Department of Critical Care Medicine, The Hospital for Sick Children, Toronto, Ontario, Canada.,Interdepartmental Division of Critical Care Medicine and Institute of Medical Science, University of Toronto, Toronto, Ontario, Canada
| | - Susan Crawford
- Neuroscience Program, Alberta Children's Hospital, Calgary, Alberta, Canada
| | - Brenda Turley
- Neuroscience Program, Alberta Children's Hospital, Calgary, Alberta, Canada
| | - Candice Cameron
- Research Pharmacy, Foothills Medical Centre, Alberta Health Services, Calgary, Alberta, Canada
| | | | - Tina Samuel
- Neuroscience Program, Alberta Children's Hospital, Calgary, Alberta, Canada
| | - Jeffrey Buchhalter
- Department of Pediatrics, Alberta Children's Hospital Research Institute and
| | - Lawrence Richer
- Department of Pediatrics and Women and Children's Health Research Institute, University of Alberta, Edmonton, Alberta, Canada
| | - Robert Platt
- McGill University, Montreal, Québec, Canada; and
| | - Roslyn Boyd
- Child Health Research Centre, The University of Queensland, Brisbane, Australia
| | - Deborah Dewey
- Department of Pediatrics, Alberta Children's Hospital Research Institute and.,Departments of Community Health Sciences
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16
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N-Acetyl-Aspartate in the Dorsolateral Prefrontal Cortex Long After Concussion in Youth. J Head Trauma Rehabil 2020; 35:E127-E135. [DOI: 10.1097/htr.0000000000000535] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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17
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Khetani A, Rohr CS, Sojoudi A, Bray S, Barlow KM. Alteration in Cerebral Activation during a Working Memory Task after Pediatric Mild Traumatic Brain Injury: A Prospective Controlled Cohort Study. J Neurotrauma 2019; 36:3274-3283. [DOI: 10.1089/neu.2018.6117] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Affiliation(s)
- Aneesh Khetani
- Department of Neuroscience and Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
- Alberta Children's Hospital Research Institute, Calgary, Alberta, Canada
- Child and Adolescent Imaging Program, Calgary, Alberta, Canada
| | - Christiane S. Rohr
- Department of Radiology, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
- Alberta Children's Hospital Research Institute, Calgary, Alberta, Canada
- Child and Adolescent Imaging Program, Calgary, Alberta, Canada
- Hotchkiss Brain Institute, Calgary, Alberta, Canada
| | - Alireza Sojoudi
- Biomedical Engineering, University of Calgary, Calgary, Alberta, Canada
| | - Signe Bray
- Department of Radiology, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
- Alberta Children's Hospital Research Institute, Calgary, Alberta, Canada
- Child and Adolescent Imaging Program, Calgary, Alberta, Canada
- Hotchkiss Brain Institute, Calgary, Alberta, Canada
| | - Karen M. Barlow
- Faculty of Medicine, Child Health Research Centre, The University of Queensland, Queensland, Australia
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18
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Iyer KK, Zalesky A, Barlow KM, Cocchi L. Default mode network anatomy and function is linked to pediatric concussion recovery. Ann Clin Transl Neurol 2019; 6:2544-2554. [PMID: 31755665 PMCID: PMC6917315 DOI: 10.1002/acn3.50951] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2019] [Accepted: 10/31/2019] [Indexed: 12/20/2022] Open
Abstract
Objective To determine whether anatomical and functional brain features relate to key persistent post–concussion symptoms (PPCS) in children recovering from mild traumatic brain injuries (mTBI), and whether such brain indices can predict individual recovery from PPCS. Methods One hundred and ten children with mixed recovery following mTBI were seen at the concussion clinic at Neurology department Alberta Children’s Hospital. The primary outcome was the Post–Concussion Symptom Inventory (PCSI, parent proxy). Sleep disturbance scores (PCSI subdomain) and the Neurocognition Index (CNS Vital Signs) were also measured longitudinally. PPCS was assessed at 4 weeks postinjury and 8–10 weeks postinjury. Gray matter volumes were assessed using magnetic resonance imaging (MRI) and voxel‐based morphometry at 4 weeks postinjury. Functional connectivity was estimated at the same timepoint using resting‐state MRI. Two complementary machine learning methods were used to assess if the combination of gray matter and functional connectivity indices carried meaningful prognostic information. Results Higher scores on a composite index of sleep disturbance, including fatigue, were associated with converging decreases in gray matter volume and local functional connectivity in two key nodes of the default mode network: the posterior cingulate cortex and the medial prefrontal cortex. Sleep‐related disturbances also significantly correlated with reductions in functional connectivity between these brain regions. The combination of structural and functional brain indices associated to individual variations in the default mode network accurately predicted clinical outcomes at follow‐up (area under the curve = 0.86). Interpretation These results highlight that the function–structure profile of core default mode regions underpins sleep‐related problems following mTBI and carries meaningful prognostic information for pediatric concussion recovery.
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Affiliation(s)
- Kartik K. Iyer
- Child Health Research CentreFaculty of MedicineThe University of QueenslandBrisbaneQueenslandAustralia
| | - Andrew Zalesky
- Melbourne Neuropsychiatry Centre & Department of Biomedical EngineeringThe University of MelbourneVictoriaAustralia
| | - Karen M. Barlow
- Child Health Research CentreFaculty of MedicineThe University of QueenslandBrisbaneQueenslandAustralia
- Department of NeurologyQueensland Children’s HospitalBrisbaneQueenslandAustralia
- Alberta Children's Hospital Research InstituteCalgaryCanada
- University of CalgaryCalgaryCanada
| | - Luca Cocchi
- Clinical Brain Networks GroupQIMR Berghofer Medical Research InstituteHerstonQueenslandAustralia
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19
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Yamakawa GR, Weerawardhena H, Eyolfson E, Griep Y, Antle MC, Mychasiuk R. Investigating the Role of the Hypothalamus in Outcomes to Repetitive Mild Traumatic Brain Injury: Neonatal Monosodium Glutamate Does Not Exacerbate Deficits. Neuroscience 2019; 413:264-278. [DOI: 10.1016/j.neuroscience.2019.06.022] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2018] [Revised: 05/29/2019] [Accepted: 06/15/2019] [Indexed: 12/20/2022]
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20
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Dave A, Ganesh A, Adil MM, Tsao JW. Practice Current: How do you diagnose and treat post-concussive headache? Neurol Clin Pract 2019; 9:263-270. [PMID: 31341715 DOI: 10.1212/cpj.0000000000000656] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
A common complaint after concussion is the development of new or worsening headaches which can make it difficult or even impossible for patients to work or function in their day-to-day lives. Uncertainties associated with the complaints and a wide variety of approaches exist regarding the appropriate work-up and management of these patients. Areas of ongoing debate include the need for neuroimaging; optimal, acute, and preventative treatment; and proper counseling and expectation management. Given the wide variety of potential approaches and the lack of consensus, we sought expert opinion from around the globe on how to evaluate and manage patients with headache following concussion. Similar questions were posed to the rest of our readership in an online survey (links.lww.com/CPJ/A96), the results of which are also presented.
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Affiliation(s)
- Ajal Dave
- Department of Medicine (AD), Neurology Service, Tripler Army Medical Center, Honolulu, HI; Department of Clinical Neurosciences (AG), Cumming School of Medicine, University of Calgary, Calgary, Canada; Vascular Neurology (MMA), National Institute of Neurological Disorders and Stroke /National Institutes of Health (NINDS/NIH); Department of Neurology (JWT), University of Tennessee Health Science Center; and Children's Foundation Research Institute (JWT), Le Bonheur Children's Hospital, Memphis, TN
| | - Aravind Ganesh
- Department of Medicine (AD), Neurology Service, Tripler Army Medical Center, Honolulu, HI; Department of Clinical Neurosciences (AG), Cumming School of Medicine, University of Calgary, Calgary, Canada; Vascular Neurology (MMA), National Institute of Neurological Disorders and Stroke /National Institutes of Health (NINDS/NIH); Department of Neurology (JWT), University of Tennessee Health Science Center; and Children's Foundation Research Institute (JWT), Le Bonheur Children's Hospital, Memphis, TN
| | - Malik Muhammad Adil
- Department of Medicine (AD), Neurology Service, Tripler Army Medical Center, Honolulu, HI; Department of Clinical Neurosciences (AG), Cumming School of Medicine, University of Calgary, Calgary, Canada; Vascular Neurology (MMA), National Institute of Neurological Disorders and Stroke /National Institutes of Health (NINDS/NIH); Department of Neurology (JWT), University of Tennessee Health Science Center; and Children's Foundation Research Institute (JWT), Le Bonheur Children's Hospital, Memphis, TN
| | - Jack W Tsao
- Department of Medicine (AD), Neurology Service, Tripler Army Medical Center, Honolulu, HI; Department of Clinical Neurosciences (AG), Cumming School of Medicine, University of Calgary, Calgary, Canada; Vascular Neurology (MMA), National Institute of Neurological Disorders and Stroke /National Institutes of Health (NINDS/NIH); Department of Neurology (JWT), University of Tennessee Health Science Center; and Children's Foundation Research Institute (JWT), Le Bonheur Children's Hospital, Memphis, TN
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21
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King R, Kirton A, Zewdie E, Seeger TA, Ciechanski P, Barlow KM. Longitudinal Assessment of Cortical Excitability in Children and Adolescents With Mild Traumatic Brain Injury and Persistent Post-concussive Symptoms. Front Neurol 2019; 10:451. [PMID: 31156530 PMCID: PMC6533942 DOI: 10.3389/fneur.2019.00451] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2019] [Accepted: 04/12/2019] [Indexed: 01/18/2023] Open
Abstract
Introduction: Symptoms following a mild traumatic brain injury (mTBI) usually resolve quickly but may persist past 3 months in up to 15% of children. Mechanisms of mTBI recovery are poorly understood, but may involve alterations in cortical neurophysiology. Transcranial Magnetic Stimulation (TMS) can non-invasively investigate such mechanisms, but the time course of neurophysiological changes in mTBI are unknown. Objective/Hypothesis: To determine the relationship between persistent post-concussive symptoms (PPCS) and altered motor cortex neurophysiology over time. Methods: This was a prospective, longitudinal, controlled cohort study comparing children (8-18 years) with mTBI (symptomatic vs. asymptomatic) groups to controls. Cortical excitability was measured using TMS paradigms at 1 and 2 months post injury. The primary outcome was the cortical silent period (cSP). Secondary outcomes included short interval intracortical inhibition (SICI) and facilitation (SICF), and long-interval cortical inhibition (LICI). Generalized linear mixed model analyses were used to evaluate the effect of group and time on neurophysiological parameters. Results: One hundred seven participants (median age 15.1, 57% female) including 78 (73%) with symptomatic PPCS and 29 with asymptomatic mTBI, were compared to 26 controls. Cortical inhibition (cSP and SICI) was reduced in the symptomatic group compared to asymptomatic group and tended to increase over time. Measures of cortical facilitation (SICF and ICF) were increased in the asymptomatic group and decreased over time. TMS was well tolerated with no serious adverse events. Conclusions: TMS-assessed cortical excitability is altered in children following mild TBI and is dependent on recovery trajectory. Our findings support delayed return to contact sports in children even where clinical symptoms have resolved.
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Affiliation(s)
- Regan King
- Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
- Hotchkiss Brain Institute, University of Calgary, Calgary, AB, Canada
- Alberta Children's Hospital Research Institute, Alberta Children's Hospital, Calgary, AB, Canada
| | - Adam Kirton
- Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
- Hotchkiss Brain Institute, University of Calgary, Calgary, AB, Canada
- Alberta Children's Hospital Research Institute, Alberta Children's Hospital, Calgary, AB, Canada
- Departments of Pediatrics, Clinical Neurosciences and Community Health Sciences, Calgary, AB, Canada
| | - Ephrem Zewdie
- Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
- Hotchkiss Brain Institute, University of Calgary, Calgary, AB, Canada
- Alberta Children's Hospital Research Institute, Alberta Children's Hospital, Calgary, AB, Canada
| | - Trevor A Seeger
- Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
- Hotchkiss Brain Institute, University of Calgary, Calgary, AB, Canada
| | - Patrick Ciechanski
- Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
- Hotchkiss Brain Institute, University of Calgary, Calgary, AB, Canada
- Alberta Children's Hospital Research Institute, Alberta Children's Hospital, Calgary, AB, Canada
| | - Karen M Barlow
- Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
- Hotchkiss Brain Institute, University of Calgary, Calgary, AB, Canada
- Alberta Children's Hospital Research Institute, Alberta Children's Hospital, Calgary, AB, Canada
- Departments of Pediatrics, Clinical Neurosciences and Community Health Sciences, Calgary, AB, Canada
- Department of Pediatrics, Faculty of Medicine, The University of Queensland, Brisbane, QLD, Australia
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22
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King R, Grohs MN, Kirton A, Lebel C, Esser MJ, Barlow KM. Microstructural neuroimaging of white matter tracts in persistent post-concussion syndrome: A prospective controlled cohort study. Neuroimage Clin 2019; 23:101842. [PMID: 31108457 PMCID: PMC6526293 DOI: 10.1016/j.nicl.2019.101842] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2018] [Revised: 04/08/2019] [Accepted: 04/27/2019] [Indexed: 12/12/2022]
Abstract
INTRODUCTION Children with mild traumatic brain injury (mTBI) typically recover quickly, however approximately 15% experience persistent post-concussive symptoms (PPCS) past 3 months. The microstructural pathology associated with underlying persistent symptoms is poorly understood but is suggested to involve axonal injury to white matter tracts. Diffusion tensor imaging (DTI) can be used to visualize and characterize damage to white matter microstructure of the brain. OBJECTIVE We aimed to investigate white matter microstructure in children with persistent concussive symptoms as compared to typically developing controls, alongside evaluating differences in white matter changes over time and how this relates to symptom recovery. METHODS The current study is a prospective, longitudinal, controlled cohort study of children with mTBI. 104 children aged 8 to 18 years with a mTBI (72 symptomatic; 32 asymptomatic) were recruited from the Alberta Children's Hospital and compared to 20 healthy controls. Microstructural evidence of white matter injury was evaluated using DTI one month post injury and repeated 4 to 6 weeks later. Primary outcomes included fractional anisotropy and mean diffusivity of the corticospinal tracts, uncinate fasciculi, and motor fibers of the corpus callosum. Post-concussive symptoms were also measured using the Post-Concussion Symptom Inventory (PCSI) taken at both time points. RESULTS Fractional anisotropy of the left uncinate fasciculi was lower in symptomatic children compared to controls (F(2,119) = 3.582, p = 0.031). No other significant differences were observed. CONCLUSIONS Our findings provide evidence of microstructural injury following mTBI in children with ongoing post-concussive symptoms one month post injury. The changes were persistent 4-6 weeks later. Further longitudinal studies of white matter microstructure in PPCS will be helpful to clarify whether these white matter alterations resolve over time.
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Affiliation(s)
- Regan King
- Hotchkiss Brain Institute, Canada; Alberta Children's Hospital Research Institute, Canada; Department of Clinical Neurosciences, Canada
| | - Melody N Grohs
- Alberta Children's Hospital Research Institute, Canada; Department of Clinical Neurosciences, Canada
| | - Adam Kirton
- Hotchkiss Brain Institute, Canada; Alberta Children's Hospital Research Institute, Canada; Department of Clinical Neurosciences, Canada; Department of Pediatrics, Canada; Cummings School of Medicine, University of Calgary, Canada
| | - Catherine Lebel
- Alberta Children's Hospital Research Institute, Canada; Department of Clinical Neurosciences, Canada; Department of Pediatrics, Canada
| | - Michael J Esser
- Alberta Children's Hospital Research Institute, Canada; Department of Pediatrics, Canada; Cummings School of Medicine, University of Calgary, Canada
| | - Karen M Barlow
- Hotchkiss Brain Institute, Canada; Alberta Children's Hospital Research Institute, Canada; Department of Clinical Neurosciences, Canada; Department of Pediatrics, Canada; Cummings School of Medicine, University of Calgary, Canada.
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23
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Nurse practitioners' recommendations for pharmacotherapy in the management of adolescent concussion. J Am Assoc Nurse Pract 2019; 30:499-510. [PMID: 30113534 DOI: 10.1097/jxx.0000000000000070] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND AND PURPOSE Nurse practitioners (NPs) frequently treat acute conditions presenting in children and adolescents in the outpatient setting. No evidence-based guidance exists pertaining to the treatment of concussion with medications. The purpose of this study was to examine recommendations by NPs for pharmacotherapy of acute symptoms for adolescent concussion. METHODS This is a secondary analysis of data from a web-based census survey of all licensed NPs in Oregon and Washington State, where they practice as independent providers with prescriptive authority. Based on a standardized adolescent patient scenario video, NPs were asked to indicate prescription or nonprescription medication recommendations for concussion symptoms. Open-ended descriptions of medication recommendations were coded, summarized, and described. CONCLUSIONS In narrative text, 78.4% of the 991 respondents recommended at least one type of prescription or nonprescription medication. Prescription medications (recommended by 17.2%) included antiemetics and antimigraine medications; nonprescription medications (recommended by 75.5%) included nonsteroidal anti-inflammatory drugs, over-the-counter pain relievers, and herbal medications. Pharmacotherapy recommendations varied by NP practice setting and rurality. IMPLICATIONS FOR PRACTICE Nurse practitioners have full prescriptive authority in many states. No guidelines inform medication use in managing acute concussion symptoms, yet many providers recommend their use.
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Abstract
PURPOSE OF REVIEW Headache following concussion and mild traumatic brain injury is very common in pediatrics. There is significant concern about appropriate management of acute and persistent headache following mild head injuries in children among affected youth, their families and care providers. RECENT FINDINGS The current article will review definitions and diagnoses of posttraumatic headache (PTHA), recent research regarding risk factors for persistence of postconcussion symptoms and headaches, current recommendations for the evaluation of youth with PTHA, recent data regarding efficacy of treatment options for PTHA, and current recommendations for the treatment of acute and persistent PTHA. SUMMARY PTHA is common following concussion in pediatrics. Some of the most consistent risk factors for persistent symptoms following concussion include female sex, adolescent age, prior concussion with prolonged recovery, prior headache history and high number of acute symptoms, particularly migrainous symptoms, following concussion. There are few prospective studies of the treatment of PTHA in pediatrics; however, a recent study found that short-term use of ibuprofen for those with acute PTHA following concussion may be associated with lower risk of symptoms and better function 1 week after injury. Currently complete rest or cocooning following concussion is not recommended as it may actually be associated with longer recovery time; a gradual return to cognitive and physical activity appears to be most effective strategy but more study is needed.
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Brooks BL, Low TA, Plourde V, Virani S, Jadavji Z, MacMaster FP, Barlow KM, Lebel RM, Yeates KO. Cerebral blood flow in children and adolescents several years after concussion. Brain Inj 2018; 33:233-241. [DOI: 10.1080/02699052.2018.1540798] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Affiliation(s)
- Brian L. Brooks
- Departments of Paediatrics, Clinical Neurosciences, and Psychology, University of Calgary, Calgary, Alberta, Canada
- Alberta Children’s Hospital Research Institute, University of Calgary, Calgary, Alberta, Canada
- Neurosciences Program, Alberta Children’s Hospital, Calgary, Alberta, Canada
| | - Trevor A. Low
- Department of Neurosciences, University of Calgary, Calgary, Alberta, Canada
| | - Vickie Plourde
- Faculty Saint-Jean, University of Alberta, Edmonton, AB, Canada
| | - Shane Virani
- Vi Riddell Pain and Rehabilitation Program, Alberta Children’s Hospital Research Institute, Calgary, Alberta, Canada
- Sport Injury Prevention Research Centre, Faculty of Kinesiology, University of Calgary, Calgary, Alberta, Canada
| | - Zeanna Jadavji
- Department of Neurosciences, University of Calgary, Calgary, Alberta, Canada
- Alberta Children’s Hospital Research Institute, University of Calgary, Calgary, Canada
| | - Frank P. MacMaster
- Alberta Children’s Hospital Research Institute, University of Calgary, Calgary, Alberta, Canada
- Mathison Centre for Mental Health Research and Education, Hotchkiss Brain Institute, Calgary, Alberta, Canada
- Strategic Clinical Network for Addictions and Mental Health, Alberta Health Services, Calgary, Alberta, Canada
- Departments of Psychiatry and Paediatrics, University of Calgary, Calgary, Alberta, Canada
| | - Karen M. Barlow
- Child Health Research Centre, University of Queensland, Brisbane, Australia
- Departments of Paediatrics and Clinical Neurosciences, University of Calgary, Brisbane, Australia
- Alberta Children’s Hospital Research Institute, University of Calgary, Brisbane, Australia
| | - R. Marc Lebel
- Alberta Children’s Hospital Research Institute, University of Calgary, Calgary, Alberta, Canada
- Departments of Radiology and Biomedical Engineering, University of Calgary, Calgary, Alberta, Canada
- GE Healthcare, Calgary, Alberta, Canada
| | - Keith Owen Yeates
- Alberta Children’s Hospital Research Institute, University of Calgary, Calgary, Alberta, Canada
- Departments of Psychology, Paediatrics, and Clinical Neurosciences, University of Calgary, Calgary, Alberta, Canada
- Hotchkiss Brain Institute, University of Calgary, Calgary, Alberta, Canada
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Spotlight on Neurotrauma Research in Canada's Leading Academic Centers. J Neurotrauma 2018; 35:1986-2004. [PMID: 30074875 DOI: 10.1089/neu.2018.29017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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Abstract
Sports-related concussions continue to generate widespread interest. A concussion is a complex pathophysiologic process, with or without loss of consciousness, that results in a disturbance of brain function. Risk factors include age <18 years, female sex, and history of a previous concussion. A sideline physical examination with standardized assessment tools can assist diagnosis. Management for suspected concussion begins with immediate removal from play and requires clinical follow-up. Symptoms are usually self-limited and resolve within 2 to 3 weeks. Initial treatment consists of a reduction in cognitive activity and physical rest. A stepwise return-to-play protocol, taking into consideration state laws, with a gradual increase in activity until the athlete is able to perform full activity without symptoms should be followed. Neuropsychologic testing may be used as a tool in management. For prolonged concussion, physical rehabilitation or medications for headaches, mood, or sleep disturbance may be required. Education, rule changes, and equipment improvements may assist in prevention. The long-term consequences of concussions are not fully understood and merit additional research.
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Melatonin as a Therapy for Traumatic Brain Injury: A Review of Published Evidence. Int J Mol Sci 2018; 19:ijms19051539. [PMID: 29786658 PMCID: PMC5983792 DOI: 10.3390/ijms19051539] [Citation(s) in RCA: 33] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2018] [Revised: 05/04/2018] [Accepted: 05/07/2018] [Indexed: 12/15/2022] Open
Abstract
Melatonin (MEL) is a hormone that is produced in the brain and is known to bind to MEL-specific receptors on neuronal membranes in several brain regions. MEL’s documented neuroprotective properties, low toxicity, and ability to cross the blood-brain-barrier have led to its evaluation for patients with traumatic brain injury (TBI), a condition for which there are currently no Food and Drug Administration (FDA)-approved therapies. The purpose of this manuscript is to summarize the evidence surrounding the use of melatonin after TBI, as well as identify existing gaps and future directions. To address this aim, a search of the literature was conducted using Pubmed, Google Scholar, and the Cochrane Database. In total, 239 unique articles were screened, and the 22 preclinical studies that met the a priori inclusion/exclusion criteria were summarized, including the study aims, sample (size, groups, species, strain, sex, age/weight), TBI model, therapeutic details (preparation, dose, route, duration), key findings, and conclusions. The evidence from these 22 studies was analyzed to draw comparisons across studies, identify remaining gaps, and suggest future directions. Taken together, the published evidence suggests that MEL has neuroprotective properties via a number of mechanisms with few toxic effects reported. Notably, available evidence is largely based on data from adult male rats and, to a lesser extent, mice. Few studies collected data beyond a few days of the initial injury, necessitating additional longer-term studies. Other future directions include diversification of samples to include female animals, pediatric and geriatric animals, and transgenic strains.
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Lucke-Wold BP, Logsdon AF, Nguyen L, Eltanahay A, Turner RC, Bonasso P, Knotts C, Moeck A, Maroon JC, Bailes JE, Rosen CL. Supplements, nutrition, and alternative therapies for the treatment of traumatic brain injury. Nutr Neurosci 2018; 21:79-91. [PMID: 27705610 PMCID: PMC5491366 DOI: 10.1080/1028415x.2016.1236174] [Citation(s) in RCA: 44] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
Studies using traditional treatment strategies for mild traumatic brain injury (TBI) have produced limited clinical success. Interest in treatment for mild TBI is at an all time high due to its association with the development of chronic traumatic encephalopathy and other neurodegenerative diseases, yet therapeutic options remain limited. Traditional pharmaceutical interventions have failed to transition to the clinic for the treatment of mild TBI. As such, many pre-clinical studies are now implementing non-pharmaceutical therapies for TBI. These studies have demonstrated promise, particularly those that modulate secondary injury cascades activated after injury. Because no TBI therapy has been discovered for mild injury, researchers now look to pharmaceutical supplementation in an attempt to foster success in human clinical trials. Non-traditional therapies, such as acupuncture and even music therapy are being considered to combat the neuropsychiatric symptoms of TBI. In this review, we highlight alternative approaches that have been studied in clinical and pre-clinical studies of TBI, and other related forms of neural injury. The purpose of this review is to stimulate further investigation into novel and innovative approaches that can be used to treat the mechanisms and symptoms of mild TBI.
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Affiliation(s)
- Brandon P. Lucke-Wold
- Department of Neurosurgery, West Virginia University School of Medicine, Morgantown, USA
- Center for Neuroscience, West Virginia University School of Medicine, Morgantown, USA
| | - Aric F. Logsdon
- Center for Neuroscience, West Virginia University School of Medicine, Morgantown, USA
| | - Linda Nguyen
- Center for Neuroscience, West Virginia University School of Medicine, Morgantown, USA
| | - Ahmed Eltanahay
- Department of Neurosurgery, Oregon Health Sciences University, Portland, USA
| | - Ryan C. Turner
- Department of Neurosurgery, West Virginia University School of Medicine, Morgantown, USA
| | - Patrick Bonasso
- Center for Neuroscience, West Virginia University School of Medicine, Morgantown, USA
| | - Chelsea Knotts
- Department of Neurosurgery, West Virginia University School of Medicine, Morgantown, USA
| | - Adam Moeck
- Department of Surgery, Matigan Army Medical Center, Tacoma, WA, USA
| | - Joseph C. Maroon
- Department of Neurosurgery, University of Pittsburgh Medical Center, PA, USA
| | - Julian E. Bailes
- Department of Neurosurgery, Northshore Healthcare System, Evanston, IL, USA
| | - Charles L. Rosen
- Department of Neurosurgery, West Virginia University School of Medicine, Morgantown, USA
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Abstract
Sports-related concussion (SRC) is a common problem in youth sports. Concussion may occur after a forceful hit to the body or head, resulting in transient neuropathological changes that spontaneously resolve with relative rest and activity modification in most patients. Most SRCs are effectively managed by primary care physicians and sports medicine specialists. In some cases, symptoms may persist and the child and adolescent psychiatrist may be consulted. This article reviews important background information regarding SRC and highlights a variety of pharmacologic and nonpharmacologic treatment options that consultant psychiatrists should know.
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Bramley H, Henson A, Lewis MM, Kong L, Stetter C, Silvis M. Sleep Disturbance Following Concussion Is a Risk Factor for a Prolonged Recovery. Clin Pediatr (Phila) 2017; 56:1280-1285. [PMID: 29073787 DOI: 10.1177/0009922816681603] [Citation(s) in RCA: 50] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
Sleep disturbance is a common problem following concussion. A retrospective chart review was conducted at a regional concussion clinic on patients 13 to 18 years of age between 2005 and 2011. Statistical analysis evaluated sleep disturbance and duration of concussion, as well as the use and effectiveness of melatonin. A total of 417 patients met inclusion criteria. One hundred twenty-three (34%) reported disturbance in sleep. There was no difference in sleep disturbance based on age, gender, or past number of concussions. Sleep disturbance was associated with a 3- to 4-fold increase in recovery time. Non-sport-related concussions were more likely to be associated with sleep disturbance compared to sport-related concussions (45% vs 29%, P = .01). Melatonin improved sleep disturbance in 67% of the patients. Evaluating sleep disorders following concussion is an important part of the assessment. These findings will help clinicians provide anticipatory guidance and treatment for adolescents recovering from concussion.
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Affiliation(s)
- Harry Bramley
- 1 Penn State Milton S. Hershey Medical Center, Hershey, PA, USA
| | - Alyssa Henson
- 1 Penn State Milton S. Hershey Medical Center, Hershey, PA, USA
| | | | - Lan Kong
- 1 Penn State Milton S. Hershey Medical Center, Hershey, PA, USA
| | - Christy Stetter
- 1 Penn State Milton S. Hershey Medical Center, Hershey, PA, USA
| | - Matthew Silvis
- 1 Penn State Milton S. Hershey Medical Center, Hershey, PA, USA
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Maas AIR, Menon DK, Adelson PD, Andelic N, Bell MJ, Belli A, Bragge P, Brazinova A, Büki A, Chesnut RM, Citerio G, Coburn M, Cooper DJ, Crowder AT, Czeiter E, Czosnyka M, Diaz-Arrastia R, Dreier JP, Duhaime AC, Ercole A, van Essen TA, Feigin VL, Gao G, Giacino J, Gonzalez-Lara LE, Gruen RL, Gupta D, Hartings JA, Hill S, Jiang JY, Ketharanathan N, Kompanje EJO, Lanyon L, Laureys S, Lecky F, Levin H, Lingsma HF, Maegele M, Majdan M, Manley G, Marsteller J, Mascia L, McFadyen C, Mondello S, Newcombe V, Palotie A, Parizel PM, Peul W, Piercy J, Polinder S, Puybasset L, Rasmussen TE, Rossaint R, Smielewski P, Söderberg J, Stanworth SJ, Stein MB, von Steinbüchel N, Stewart W, Steyerberg EW, Stocchetti N, Synnot A, Te Ao B, Tenovuo O, Theadom A, Tibboel D, Videtta W, Wang KKW, Williams WH, Wilson L, Yaffe K, Adams H, Agnoletti V, Allanson J, Amrein K, Andaluz N, Anke A, Antoni A, van As AB, Audibert G, Azaševac A, Azouvi P, Azzolini ML, Baciu C, Badenes R, Barlow KM, Bartels R, Bauerfeind U, Beauchamp M, Beer D, Beer R, Belda FJ, Bellander BM, Bellier R, Benali H, Benard T, Beqiri V, Beretta L, Bernard F, Bertolini G, Bilotta F, Blaabjerg M, den Boogert H, Boutis K, Bouzat P, Brooks B, Brorsson C, Bullinger M, Burns E, Calappi E, Cameron P, Carise E, Castaño-León AM, Causin F, Chevallard G, Chieregato A, Christie B, Cnossen M, Coles J, Collett J, Della Corte F, Craig W, Csato G, Csomos A, Curry N, Dahyot-Fizelier C, Dawes H, DeMatteo C, Depreitere B, Dewey D, van Dijck J, Đilvesi Đ, Dippel D, Dizdarevic K, Donoghue E, Duek O, Dulière GL, Dzeko A, Eapen G, Emery CA, English S, Esser P, Ezer E, Fabricius M, Feng J, Fergusson D, Figaji A, Fleming J, Foks K, Francony G, Freedman S, Freo U, Frisvold SK, Gagnon I, Galanaud D, Gantner D, Giraud B, Glocker B, Golubovic J, Gómez López PA, Gordon WA, Gradisek P, Gravel J, Griesdale D, Grossi F, Haagsma JA, Håberg AK, Haitsma I, Van Hecke W, Helbok R, Helseth E, van Heugten C, Hoedemaekers C, Höfer S, Horton L, Hui J, Huijben JA, Hutchinson PJ, Jacobs B, van der Jagt M, Jankowski S, Janssens K, Jelaca B, Jones KM, Kamnitsas K, Kaps R, Karan M, Katila A, Kaukonen KM, De Keyser V, Kivisaari R, Kolias AG, Kolumbán B, Kolundžija K, Kondziella D, Koskinen LO, Kovács N, Kramer A, Kutsogiannis D, Kyprianou T, Lagares A, Lamontagne F, Latini R, Lauzier F, Lazar I, Ledig C, Lefering R, Legrand V, Levi L, Lightfoot R, Lozano A, MacDonald S, Major S, Manara A, Manhes P, Maréchal H, Martino C, Masala A, Masson S, Mattern J, McFadyen B, McMahon C, Meade M, Melegh B, Menovsky T, Moore L, Morgado Correia M, Morganti-Kossmann MC, Muehlan H, Mukherjee P, Murray L, van der Naalt J, Negru A, Nelson D, Nieboer D, Noirhomme Q, Nyirádi J, Oddo M, Okonkwo DO, Oldenbeuving AW, Ortolano F, Osmond M, Payen JF, Perlbarg V, Persona P, Pichon N, Piippo-Karjalainen A, Pili-Floury S, Pirinen M, Ple H, Poca MA, Posti J, Van Praag D, Ptito A, Radoi A, Ragauskas A, Raj R, Real RGL, Reed N, Rhodes J, Robertson C, Rocka S, Røe C, Røise O, Roks G, Rosand J, Rosenfeld JV, Rosenlund C, Rosenthal G, Rossi S, Rueckert D, de Ruiter GCW, Sacchi M, Sahakian BJ, Sahuquillo J, Sakowitz O, Salvato G, Sánchez-Porras R, Sándor J, Sangha G, Schäfer N, Schmidt S, Schneider KJ, Schnyer D, Schöhl H, Schoonman GG, Schou RF, Sir Ö, Skandsen T, Smeets D, Sorinola A, Stamatakis E, Stevanovic A, Stevens RD, Sundström N, Taccone FS, Takala R, Tanskanen P, Taylor MS, Telgmann R, Temkin N, Teodorani G, Thomas M, Tolias CM, Trapani T, Turgeon A, Vajkoczy P, Valadka AB, Valeinis E, Vallance S, Vámos Z, Vargiolu A, Vega E, Verheyden J, Vik A, Vilcinis R, Vleggeert-Lankamp C, Vogt L, Volovici V, Voormolen DC, Vulekovic P, Vande Vyvere T, Van Waesberghe J, Wessels L, Wildschut E, Williams G, Winkler MKL, Wolf S, Wood G, Xirouchaki N, Younsi A, Zaaroor M, Zelinkova V, Zemek R, Zumbo F. Traumatic brain injury: integrated approaches to improve prevention, clinical care, and research. Lancet Neurol 2017; 16:987-1048. [DOI: 10.1016/s1474-4422(17)30371-x] [Citation(s) in RCA: 822] [Impact Index Per Article: 117.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2016] [Revised: 07/06/2017] [Accepted: 09/27/2017] [Indexed: 12/11/2022]
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Romero-Rivera HR, Cabeza-Morales M, Soto-Zarate E, Satyarthee GD, Padilla-Zambrano H, Joaquim AF, Rubiano AM, Hernandez AP, Agrawal A, Moscote-Salazar LR. Antioxidant therapies in traumatic brain injury: a review. ROMANIAN NEUROSURGERY 2017. [DOI: 10.1515/romneu-2017-0053] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Abstract
Oxidative stress constitute one of the commonest mechanism of the secondary injury contributing to neuronal death in traumatic brain injury cases. The oxidative stress induced secondary injury blockade may be considered as to be a good alternative to improve the outcome of traumatic brain injury (TBI) treatment. Due to absence of definitive therapy of traumatic brain injury has forced researcher to utilize unconventional therapies and its roles investigated in the improvement of management and outcome in recent year. Antioxidant therapies are proven effective in many preclinical studies and encouraging results and the role of antioxidant mediaction may act as further advancement in the traumatic brain injury management it may represent aonr of newer moadlaity in neurosurgical aramamentorium, this kind of therapy could be a good alternative or adjuct to the previously established neuroprotection agents in TBI.
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Manipulating cognitive reserve: Pre-injury environmental conditions influence the severity of concussion symptomology, gene expression, and response to melatonin treatment in rats. Exp Neurol 2017; 295:55-65. [PMID: 28579327 DOI: 10.1016/j.expneurol.2017.06.001] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2017] [Revised: 05/21/2017] [Accepted: 06/01/2017] [Indexed: 11/22/2022]
Abstract
In an effort to understand the factors that contribute to heterogeneity in outcomes often associated with mTBI in youth, this study examined the role of premorbid differences in cognitive reserve on post-concussive symptoms (PCS), molecular markers, and treatment response. Male and female rats matured in one of three environmental conditions (Stress, Enrichment, Control), received a mTBI in adolescence, and were randomized to melatonin or placebo treatment. All animals underwent a behavioural test battery designed to examine PCS. Using prefrontal cortex and hippocampus tissue, expression of 9 genes was assessed in an effort to determine how the brain's epigenome was influenced by cognitive reserve, mTBI, and melatonin. Enrichment increased cognitive reserve (CR) and prevented lingering symptoms. Conversely, stress was associated with progressive worsening and manifestation of PCS in the longer-term. Melatonin was able to restore baseline function for control and enriched animals, but was ineffective for the stress condition. Epigenetic change in the prefrontal cortex was largely driven by the injury, while gene expression changes in the hippocampus were dependent upon cognitive reserve. The occurrence and severity of PCS is dependent upon a complex and multifaceted array of factors that modify behavioural and epigenetic responses to mTBI and its treatment.
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Seeger TA, Kirton A, Esser MJ, Gallagher C, Dunn J, Zewdie E, Damji O, Ciechanski P, Barlow KM. Cortical excitability after pediatric mild traumatic brain injury. Brain Stimul 2017; 10:305-314. [DOI: 10.1016/j.brs.2016.11.011] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2016] [Revised: 11/15/2016] [Accepted: 11/18/2016] [Indexed: 12/23/2022] Open
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Trojian TH, Wang DH, Leddy JJ. Nutritional Supplements for the Treatment and Prevention of Sports-Related Concussion—Evidence Still Lacking. Curr Sports Med Rep 2017; 16:247-255. [DOI: 10.1249/jsr.0000000000000387] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
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Abstract
Context: Pediatric concussions are common, and emphasis on correct diagnosis and management is stressed in consensus guidelines. Medications may have a role in management of concussion, but no consensus exists regarding appropriate pharmacologic therapy. Evidence Acquisition: Nonsystematic review. Study Design: Clinical review. Level of Evidence: Level 4. Results: There is limited evidence for hypertonic saline to improve posttraumatic headache in the emergency department setting. There is essentially no evidence for the use of any other medication in management of pediatric sport-related concussion. Conclusion: Further research is necessary to determine whether there is benefit to the use of any pharmacotherapy in the management of pediatric-aged athletes with concussions.
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Affiliation(s)
- Mark E. Halstead
- Departments of Orthopedics and Pediatrics, Washington University School of Medicine, St Louis, Missouri
- Mark E. Halstead, MD, 14532 South Outer Forty Drive, Chesterfield, MO 63017 ()
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The Incidence of Postconcussion Syndrome Remains Stable Following Mild Traumatic Brain Injury in Children. Pediatr Neurol 2015; 53:491-7. [PMID: 26421987 DOI: 10.1016/j.pediatrneurol.2015.04.011] [Citation(s) in RCA: 78] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/10/2015] [Revised: 04/22/2015] [Accepted: 04/22/2015] [Indexed: 11/22/2022]
Abstract
BACKGROUND Improving our knowledge about the natural history and persistence of symptoms following mild traumatic brain injury is a vital step in improving the provision of health care to children with postconcussion syndrome. The purposes of this study were to (1) determine the incidence and persistence of symptoms after mild traumatic brain injury and (2) ascertain whether Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV), symptom criteria for postconcussion syndrome in adults are appropriate for use in children. METHODS A tertiary care pediatric emergency department was the setting for this study. This was a prospective observational follow-up cohort study of children (ages 2 to 18 years) with mild traumatic brain injury. Data were collected in person during the acute presentation, and subsequent follow-up was performed by telephone at 7-10 days and 1, 2, and 3 months postinjury. Postconcussion Symptom Inventory for parents and children was used. The DSM-IV diagnostic criteria for postconcussion syndrome were explored using receiver operating characteristic curve analysis. RESULTS A total of 467 children (62.5% boys, median age 12.04, range 2.34-18.0) with mild traumatic brain injury participated. The median time until symptom resolution was 29.0 days (95% confidence intervals: 26.09-31.91). Three months after injury, 11.8% of children with mild traumatic brain injury remained symptomatic. Receiver operating curve characteristic analysis of the postconcussion syndrome criteria successfully classified symptomatic participants at three months postinjury; the adolescent receiver operating characteristic curve was excellent with the area under the curve being 0.928 (P < 0.001, standard error 0.019). CONCLUSIONS Consistent with our previous study, 11.8% of children presenting to the emergency room with a mild traumatic brain injury remain symptomatic at 3 months postinjury. This is the first study to demonstrate stable incidence rates of postconcussion syndrome in children and that modified DSM-IV criteria can be used to successfully classify postconcussion syndrome in children. Although most children report a decay in symptoms over time, 10% of children develop symptoms even though they initially had a good outcome. Caution should be used when using only parent report as a surrogate for childhood outcomes following a concussion.
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Seifman MA, Gomes K, Nguyen PN, Bailey M, Rosenfeld JV, Cooper DJ, Morganti-Kossmann MC. Measurement of serum melatonin in intensive care unit patients: changes in traumatic brain injury, trauma, and medical conditions. Front Neurol 2014; 5:237. [PMID: 25477861 PMCID: PMC4235080 DOI: 10.3389/fneur.2014.00237] [Citation(s) in RCA: 41] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2014] [Accepted: 11/01/2014] [Indexed: 12/16/2022] Open
Abstract
Melatonin is an endogenous hormone mainly produced by the pineal gland whose dysfunction leads to abnormal sleeping patterns. Changes in melatonin have been reported in acute traumatic brain injury (TBI); however, the impact of environmental conditions typical of the intensive care unit (ICU) has not been assessed. The aim of this study was to compare daily melatonin production in three patient populations treated at the ICU to differentiate the role of TBI versus ICU conditions. Forty-five patients were recruited and divided into severe TBI, trauma without TBI, medical conditions without trauma, and compared to healthy volunteers. Serum melatonin levels were measured at four daily intervals at 0400 h, 1000 h, 1600 h, and 2200 h for 7 days post-ICU admission by commercial enzyme linked immunosorbent assay. The geometric mean concentrations (95% confidence intervals) of melatonin in these groups showed no difference being 8.3 (6.3–11.0), 9.3 (7.0–12.3), and 8.9 (6.6–11.9) pg/mL, respectively, in TBI, trauma, and intensive care cohorts. All of these patient groups demonstrated decreased melatonin concentrations when compared to control patients. This study suggests that TBI as well as ICU conditions, may have a role in the dysfunction of melatonin. Monitoring and possibly substituting melatonin acutely in these settings may assist in ameliorating long-term sleep dysfunction in all of these groups, and possibly contribute to reducing secondary brain injury in severe TBI.
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Affiliation(s)
- Marc A Seifman
- National Trauma Research Institute, The Alfred , Melbourne, VIC , Australia ; Department of Surgery, Monash University , Melbourne, VIC , Australia ; Department of Neurosurgery, The Alfred , Melbourne, VIC , Australia
| | - Keith Gomes
- National Trauma Research Institute, The Alfred , Melbourne, VIC , Australia ; Department of Neurosurgery, The Alfred , Melbourne, VIC , Australia
| | - Phuong N Nguyen
- National Trauma Research Institute, The Alfred , Melbourne, VIC , Australia
| | - Michael Bailey
- Department of Epidemiology, Monash University , Melbourne, VIC , Australia ; Australian New Zealand Intensive Care Research Centre , Melbourne, VIC , Australia
| | - Jeffrey V Rosenfeld
- Department of Surgery, Monash University , Melbourne, VIC , Australia ; Department of Neurosurgery, The Alfred , Melbourne, VIC , Australia
| | - David J Cooper
- Department of Epidemiology, Monash University , Melbourne, VIC , Australia ; Australian New Zealand Intensive Care Research Centre , Melbourne, VIC , Australia ; Intensive Care Unit, The Alfred , Melbourne, VIC , Australia
| | - Maria Cristina Morganti-Kossmann
- Department of Epidemiology, Monash University , Melbourne, VIC , Australia ; Australian New Zealand Intensive Care Research Centre , Melbourne, VIC , Australia ; Department of Child Health, Barrow Neurological Institute, University of Arizona , Phoenix, AZ , USA
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