Predictors and indicators of academic outcome in children 2 years following traumatic brain injury

Within the context of a longitudinal study investigating outcome for children following traumatic brain injury, this paper reports on the utility of neuropsychological testing in predicting academic outcome in children 2 years following traumatic brain injury (TBI). Twenty-nine school-age children who were admitted to hospital after TBI were assessed with a battery of neuropsychological and academic measures at 3 and 24 months postinjury. The neuropsychological battery included measures of memory, learning, and speed of information processing. Academic outcome was assessed in terms of post-TBI change in school placement. According to logistic regression analysis, change in placement from regular to special education at 2 years post-TBI was predicted by injury severity and by neuropsychological performance at 3 months post-TBI. Findings suggest that neuropsychological testing is useful in identifying children with special educational needs subsequent to TBI.     

Personality and functional outcome following traumatic brain injury.

Objective: To investigate pre- to postinjury personality change in relation to outcomes following traumatic brain injury (TBI). Design: Prospective analysis of personality ratings, depression, and outcome using multiple regression analyses. Participants: Cohort of 3 clinical trauma groups (mild TBI, moderate-severe TBI, orthopedic injury) and their significant others (SO). Outcome Measures: Independent Living Scale, Vocational Independence Scale, and Mayo-Portland Adaptability Inventory, 1-2 years postinjury. Predictor Variables: Posttraumatic amnesia (PTA); patient and SO NEO Personality Inventory-Revised ratings of preinjury personality taken at 1-2 months postinjury. Results: Personality function was normal for all groups (regardless of rating source) and stable over time. Neuroticism, and specifically depression, accounted for small proportions of variance in functional outcome, beyond PTA. Conclusions: There is little empirical evidence for significant personality disturbance or change up to 2 years post-TBI. Personality and depression contribute modestly to functional outcomes. Results support a distinction between "personality change" and behavior change following TBI. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Trajectories of life satisfaction in the first 5 years following traumatic brain injury.

Objectives: The trajectories of life satisfaction for 609 individuals who sustained a traumatic brain injury (TBI) were studied. Hierarchical linear modeling analysis examined individual level growth trends over the first 5 years following TBI using gender, functional independence, age, and time to estimate life satisfaction trajectories. Measures: Participants completed the Functional Independence Measure and the Life Satisfaction Inventory at years 1, 2, 4, and 5 after sustaining TBI. Results: Participants who reported higher functional independence at year 1 also had higher life satisfaction at year 1. Participants with lower functional independence across the 5-year period had life satisfaction trajectories that decreased at significantly greater rates than the individuals with more functional independence. The life satisfaction trajectory declined for the sample, but participants reporting lower cognitive and motor functional independence had significantly greater declines in life satisfaction trajectories. Age and gender were not significant factors in predicting life satisfaction trajectories following TBI. Implications: Individuals with greater cognitive and motor impairments following TBI are likely to experience significant declines in life satisfaction within 5 years of living with TBI. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Newborn surgical emergencies. Congenital diaphragmatic hernia and extracorporeal membrane oxygenation

Bochdalek hernia is a posterolateral defect in the embryogenesis of the diaphragm. Abdominal contents enter the thorax during fetal development and result in pulmonary hypoplasia. A cause of respiratory distress in the newborn, the management of this disease has undergone dramatic changes. The defect requires surgical repair, but success depends more on preoperative and postoperative management of the associated physiologic derangements.     

Cognitive functioning ten years following traumatic brain injury and rehabilitation.

Many previous studies investigating long-term cognitive impairments following traumatic brain injury (TBI) have focused on extremely severely injured patients, relied on subjective reports of change and failed to use demographically relevant control data. The aim of this study was to investigate cognitive impairments 10 years following TBI and their association with injury severity. Sixty TBI and 43 control participants were assessed on tests of attention, processing speed, memory, and executive function. The TBI group demonstrated significant cognitive impairment on measures of processing speed (Symbol Digit Modalities Test [SDMT], Smith, 1973; Digit Symbol Coding, Wechsler, 1997), memory (Rey Auditory Verbal Learning Test [RAVLT]; Rey, 1958; Lezak, 1976), Doors and People tests; Baddeley, Emslie & Nimmo-Smith, 1994) and executive function (Hayling C [Burgess & Shallice, 1997] and SART errors, Robertson, Manly, Andrade, Baddeley & Yiend, 1997). Logistic Regression analyses indicated that the SDMT, Rey AVLT and Hayling C and SART errors most strongly differentiated the groups in the domains of attention/processing speed, memory and executive function, respectively. Greater injury severity was significantly correlated with poorer test performances across all domains. This study shows that cognitive impairments are present many years following TBI and are associated with injury severity. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Utility of daily head ultrasonography for infants on extracorporeal membrane oxygenation

BACKGROUND/PURPOSE: Intracranial hemorrhage (ICH) is a major concern during extracorporeal membrane oxygenation (ECMO). Daily cranial ultrasonography has been used by many ECMO centers as a diagnostic tool for both detecting and following ICH while infants are on bypass. The purpose of this patient review was to look at the usefulness of performing daily cranial ultrasonography (HUS) in infants on ECMO in detecting intraventricular hemorrhage of a magnitude sufficient to alter patient treatment. METHODS: The authors reviewed retrospectively all of the records of all neonates treated with ECMO at the Hermann Children's Hospital, Wilford Hall USAF Medical Center, Cincinnati Children's Hospital, The University of Texas Medical Branch at Galveston, and Texas Children's Hospital between February 1986 to March 1995. Two hundred ninety-eight patients were placed on ECMO during this period. All patients had HUS before, and daily while on ECMO, and all were reviewed by the staff radiologists. A total of 2,518 HUS examinations were performed. RESULTS: Fifty-two of 298 patients (17.5%) had an intraventricular hemorrhage seen on ultrasound scan. Nine of 52 patients (17.3%) had an ICH seen on the initial HUS examination before ECMO, all of which were grade I, and 43 of 52 patients (82.7%) had ICH while on ECMO. Of these ICH, 15 were grade I, 10 were grade II, 10 were grade III, and eight were grade IV. Forty of these ICH (93%) were diagnosed by HUS during the first 5 days of the ECMO course. Seven hundred eighty-six HUS were performed after day 5, at an estimated cost of $300,000 to $450,000 (charges), demonstrating three new intraventricular hemorrhages, one grade I, and one grade IV on day 7 and one grade I on day 8. Eight patients were taken off ECMO because of ICH diagnosed within the first 5 days. One patient was taken off ECMO because of ICH diagnosed after 5 days. This patient had clinical symptoms suggestive of ICH. CONCLUSIONS: Almost all ICH occur during the first 5 days of an ECMO course. Unless there is a clinical suspicion, it is not cost effective to perform HUS after the fifth day on ECMO, because subsequent HUS examinations are unlikely to yield information significant enough to alter management.     

Usefulness of extracorporeal membrane oxygenation for treatment of fulminant myocarditis and circulatory collapse

Prognosis for fulminant myocarditis with cardiogenic shock refractory to conventional therapy is poor. This report describes mechanical circulatory support with extracorporeal membrane oxygenation as an effective alternative for treating fulminant myocarditis with circulatory collapse.     

Cerebral blood flow as a predictor of outcome following traumatic brain injury

As part of a prospective study of the cerebrovascular effects of head injury, 54 moderate and severely injured patients underwent 184 133Xe-cerebral blood flow (CBF) studies to determine the relationship between the period of maximum blood flow and outcome. The lowest blood flows were observed on the day of injury (Day 0) and the highest CBFs were documented on postinjury Days 1 to 5. Patients were divided into three groups based on CBF values obtained during this period of maximum flow: Group 1 (seven patients), CBF less than 33 ml/100 g/minute on all determinations; Group 2 (13 patients), CBF both less than and greater than or equal to 33 ml/100 g/minute; and Group 3 (34 patients), CBF greater than or equal to 33 ml/100 g/minute on all measurements. For Groups 1, 2, and 3, mean CBF during Days 1 to 5 postinjury was 25.7 +/- 4, 36.5 +/- 4.2, and 49.4 +/- 9.3 ml/100 g/minute, respectively, and PaCO2 at the time of the CBF study was 31.4 +/- 6, 32.7 +/- 2.9, and 33.4 +/- 4.7 mm Hg, respectively. There were significant differences across Groups 1, 2, and 3 regarding mean age, percentage of individuals younger than 35 years of age (42.9%, 23.1%, and 76.5%, respectively), incidence of patients requiring evacuation of intradural hematomas (57.1%, 38.5%, and 17.6%, respectively) and incidence of abnormal pupils (57.1%, 61.5%, and 32.4%, respectively). Favorable neurological outcome at 6 months postinjury in Groups 1, 2, and 3 was 0%, 46.2%, and 58.8%, respectively (p < 0.05). Further analysis of patients in Group 3 revealed that of 14 with poor outcomes, six had one or more episodes of hyperemia-associated intracranial hypertension (simultaneous CBF > 55 ml/100 g/minute and ICP > 20 mm Hg). These six patients were unique in having the highest CBFs for postinjury Days 1 to 5 (mean 59.8 ml/100 g/minute) and the most severe degree of intracranial hypertension and reduced cerebral perfusion pressure (p < 0.0001). These results indicate that a phasic elevation in CBF acutely after head injury is a necessary condition for achieving functional recovery. It is postulated that for the majority of patients, this rise in blood flow results from an increase in metabolic demands in the setting of intact vasoreactivity. In a minority of individuals, however, the constellation of supranormal CBF, severe intracranial hypertension, and poor outcome indicates a state of grossly impaired vasoreactivity with uncoupling between blood flow and metabolism.     

Maternal and neonatal outcome following prolonged labor induction

Early diagnosis of invasive group A beta streptococcal (GABS) infection has been achieved in a patient using magnetic resonance imaging (MRI) complemented by needle aspiration. Life-saving treatments of GABS infection that include immediate surgical debridement along with the administration of i.v. antibiotics, gamma globulin, and hyperbaric oxygen were then implemented successfully to prevent the development of streptococcal toxic shock syndrome. While MRI is valuable in making early diagnosis of GABS, it should not delay surgical intervention.     

Neurodevelopmental outcome in very low birth weight infants at 24 months and 5 to 7 years of age: changing diagnosis

The purpose of this study was to evaluate the importance of root canal therapy in the healing process of severe intrabony defects. Four beagle dogs were used and 32 interproximal intrabony defects, up to the apical third, were created. Wire ligatures were placed into these defects for plaque accumulation. Three weeks later, the ligatures were removed and 4 different treatment modalities were employed: group 1) scaling and root planing (SRP); group 2) modified Widman flap (MWF); group 3) modified Widman flap and root canal therapy performed at the same time (RCT/MWF); and group 4) modified Widman flap and root canal therapy performed 3 weeks after the surgical procedure (MWF + RCT). Postoperative oral hygiene was obtained by spraying a 0.12% chlorhexidine solution 3 times a week. The animals were sacrificed 7 weeks after treatment. Blocks were obtained and processed for routine histology. Results were expressed as a percentage of the total defect length (TDL). No differences were observed when SRP was compared to MWF. New bone formation (BF) presented better results for SRP (43.4%) and MWF (53.4%) when compared to RCT/MWF (15.5%). New cementum formation (CF) presented better results for SRP (59.8%) and MWF (64.6%) when compared to RCT/MWF (19.3%) and MWF + RCT (31.5%). Connective tissue repair (CTR) presented better results for SRP (72.4%) and MWF (74.2%) when compared to RCT/MWF (47.5%) and MWF + RCT (44.4%). Results were statistically significant at the level of 0.05. Within the limits of this study, it was concluded that root canal therapy performed simultaneously or 3 weeks after surgery modified the healing of intrabony defects, impairing new bone formation, new cementum formation and new attachment.     

Visual outcome at 5 years of newborn infants at risk of cerebral visual impairment

Among some 7500 respondents with known place of birth who had completed a nationwide questionnaire survey for multiple sclerosis (MS) in France in 1986, there were 260 born in former French North Africa (Algeria, Morocco, Tunisia). They had migrated to France between 1923 and 1986, but 66% came between 1956 and 1964. Two-thirds were from Algeria, where virtually the entire European population had emigrated in 1962 at the end of the Algerian war for independence. The migrants were younger at prevalence day (mean 43.4 years) and at onset (29.4 years) than the French-born MS (46.6; 31.3 years). Eight migrants lacked age information. The 225 migrants with onset more than 1 year after immigration presumably acquired their MS in France. They provided an age adjusted (US 1960) MS prevalence rate 1.54 times that for all France. If the latter is taken at 50 per 100,000 population their estimated adjusted rate is 76.8 with 95% confidence interval of 67.1 to 87.5. The other 27 with presumed acquisition in North Africa gave an estimated adjusted prevalence of 16.6 per 100,000 (95% CI 10.9-24.1). For those migrants with acquisition in France there was a mean interval of 13 years between immigration or age 11 and clinical onset, with a minimum of 3 years. This series provides further support for the theses: 1) that MS is primarily an environmental disease acquired after childhood; 2) that acquisition requires prolonged or repeated exposure (here 3 years for these medium-to-high MS risk migrants) followed by a prolonged latent or incubation period between acquisition and symptom onset (here 10 years); and 3) that this disease is most likely a widespread but unknown persistent infection which results in clinical MS in only a small proportion of those affected.     

Neuromotor and cognitive development of high-risk newborn infants at 5 years of age

A group of 5-year-old children bearing a perinatal neurological risk is divided into subgroups according to the specific courses of their neuromotoric development. Then comparison is made between two of the subgroups consisting of children with a favourable neuromotoric development at the age of 5 and a control-group of healthy born children with regard to the neuromotoric as well as the cognitive development. As a result the children of the two subgroups, whose neuromotoric development in the age of five was comparable to that of the control group, showed a significantly lower performance on a concentration test than those of the control group. Additionally there is also a deficiency within the scope of verbal competence, whereas the level of the performance IQ of the children with perinatal neurological risk is quite comparable with that of the children of the control group.     

Caregiver burden at 6 months following severe traumatic brain injury

We compared the performance of three computer based classification methods when applied to the problem of detecting microaneurysms on digitised angiographic images of the retina. An automated image processing system segmented 'candidate' objects (microaneurysms or spurious objects), and produced a list of features on each candidate for use by the classifiers. We compared an empirically derived rule based system with two automated methods, linear discriminant analysis and a learning vector quantiser artificial neural network, to classify the objects as microaneurysms or otherwise. ROC analysis shows that the rule based system gave a higher performance than the other methods (p = 0.92) although a much greater development time is required.     

Relation of deranged neonatal cerebral oxidative metabolism with neurodevelopmental outcome and head circumference at 4 years

Cerebral oxidative metabolism was studied using phosphorus magnetic resonance spectroscopy during the first week of life and neurodevelopmental outcome was assessed at 4 years in 62 infants who had clinical and/or biochemical evidence consistent with birth asphyxia (critically impaired intrapartum gas exchange). Twenty-one died and the neurodevelopmental status of the 41 who survived was assessed by a range of tests at age 4 years. The minimum recorded values for the cerebral phosphocreatine:inorganic phosphate concentration ratio (an index of oxidative metabolism) were related to outcome. The results showed significant relations between the extent of derangement of neonatal oxidative metabolism and a range of adverse outcomes, including death, and at 4 years reduced head growth and the presence and severity of neuromotor impairments, overall neurodevelopmental impairments, and cognitive functioning. Strong correlations between the extent of derangement of neonatal oxidative metabolism and outcome at 1 and 4 years were also shown. We conclude that the severities of adverse outcomes at 1 and 4 years of age were closely related to the extent of cerebral energy derangement in the first week of life, and we also conclude that primary intrapartum hypoxic-ischaemic cerebral injury was generally responsible for the events that led to death, microcephaly, and impaired     

Patients with traumatic brain injury referred to a rehabilitation and re-employment programme: social and professional outcome for 508 Finnish patients 5 or more years after injury

We studied influence of age and educational level before injury on the social and vocational outcome among a group of traumatic brain injury (TBI) patients with post-injury problems in their education and employment. Patients with TBI, followed up for at least 5 years, and who were admitted to a rehabilitation and re-employment programme, were selected for evaluation of long-term outcome. We used the Glasgow Coma Scale (GCS) scores at the time of emergency admission to the hospital to measure brain injury severity. Age at the time of TBI and educational status before TBI were correlated with the outcome measures at the end of follow-up separately in each category of brain injury severity. The study was carried out at the Kauniala outpatient neurological clinic, which specializes in brain injuries in Finland; it works closely with the Departments of Neurology and Neurosurgery at the Helsinki University Central Hospital. Main outcome measures were functional outcome measured by the Glasgow Outcome Scale (GOS), the educational level reached, and post-injury occupation, as well as the incapacity for work at the end of follow-up. In the severe category of brain injuries, children 7 years or younger at the time of injury suffered severe disability as measured by the GOS scores more often than did the older age groups (p = 0.010, chi 2). They were less often capable of independent employment (p = 0.011, chi 2) than the children injured at the age of 8-16. Patients with a higher education usually had a better outcome. In the category of mild brain injuries the majority of the patients, regardless of age, recovered well according to the GOS, and were capable of independent employment at the end of follow-up. Our patients were selected from the TBI population as survivors with problems in education and re-employment. Those with severe injury sustained early in life (childhood and early teens) coupled with poor educational attainment had relatively worse social and vocational outcome; better outcomes were enjoyed by those severely injured individuals whose injuries were sustained later (late teens or early adulthood). In the groups of patients with moderate and mild brain injuries such a relationship was not found between age or pre-injury education and outcome.     

Evaluation of an extracorporeal membrane oxygenation system using a nonporous membrane oxygenator and a new method for heparin coating

A new heparin binding method was applied to a miniature extracorporeal membrane oxygenation (ECMO) system with a nonporous membrane oxygenator (the priming volume, 45 mL; the membrane surface area, 0.4 m2; maximal flow rate, 2 L/min) that is resistant to plasma leakage. The authors evaluated the stability of the immobilized heparin in vitro and the feasibility of this system in animals. Samples of hollow fibers and tubing were rinsed at 40 degrees C for 4 days in normal saline, Ringer's lactate, and 1 mol/L NaCl solution. Heparin activities on hollow fibers after rinsing were 99 +/- 2.3% (mean +/- SD), 96 +/- 3.9%, and 93 +/- 2.0% of the control in each solution, while those of the tubing were 87 +/- 4.1%, 86 +/- 3.1%, and 76 +/- 8.6%, respectively. Veno-arterial ECMO using this heparin-coated system was performed on five beagles (8 to 12 kg) for 10 hours. Neither major thrombus formation nor plasma leakage was detected during the procedure in spite of a low flow rate (300 mL/min) and a reduced activated clotting time (mean, 128 seconds). Platelets decreased to 52% of the control (P < .01) at 1 hour, but no progressive decrease was seen thereafter. Antithrombin-III decreased (P < .01) and thrombin/antithrombin III complex increased (P < .05 at 4 hours and P < .01 at 6, 8, and 10 hours) during bypass, but the changes of fibrinogen and fibrinopeptide A were not significant. Fibrinogen/fibrin degeneration products, fibrinopeptide B beta 15-42, and plasma-free hemoglobin levels did not rise significantly. O2 transfer of the oxygenators at a flow rate of 300 mL/min were 12.3 +/- 0.4 mL/min at 30 minutes, 14.3 +/- 1.2 mL/min at 5 hours, and 14.7 +/- 1.7 mL/min at 10 hours (no statistical difference). Histological examination of the brains and the kidneys showed no evidence of thromboembolic sequela in any of the animals. These results suggest that this new system is a promising device for long-term ECMO in which the amount of systemic heparinization can be reduced with the minimal possibility of plasma leakage.     

Traumatic brain injury in children and adolescents: psychiatric disorders at two years

OBJECTIVE: To extend findings regarding predictive factors of psychiatric outcome from the first to the second year after traumatic brain injury (TBI) in children and adolescents. METHOD: Subjects were children aged 6 to 14 years at the time they were hospitalized after TBI. The study used a prospective follow-up design. Assessments of preinjury psychiatric, behavioral, adaptive functioning, family functioning and family psychiatric history status were conducted. Severity of injury was assessed by standard clinical scales and neuroimaging was analyzed. The outcome measure was the presence of a psychiatric disorder, not present before the injury ("novel"), during the second year after TBI. RESULTS: Fifty subjects enrolled, and the analyses focused on 42 subjects followed at 24 months. Severity of injury, preinjury family function, and preinjury lifetime psychiatric history predicted the development of a "novel" psychiatric disorder present in the second year. CONCLUSION: These data suggest that there are children, identifiable through clinical assessment, at increased risk for "novel" psychiatric disorders in the second year after TBI.     

Prevalence of impairments 5 years after a head injury, and their relationship with disabilities and outcome

To determine what consequences cognitive, behavioural or somatic impairments had on disabilities and recovery after a head injury (HI), a population-based sample of 231 adult patients was studied 5 years after an HI. Eighty lower-limb-injured (LLI) patients were considered as controls. Sixty-four LLI and 176 HI patients were reviewed (114 minor, 35 moderate, and 27 severe HI). Prevalence values of headaches (44-54%), dizziness (26-37%), and anxiety (47-63%) were not significantly different in the three HI severity groups, but were significantly lower in patients with an isolated limb injury (12-15%). Memory problems and depressive mood increased with injury severity. Mental impairments were frequent in severe HI patients (18-40% of patients). In minor and moderate HI patients, most disabilities were related to associated injuries. According to the Glasgow Outcome Scale (GOS), recovery was not considered as good because of somatic, behavioural or cognitive complaints in 2.5%, 5.7% and 59.2% of surviving patients in each of the above HI groups. Somatic or behavioural complaints may have considerable consequences in some minor HI patients, and the long-term management of certain patients needs improvement because these impairments are misunderstood.