Are the subjective complaints of traumatically brain injured patients reliable?

The present study was designed to compare the subjective complaints of 50 traumatically brain injured (TBI) patients with the observations of their significant others. The complaints of the TBI patients and their significant others were contrasted according to the severity of the TBI and the type of complaint (physical, cognitive/behavioural and emotional). While no differences were found in physical complaints, the cognitive/behavioural and emotional complaints of TBI patients, regardless of the severity of the initial TBI, were significantly under-reported in comparison to the observations of their significant others. The data suggests that while this finding was most likely due to the TBI patients' poor awareness, it was unlikely to be the result of psychological denial since all of these individuals were evaluated in the context of being a plaintiff in personal injury litigation or a claimant in a Workers' Compensation claim. The data suggests that the cerebral trauma these patients sustained played a major role in their ability to recognize their cognitive, behavioural and emotional symptoms. Finally, the data suggests that clinicians should obtain information about the TBI patients' cognitive/behavioural and emotional functioning from their significant others, rather than rely entirely on the TBI patients' subjective assessment of these problems.     

Agreement between persons with traumatic brain injury and their relatives regarding psychosocial outcome using the Community Integration Questionnaire

Cerebral cavernous angiomas are congenital malformations usually presenting with symptomatic hemorrhages or seizures. The advent of MRI has allowed to detect asymptomatic, "cryptic" brain cavernomas. They can occur in a sporadic, isolated form and in a familial form characterized by multiple lesions. Surgical treatment is recommended by most authors in symptomatic cases when the lesion is isolated and readily accessible. Treatment is more controversial when the vascular malformation is located in critical brain region. On the other hand the increased risk of rebleeding after a prior hemorrhage and the decreased effectiveness of lesionectomy in patients with a long seizure history could lead to perform an early surgical excision also for cavernous angiomas located in those areas. We report three cases of symptomatic cerebral cavernomas located in critical areas, in children. In all cases the surgical removal of the lesions was successfully performed. The two cases presented with seizures are seizure-free in spite of the interruption of the antiepileptic therapy. The patient presented with neurological deficit due to intraparenchymal hemorrhage progressively recovered his motor function. Our experience seems to confirm the value of surgical removal regardless of where the cavernoma is located.     

Spontaneous long-term remyelination after traumatic spinal cord injury in rats

The capability of the central nervous system to remyelinate axons after a lesion has been well documented, even though it had been described as an abortive and incomplete process. At present there are no long-term morphometric studies to assess the spinal cord (S.C.) remyelinative capability. With the purpose to understand this phenomenon better, the S.C. of seven lesionless rats and the S.C. of 21 rats subjected to a severe weight-drop contusion injury were evaluated at 1, 2, 4, 6, and 12 months after injury. The axonal diameter and the myelination index (MI = axolemmal perimeter divided by myelinated fiber perimeter) were registered in the outer rim of the cord at T9 SC level using a transmission electron microscope and a digitizing computer system. The average myelinated fiber loss was 95.1%. One month after the SC, 64% of the surviving fibers were demyelinated while 12 months later, only 30% of the fibers had no myelin sheath. The MI in the control group was 0.72 +/- 0.07 (X +/- S.D.). In the experimental groups, the greatest demyelination was observed two months after the lesion (MI = 0.90 +/- 0.03), while the greatest myelination was observed 12 months after the injury (MI = 0.83 +/- 0.02). There was a statistical difference (p < 0.02) in MI between 2 and 12 months which means that remyelination had taken place. Remyelination was mainly achieved because of Schwann cells. The proportion of small fibers (diameter = 0.5 micron or less) considered as axon collaterals, increased from 18.45% at 1 month to 27.66% a year after the contusion. Results suggest that remyelination is not an abortive phenomenon but in fact a slow process occurring parallel to other tissue plastic phenomena, such as the emission of axon collaterals.     

Awareness of disability and long-term outcome after traumatic brain injury.

The degree of long-term (7.41 yrs postinjury) impairment of disability awareness was quantified in 63 adults (aged 18–45 yrs) with closed-head injuries as the difference between self-ratings and staff ratings on the Scales of Independent Behavior. Other measures included the Wechsler Adult Intelligence Scale--Revised (WAIS--R), the Wechsler Memory Test—Revised, the Wisconsin Card Sorting Test, and ratings of actual functional status based on classifications in vocational and independent living level. Impaired awareness and its relationship to actual level of present vocational and residential status, maladaptive behaviors, attention and freedom from distractibility, and a measure of frontal system functioning was examined. Impaired awareness was significantly associated with lower vocational and residential status, maladaptive behavior, greater distractibility, and increased perseveration. Impaired awareness is directly proportional to duration of posttraumatic amnesia and general memory. Impaired awareness of disability appears to be a consequence of a general cognitive impairment rather than a specific deficit. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Creativity in manic-depressives, cyclothymes, their normal relatives, and control subjects.

Studies of creativity and affective illness typically focus on eminent individuals in specific fields. This is the first study to select subjects solely by diagnosis, and then evaluate their overall creative accomplishments. Seventeen manic-depressives, 16 cyclothymes, and 11 normal first-degree relatives were compared with 33 controls with no personal or family history of major affective disorder, cyclothymia, or schizophrenia; 15 controls were normal and 18 carried another diagnosis. Peak creativity was assessed by raters blind to subjects' diagnosis with the use of the Lifetime Creativity Scales. Orthogonal contrasts showed (a) creativity to be significantly higher among the combined index subjects (manic-depressives, cyclothymes, and normal relatives) than among controls (p?p?     

Spontaneous and traumatic vitreous hemorrhage

PURPOSE: The authors sought to provide relevant data regarding the demographic and clinical aspects of spontaneous and traumatic vitreous hemorrhages to guide clinicians in better delineating the expected etiologic patterns of these hemorrhages in an urban environment. METHODS: The records of 253 consecutive patients with newly diagnosed vitreous hemorrhage seen in a general eye clinic were selected for retrospective analysis. To minimize selection bias of a tertiary care center, patients who were referred to the clinic by outside ophthalmologists for vitreoretinal consultation or those with a history of recent intraocular surgery, postoperative complications, or loss to follow-up were excluded from study. Demographic, ocular, and general medical variables were tabulated for the 200 patients (230 eyes) who met our inclusion criteria. RESULTS: Fifty percent of the patients were black, 26% were white, 23% were Hispanic, and 1% was Oriental. The causes of vitreous hemorrhage were proliferative diabetic retinopathy (PDR) (35.2%), trauma (18.3%), retinal vein occlusion (7.4%), retinal tear without a detachment (7.0%), posterior vitreous detachment (6.5%), proliferative sickle retinopathy (5.7%), retinal tear with a detachment (4.8%), subretinal neovascularization from macular degeneration (2.2%), hypertensive retinopathy (1.7%), unknown (2.5%), and other causes (8.7%). Among black patients with spontaneous vitreous hemorrhage, sickle cell retinopathy and retinal vein occlusion were major causes, each accounting for more than 15% of the cases. Systemic hypertension was associated with vitreous hemorrhage from retinal vein occlusion. CONCLUSION: The authors propose that despite the wide array of causative factors of vitreous hemorrhage, the evaluation of demographic, ocular, and medical variables can significantly aid clinicians in identifying its etiologic patterns.     

Impact of age on long-term cognitive function after traumatic brain injury.

Objective: To examine the association of age and time postinjury with cognitive outcome 5–22 years following traumatic brain injury (TBI), in relation to matched uninjured controls. Methods: One hundred twelve participants with mild to very severe TBI, aged 16–81 years at the time of injury, were cognitively assessed on measures of processing speed and attention, verbal and visual memory, executive function, and working memory. Results were compared with those of 112 healthy controls individually matched for current age, gender, education, and estimated IQ. Results: Older injured individuals performed worse than did younger injured individuals across all cognitive domains, after controlling for the performance of controls. In relation to matched controls, long-time survivors performed disproportionately worse than did more recently injured individuals, irrespective of age. Conclusions: After maximum spontaneous recovery from TBI, poorer cognitive functioning appears to be associated with both older age at the time of injury and increased time postinjury. These findings have implications for prognosis, early treatment recommendations, and long-term issues of differential diagnosis and management planning. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

A prospective study of short- and long-term neuropsychological outcomes after traumatic brain injury in children.

Longitudinal neuropsychological outcomes of traumatic brain injury (TBI) were investigated in 53 children with severe TBI, 56 children with moderate TBI, and 80 children with orthopedic injuries only. Neuropsychological functioning was assessed at baseline, at 6- and 12-month follow-ups, and at an extended follow-up (a mean of 4 years postinjury). Mixed model analyses revealed persistent neuropsychological sequelae of TBI that generally did not vary as a function of time postinjury. Some recovery occurred during the first year postinjury, but recovery reached a plateau after that time, and deficits were still apparent at the extended follow-up. Further recovery was uncommon after the first year postinjury. Family factors did not moderate neuropsychological outcomes, despite their demonstrated influence on behavior and academic achievement after childhood TBI. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

The families of problem drug users: a study of 50 close relatives

The research described in this paper resulted from a collaborative multi-centre study of the relatives of problem drug users involving six practitioners and researchers, in four centres within the south-west of England. The objective of this research was simply to interview 50 close relatives of identified problem drug users, with the identification occurring through clinics and self-help groups. Quantitative and qualitative results show that large numbers of these relatives reported many negative experiences. The partners of illicit drug users reported both more and differently patterned problematic behaviours than those of prescribed tranquillizer users. The partners of illicit users also reported different problems to those of the parents. Relatives reported many negative effects in terms of how they viewed the drug user, and how the experiences had affected their health. They also described various coping mechanisms, and the extent of the support which they had received. The results are discussed in terms of coping, and similarity with research into the families of problem drinkers.     

Acute and long-term outcomes of extremely injured blunt trauma victims

Long-term outcomes after blunt trauma remain poorly defined. The purpose of this study was to document such outcomes in extremely injured adults (Injury Severity Score > or = 50). From April 1990 to June 1993, 76 patients (5% of all trauma victims) had an ISS > or = 50 at a single trauma center. Thirty-five (46%) survived to hospital discharge. The mean duration of hospital stay was longer for survivors than for nonsurvivors (92 days versus 16 days, p < 0.001). Of the 35 survivors, 26% were discharged directly home, 60% to a rehabilitation hospital, 8% to a chronic care facility, and 6% to an acute care hospital. After a mean follow-up of 27 months, 6% had died, 9% refused participation, and the remaining 30 patients (91% of long-term survivors) demonstrated significant residual disabilities in physical, emotional, and mental health status. We suggest that extremely injured patients comprise a small proportion of blunt trauma victims, consume substantial acute care hospital resources, often survive, and yet frequently have residual disability. A reduction in this long-term disability may represent the greatest challenge in modern trauma care.     

Stressors in the primary caregivers of traumatic head injured persons

This study was designed to identify the intrapersonal, interpersonal and extrapersonal stressors of primary caregivers caring for a traumatic-head-injured person. Betty Neuman's (1989) theoretical model provides a conceptual framework for studying the relationship between stressors and the changing stress level of primary caregivers caring for a traumatic-head-injured person. The Appraisal Caregiving Scale and the Burden Interview were administered to 23 caregivers. Intrapersonal, interpersonal and extrapersonal stressors are identified. Caregivers differed in the changing stress level they experienced. Positive correlations were found between the intrapersonal stressors and the changing stress level and the interpersonal stressors and the changing stress level.     

A prospective study of short- and long-term outcomes after traumatic brain injury in children: Behavior and achievement.

Longitudinal behavior and achievement outcomes of traumatic brain injury (TBI) were investigated in 53 children with severe TBI, 56 children with moderate TBI, and 80 children with orthopedic injuries not involving brain insult. Measures of preinjury child and family status and of postinjury achievement skills were administered shortly after injury. Assessments were repeated 3 times across a mean follow-up interval of 4 years. Results from mixed model analysis revealed persisting sequelae of TBI. Recovery of math skills was observed in the severe TBI group but only for children from less stressed families. Social disadvantage in children with TBI predicted more adverse behavioral sequelae and less favorable changes in some outcome measures. The findings suggest that pediatric TBI has long-term effects on behavior and achievement but that postinjury progress is influenced by the family environment. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Spontaneous disappearance of traumatic macular holes in young patients

PURPOSE: To report the disappearance of traumatic macular hole in three eyes of three patients. METHODS: Clinical data of the patients were reviewed. RESULTS: The three patients were relatively young, ranging in age from 12 to 18 years old. In one eye of each patient, a small traumatic macular hole was observed at the first visit. Visual acuities ranged from 20/100 to 20/40. The macular holes resolved spontaneously 3 to 4 months after the trauma, and final visual acuity improved to 20/20 in all patients. CONCLUSION: Small traumatic macular holes in young patients can resolve spontaneously, and this can be associated with good visual recovery.     

Pituitary autoantibodies in patients with hypopituitarism and their relatives

In order to investigate the physiological role of calcitonin gene-related peptide (CGRP) in mollusc, both circulating CGRP-related molecules and gill or mantle carbonic anhydrase activity were analysed during the annual growth of Pecten maximus. CGRP like molecules measured by radioreceptor assay increased significantly during the annual cycle. Similarly, gill carbonic anhydrase activity increased and showed a maximum activity when growth is stimulated to the greatest extent. Correlation studies showed a significant relationship between the tissue weight and either the gill carbonic anhydrase activity or the CGRP-related molecules determined by radioreceptorassay. This observation suggests a possible interaction between carbonic anhydrase activity and CGRP. Accordingly, we searched for a direct effect of CGRP on the gill carbonic anhydrase activity. In gill membranes, CGRP stimulated the carbonic anhydrase activity. The maximum effect was obtained at a CGRP concentration of 50 nM.     

Subjective cognitive complaints and longitudinal changes in memory and brain function.

Objective: Subjective cognitive complaints are often used in the diagnosis of memory and other cognitive impairment. This study examined whether cognitive complaints are associated with longitudinal changes in cognition and cross-sectional differences in regional brain function during memory performance in 98 participants with a mean age of 75. Method: The Cognitive Failures Questionnaire (CFQ) assessed cognitive complaints and mixed effects regression models were used to determine whether mean CFQ scores predicted rates of change in cognitive function over a period of 11.5 years. Results: Higher CFQ scores, reflecting increased subjective complaints, were associated with steeper rates of decline in immediate and delayed recall on the California Verbal Learning Test. Voxel-based regression analysis was used to determine the cross-sectional relationship between CFQ scores and regional cerebral blood flow measured by PET during a resting condition and during verbal and figural memory tasks. Higher levels of cognitive complaints were associated with increased activity in insular, lingual and cerebellar areas during memory tasks. Conclusions: These findings offer some support for the validity of subjective cognitive complaints as markers of age related changes in memory and brain activity. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Quality of life 10 years after a very severe traumatic brain injury (TBI): the perspective of the injured and the closest relative

This study is a further follow-up of a group of 15 very severely injured TBI patients who have earlier been followed-up 5 years after the injury, and their closest relatives. The aim of this study was to evaluate the factors related to the quality of life of the injured and the strain felt by the relatives. The information was gathered by questionnaires for the injured and the relative and clinical ratings based on the observations of a clinician. The self-reported quality of life of both the injured and their closest relatives was rather high in spite of the various physical, cognitive and emotional/behavioral disturbances. However, the strain felt by many of the relatives was still high 10 years after the injury although it had decreased over the years. The neurobehavioral and emotional disturbances had the most significant effect on the quality of life of the injured and strain felt by the relative. The relationship between the quality of life of the injured and strain felt by the relative was not linear. The implications of the findings for developing different forms of rehabilitation and support systems is discussed.     

The management of severe traumatic brain injury

An approach to the initial evaluation, resuscitation, and treatment of the patient with severe traumatic brain injury is presented in terms of the underlying physiology and literature support. The primary importance of rapid and complete systemic resuscitation in terms of the "ABCs" is stressed, with the goal of optimizing cerebral perfusion and preventing secondary insults to the injured brain. The integration of brain-specific treatments and diagnostic maneuvers into resuscitation protocols is discussed, including the role of mannitol and hyperventilation as well as the prioritization of CT imaging of the brain.