Catharina Nygren-de Boussard

Systematic review of the prognosis after mild traumatic brain injury in adults: cognitive, psychiatric, and mortality outcomes: results of the International Collaboration on Mild Traumatic Brain Injury Prognosis.

OBJECTIVE To synthesize the best available evidence on objective outcomes after adult mild traumatic brain injury (MTBI). DATA SOURCES MEDLINE and other databases were searched (2001-2012) for studies related to MTBI. Inclusion criteria included published, peer-reviewed articles in English and other languages. References were also identified from the bibliographies of eligible articles. STUDY SELECTION Randomized controlled trials and cohort and case-control studies were selected according to predefined criteria. Studies had to have a minimum of 30 MTBI cases and assess objective outcomes in adults. DATA EXTRACTION Eligible studies were critically appraised using a modification of the Scottish Intercollegiate Guidelines Network (SIGN) criteria. Two reviewers independently reviewed each study and extracted data from accepted articles into evidence tables. DATA SYNTHESIS Evidence was synthesized qualitatively according to modified SIGN criteria, and studies were categorized as exploratory or confirmatory based on the strength of their design and evidence. After 77,914 records were screened, 299 were found to be relevant and critically reviewed, and 101 were deemed scientifically admissible. Of these, 21 studies that were related to the objective outcomes form the basis of this review. Most evidence indicates the presence of cognitive deficits in the first 2 weeks post-MTBI, and some evidence suggests that complete recovery may take 6 months or a year. A small number of studies indicate that MTBI increases the risk of psychiatric illnesses and suicide. CONCLUSIONS Early cognitive deficits are common, and complete recovery may be prolonged. Conclusions about mortality post-MTBI are limited. This review has implications for expected recovery after MTBI and MTBI-related health sequelae. Well-designed confirmatory studies are needed to understand the medium- to long-term consequences of MTBI and to further evaluate the effect of prior MTBI and injury severity on recovery.

Systematic Review of Self-Reported Prognosis in Adults After Mild Traumatic Brain Injury: Results of the International Collaboration on Mild Traumatic Brain Injury Prognosis

OBJECTIVE To update the mild traumatic brain injury (MTBI) prognosis review published by the World Health Organization Task Force in 2004. DATA SOURCES MEDLINE, PsycINFO, Embase, CINAHL, and SPORTDiscus were searched from 2001 to 2012. We included published, peer-reviewed studies with more than 30 adult cases. STUDY SELECTION Controlled trials and cohort and case-control studies were selected according to predefined criteria. Studies had to assess subjective, self-reported outcomes. After 77,914 titles and abstracts were screened, 299 articles were eligible and reviewed for scientific quality. This includes 3 original International Collaboration on MTBI Prognosis (ICoMP) research studies. DATA EXTRACTION Eligible studies were critically appraised using the Scottish Intercollegiate Guidelines Network criteria. Two reviewers independently reviewed each study and tabled data from accepted articles. A third reviewer was consulted for disagreements. DATA SYNTHESIS Evidence from accepted studies was synthesized qualitatively into key findings, and prognostic information was prioritized according to design as exploratory or confirmatory. Of 299 reviewed studies, 101 (34%) were accepted and form our evidence base of prognostic studies. Of these, 23 addressed self-reported outcomes in adults, including 2 of the 3 original ICoMP research studies. These studies show that common postconcussion symptoms are not specific to MTBI/concussion and occur after other injuries as well. Poor recovery after MTBI is associated with poorer premorbid mental and physical health status and with more injury-related stress. Most recover over 1 year, but persistent symptoms are more likely in those with more acute symptoms and more emotional stress. CONCLUSIONS Common subjective symptoms after MTBI are not necessarily caused by brain injury per se, but they can be persistent in some patients. Those with more initial complaints and psychological distress recover slower. We need more high-quality research on these issues.

Methodological issues and research recommendations for prognosis after mild traumatic brain injury: results of the International Collaboration on Mild Traumatic Brain Injury Prognosis.

The International Collaboration on Mild Traumatic Brain Injury (MTBI) Prognosis performed a comprehensive search and critical review of the literature from 2001 to 2012 to update the 2002 best-evidence synthesis conducted by the World Health Organization Collaborating Centre for Neurotrauma, Prevention, Management and Rehabilitation Task Force on the prognosis of MTBI. Of 299 relevant studies, 101 were accepted as scientifically admissible. The methodological quality of the research literature on MTBI prognosis has not improved since the 2002 Task Force report. There are still many methodological concerns and knowledge gaps in the literature. Here we report and make recommendations on how to avoid methodological flaws found in prognostic studies of MTBI. Additionally, we discuss issues of MTBI definition and identify topic areas in need of further research to advance the understanding of prognosis after MTBI. Priority research areas include but are not limited to the use of confirmatory designs, studies of measurement validity, focus on the elderly, attention to litigation/compensation issues, the development of validated clinical prediction rules, the use of MTBI populations other than hospital admissions, continued research on the effects of repeated concussions, longer follow-up times with more measurement periods in longitudinal studies, an assessment of the differences between adults and children, and an account for reverse causality and differential recall bias. Well-conducted studies in these areas will aid our understanding of MTBI prognosis and assist clinicians in educating and treating their patients with MTBI.

Evidence of diffuse noxious inhibitory controls (DNIC) elicited by cold noxious stimulation in patients with provoked vestibulodynia

Abstract Provoked vestibulodynia is a common cause of superficial dyspareunia in young women. Recent evidence has pointed out the importance of studying endogenous pain modulation in these women. An impairment of diffuse noxious inhibitory controls (DNIC) has been suggested in chronic pain conditions with a female predominance such as fibromyalgia and temporomandibular disorder. Our aim was to examine whether patients with provoked vestibulodynia and healthy women with or without combined oral contraceptives (COC) display a DNIC response to cold noxious stimulation. Twenty patients with provoked vestibulodynia not using COC, 20 healthy women on COC and 20 healthy women without COC were included and tested days 7–11 of their menstrual cycle. Pressure pain thresholds (PPTs) and pain ratings using VAS were measured on the arm and leg before and during a cold pressor test. A socio‐medical questionnaire, the Hospital and Anxiety Depression Scale and the Short Form‐36 were completed. The majority of the subjects in all three study groups significantly increased their PPTs during cold noxious stimulation indicating a DNIC response. The patients displayed lower PPTs compared to the healthy women. Depression, anxiety and bodily pain were more often reported by the patients. No differences related to the intake of COC were observed between the healthy women. In conclusion, women with provoked vestibulodynia as well as healthy women irrespective of COC status display a DNIC response indicating an endogenous pain inhibition. However, the results imply a systemic hypersensitivity in women with vestibulodynia with low general pain thresholds as compared to healthy women.

S100 and cognitive impairment after mild traumatic brain injury

OBJECTIVE The aim of this study was to explore the relationship between the proteins S100B and S100A1B and symptoms and signs of cognitive impairment for 3 months after mild traumatic brain injury (MTBI). METHODS Serum concentrations of S100A1B and S100B were examined in a prospective cohort study of patients with MTBI and a Glasgow Coma Scale score of 14 or 15. Cognitive performance was assessed by repeated computerized neuropsychological testing and an extended neuropsychological test. Symptoms were assessed using the Rivermead Post-Concussion Symptoms Questionnaire. RESULTS Concentrations of S100B and S100A1B were above cut-off in 31% and 48% respectively. Eight percent of the patients had signs of cognitive impairment according to the computerized neuropsychological tests and 30% according to the extended test. Symptoms of cognitive impairment were reported by 44% of the patients on the first day post-injury and by 26% at 3 months. No significant associations between S100B or S100A1B concentrations and symptoms or signs of cognitive impairment were found. CONCLUSION Abnormal S100 serum concentrations and symptoms or signs of cognitive impairment were not significantly associated in patients with MTBI and a Glasgow Coma Scale score of 14 or 15.

S100 in mild traumatic brain injury

Primary objectives: To examine the diagnostic value of S100 in mild traumatic brain injury (MTBI). Research design: Prospective cohort study. Methods and procedures: S100B, S100A1B and S100BB concentrations were examined in sera from patients with MTBI with an arrival Glasgow Coma Scale score of 15 or 14, patients with orthopaedic injuries and non-injured subjects. Main outcome and results: Mean values and proportions of subjects above cut-off limits for S100B and S100A1B were significantly higher in each trauma group than in non-injured controls, but only for S100A1B when patients with MTBI were compared with controls with orthopaedic injuries. Using a 97.5 percentile cut-off limit, the sensitivity of S100A1B for MTBI vs orthopaedic injury was 61% (95% confidence interval (CI) 49–73%), specificity 77% (95% CI 62–93%). The area under the ROC curve did not approach 0.9 for any cut off limit. Conclusions: Diagnostic validity of S100 in acute MTBI was not demonstrated. S100A1B has merits for long-term prognostic studies.

Cognitive reserve and persistent post-concussion symptoms—A prospective mild traumatic brain injury (mTBI) cohort study

Abstract Primary objective: Having three or more persisting (i.e. > 3 months) post-concussion symptoms (PCS) affects a significant number of patients after a mild traumatic brain injury (mTBI). A common complaint is cognitive deficits. However, several meta-analyses have found no evidence of long-term cognitive impairment in mTBI patients. The study sought to answer two questions: first, is there a difference in cognitive performance between PCS and recovered mTBI patients? Second, is lower cognitive reserve a risk factor for developing PCS? Research design: Prospective inception cohort study. Methods and procedure: One hundred and twenty-two adult patients were recruited from emergency departments within 24 hours of an mTBI. Three months post-injury, participants completed the Rivermead Post Concussion Symptoms Questionnaire and a neuropsychological assessment. A healthy control group (n = 35) were recruited. The estimate of cognitive reserve was based upon sub-test Information from Wechsler Adult Intelligence Scale and international classifications of educational level and occupational skill level. Main outcome and results: mTBI patients showed reduced memory performance. Patients with lower cognitive reserve were 4.14-times more likely to suffer from PCS. Conclusions: mTBI may be linked to subtle executive memory deficits. Lower cognitive reserve appears to be a risk factor for PCS and indicates individual vulnerabilities.

An investigation of attention, executive, and psychomotor aspects of cognitive fatigability

Objective: Self-perceived mental fatigue is a common presenting symptom in many neurological diseases. Discriminating objective fatigability from self-perceived mental fatigue might facilitate neuropsychological diagnosis and treatment programs. However clinically valid neuropsychological instruments suitable for assessment of fatigability are still lacking. The prime aim of the study was to investigate aspects of cognitive fatigability and to identify properties of neuropsychological tests suitable to assess fatigability in patients with persistent cognitive complaints after mild brain injury. Another aim was to investigate whether cognitive fatigability captured by neuropsychological measures is influenced by depression or sleep disturbances. Method: Twenty-four patients with persistent cognitive symptoms after mild traumatic brain injury (mTBI), (aged 18–51 years) and 31 healthy controls (aged 20–49 years) underwent neuropsychological testing measuring three cognitive fatigability domains: Attention fatigability was assessed using the Ruff 2 & 7 Selective Attention Test, executive fatigability using the Color Word Test (Stroop), and psychomotor fatigability using the Digit Symbol Substitution Test from the Wechsler Adult Intelligence Scale–Third Edition (WAIS–III). Subjective fatigue was measured using the Fatigue Severity Scale and a questionnaire of everyday consequences of fatigue. Depression was screened using the Hospital Anxiety and Depression Scale and sleep disturbances using the Pittsburgh Sleep Quality Index. Results: The patients reported significantly more mental fatigue and performed worse on tests of psychomotor and executive fatigability than the healthy controls. Furthermore, the cognitive fatigability measures were not influenced by depression or sleep disturbances, as was the case in self-reported fatigue. Conclusion: Tests demanding executive or simultaneous processing of several neuropsychological functions seem most sensitive in order to capture cognitive fatigability. Clinical tests that can capture fatigability enable a deeper understanding of how fatigability might contribute to cognitive complaints and problems in maintaining daily activities.

Cognitive Impairment after Severe Traumatic Brain Injury, Clinical Course and Impact on Outcome: A Swedish-Icelandic Study.

Objective. To assess the clinical course of cognitive and emotional impairments in patients with severe TBI (sTBI) from 3 weeks to 1 year after trauma and to study associations with outcomes at 1 year. Methods. Prospective, multicenter, observational study of sTBI in Sweden and Iceland. Patients aged 18–65 years with acute Glasgow Coma Scale 3–8 were assessed with the Barrow Neurological Institute Screen for Higher Cerebral Functions (BNIS) and the Hospital Anxiety and Depression Scale (HADS). Outcome measures were Glasgow Outcome Scale Extended (GOSE) and Rancho Los Amigos Cognitive Scale-Revised (RLAS-R). Results. Cognition was assessed with the BNIS assessed for 42 patients out of 100 at 3 weeks, 75 patients at 3 months, and 78 patients at 1 year. Cognition improved over time, especially from 3 weeks to 3 months. The BNIS subscales “orientation” and “visuospatial and visual problem solving” were associated with the GOSE and RLAS-R at 1 year. Conclusion. Cognition seemed to improve over time after sTBI and appeared to be rather stable from 3 months to 1 year. Since cognitive function was associated with outcomes, these results indicate that early screening of cognitive function could be of importance for rehabilitation planning in a clinical setting.

Resources and routines for nutritional assessment of patients with severe traumatic brain injury

OBJECTIVE To describe the resources and routines for nutritional management until 6 months after severe traumatic brain injury. METHODS Data collection was performed by use of questionnaires to staff professionals at three regional neurosurgical intensive and 75 other care units and a retrospective survey of medical and nursing records from 64 patients treated at these units. RESULTS Resources in terms of qualified staff members were reportedly good, while nutritional guidelines were adopted in less than half of the units. Screening for malnutrition at admission was rarely performed and the nutritional data in medical and nursing records were incomplete, i.e. there was a lack of body weight measurements in more than one-third of the care unit episodes and of body height data in more than half of the patients and a declining surveillance of energy intake when patients changed from parenteral or enteral nutrition to oral intake. Assessment of energy requirements relied on calculations and the assignment of who was to estimate it varied depending on which nutritional route was used and also between unit specialities. Finally, information on energy requirement, weight development and body mass index was present in only 16%, 7% and in 2% of the transferrals. CONCLUSIONS Despite good resources of qualified staff, the nutritional assessment routines were deficient, resulting in incomplete nutritional data and lost nutritional information.