Hilaire J. Thompson

Experimental models of traumatic brain injury: Do we really need to build a better mousetrap?

Approximately 4000 human beings experience a traumatic brain injury each day in the United States ranging in severity from mild to fatal. Improvements in initial management, surgical treatment, and neurointensive care have resulted in a better prognosis for traumatic brain injury patients but, to date, there is no available pharmaceutical treatment with proven efficacy, and prevention is the major protective strategy. Many patients are left with disabling changes in cognition, motor function, and personality. Over the past two decades, a number of experimental laboratories have attempted to develop novel and innovative ways to replicate, in animal models, the different aspects of this heterogenous clinical paradigm to better understand and treat patients after traumatic brain injury. Although several clinically-relevant but different experimental models have been developed to reproduce specific characteristics of human traumatic brain injury, its heterogeneity does not allow one single model to reproduce the entire spectrum of events that may occur. The use of these models has resulted in an increased understanding of the pathophysiology of traumatic brain injury, including changes in molecular and cellular pathways and neurobehavioral outcomes. This review provides an up-to-date and critical analysis of the existing models of traumatic brain injury with a view toward guiding and improving future research endeavors.

Traumatic Brain Injury in Older Adults: Epidemiology, Outcomes, and Future Implications

Traumatic brain injury (TBI) is a significant problem in older adults. In persons aged 65 and older, TBI is responsible for more than 80,000 emergency department visits each year; three‐quarters of these visits result in hospitalization as a result of the injury. Adults aged 75 and older have the highest rates of TBI‐related hospitalization and death. Falls are the leading cause of TBI for older adults (51%), and motor vehicle traffic crashes are second (9%). Older age is known to negatively influence outcome after TBI. Although geriatric and neurotrauma investigators have identified the prognostic significance of preadmission functional ability, comorbidities, sex, and other factors such as cerebral perfusion pressure on recovery after illness or injury, these variables remain understudied in older adults with TBI. In the absence of good clinical data, predicting outcomes and providing care in the older adult population with TBI remains problematic. To address this significant public health issue, a refocusing of research efforts on this population is justified to prevent TBI in the older adult and to discern unique care requirements to facilitate best patient outcomes.

Framing the evidence for health smart homes and home-based consumer health technologies as a public health intervention for independent aging: a systematic review.

INTRODUCTION There is a critical need for public health interventions to support the independence of older adults as the worlds population ages. Health smart homes (HSH) and home-based consumer health (HCH) technologies may play a role in these interventions. METHODS We conducted a systematic review of HSH and HCH literature from indexed repositories for health care and technology disciplines (e.g., MEDLINE, CINAHL, and IEEE Xplore) and classified included studies according to an evidence-based public health (EBPH) typology. RESULTS One thousand, six hundred and thirty-nine candidate articles were identified. Thirty-one studies from the years 1998-2011 were included. Twenty-one included studies were classified as emerging, 10 as promising and 3 as effective (first tier). CONCLUSION The majority of included studies were published in the period beginning in the year 2005. All 3 effective (first tier) studies and 9 of 10 of promising studies were published during this period. Almost all studies included an activity sensing component and most of them used passive infrared motion sensors. The three effective (first tier) studies all used a multicomponent technology approach that included activity sensing, reminders and other technologies tailored to individual preferences. Future research should explore the use of technology for self-management of health by older adults; social support; and self-reported health measures incorporated into personal health records, electronic medical records, and community health registries.

Evaluation of the effect of intensity of care on mortality after traumatic brain injury

Objectives:To evaluate the effect of age on intensity of care provided to traumatically brain-injured adults and to determine the influence of intensity of care on mortality at discharge and 12 months postinjury, controlling for injury severity. Design:Cohort study using the National Study on the Costs and Outcomes of Trauma (NSCOT) database. Risk ratio and Poisson regression analyses were performed using data weighted according to the population of eligible patients. Setting and Patients:A total of 18 level 1 and 51 level 2 non-trauma centers located in 14 states in the United States and 1,776 adults aged 25–84 yrs with a diagnosis of traumatic brain injury. Measurements:Injury severity was determined by the motor component of the Glasgow Coma Scale score, the Injury Severity Score, pupillary reactivity, and presence of midline shift. Factors evaluated as contributing to intensity of care included: admission to the intensive care unit, mechanical ventilation, placement of an intracranial pressure monitor, placement of a jugular bulb catheter, placement of a pulmonary artery catheter, critical care consultation, the number of specialty care consultations, mannitol use, treatment with barbiturate coma, decompressive craniectomy, number of nonneurosurgical procedures performed, the presence of a do-not-resuscitate order, and withdrawal of therapy. Main Results:Controlling for injury-related factors, sex, and comorbidity, as age increased, the overall likelihood of receiving various interventions decreased. After controlling for injury severity, sex, and comorbidity, factors associated with higher risk of in-hospital death were: being aged 75–84 yrs (relative risk [RR] 1.32, 95% confidence interval [CI] 1.13, 1.55), pulmonary artery catheter use (RR 1.56, 95% CI 1.30, 1.86), intubation (RR 4.17, 95% CI 2.28, 7.61), the presence of a do-not-resuscitate order (RR 3.21, 95% CI 2.21, 4.65), and withdrawal of therapy (RR 2.33, 95% CI 1.69, 3.23). In contrast, a higher number of specialty care consultations (surgical consults: RR 0.63, 95% CI 0.54, 0.74; medical consults: RR 0.87, 95% CI 0.79, 0.95; and other consults: RR 0.43, 95% CI 0.26, 0.69) were associated with decreased risk of death. The results were similar for factors associated with death at 12 months, with the exception that the number of medical consultations was not significant, whereas the number of nonneurosurgical procedures performed was associated with lower risk of death (RR 0.96, 95% CI 0.92, 0.99), as was obtaining critical care consultation services (RR 0.84, 95% CI 0.71, 1.0). Conclusions:There is a lower intensity of care provided to older adults with traumatic brain injury. Although the specific contributions of specialists to patient management are unknown, their consultation was associated with decreased risk of in-hospital death and death within 12 months. It is important that careproviders have an increased awareness of the potential contribution of multidisciplinary clinical decision making to patient outcomes in older traumatically brain-injured patients.

Fall detection devices and their use with older adults: A systematic review

Background:Falls represent a significant threat to the health and independence of adults aged 65 years and older. As a wide variety and large number of passive monitoring systems are currently and increasingly available to detect when individuals have fallen, there is a need to analyze and synthesize the evidence regarding their ability to accurately detect falls to determine which systems are most effective. Objectives:The purpose of this literature review is to systematically assess the current state of design and implementation of fall-detection devices. This review also examines to what extent these devices have been tested in the real world as well as the acceptability of these devices to older adults. Data Sources:A systematic literature review was conducted in PubMed, CINAHL, EMBASE, and PsycINFO from their respective inception dates to June 25, 2013. Study Eligibility Criteria and Interventions:Articles were included if they discussed a project or multiple projects involving a system with the purpose of detecting a fall in adults. It was not a requirement for inclusion in this review that the system targets persons older than 65 years. Articles were excluded if they were not written in English or if they looked at fall risk, fall detection in children, fall prevention, or a personal emergency response device. Study Appraisal and Synthesis Methods:Studies were initially divided into those using sensitivity, specificity, or accuracy in their evaluation methods and those using other methods to evaluate their devices. Studies were further classified into wearable devices and nonwearable devices. Studies were appraised for inclusion of older adults in sample and if evaluation included real-world settings. Results:This review identified 57 projects that used wearable systems and 35 projects using nonwearable systems, regardless of evaluation technique. Nonwearable systems included cameras, motion sensors, microphones, and floor sensors. Of the projects examining wearable systems, only 7.1% reported monitoring older adults in a real-world setting. There were no studies of nonwearable devices that used older adults as subjects in either a laboratory or a real-world setting. In general, older adults appear to be interested in using such devices although they express concerns over privacy and understanding exactly what the device is doing at specific times. Limitations:This systematic review was limited to articles written in English and did not include gray literature. Manual paper screening and review processes may have been subject to interpretive bias. Conclusions and Implications of Key Findings:There exists a large body of work describing various fall-detection devices. The challenge in this area is to create highly accurate unobtrusive devices. From this review it appears that the technology is becoming more able to accomplish such a task. There is a need now for more real-world tests as well as standardization of the evaluation of these devices.

A Systematic Review of the Use of Technology for Reminiscence Therapy

As the segment of the population 65 years of age or older continues to grow, the number of individuals with dementia increases proportionally, highlighting the need to design therapies that meet the social and emotional needs of people with dementia. Information and communication technologies (ICT) are potential venues for supporting the delivery of such therapies, including reminiscence therapy (RT), which is a non-pharmacological intervention involving the prompting of past memories, often with artifacts such as old photographs or music for therapeutic benefits such as the facilitation of social interactions or the increase of self-esteem. This paper systematically examines the scientific literature on the use of ICT for facilitating RT to assess the current state of the evidence and identify future trends. We searched the PubMed (1966-2013), ACM (1954-2013), and PsycINFO (1908-2013) repositories using the keywords dementia and reminiscence. Three hundred eighty-six articles were retrieved, 44 of which met the inclusion and exclusion criteria. Findings of the systematic review include that there are benefits to using ICT for RT interventions. Some of these benefits are access to rich and engaging multimedia reminiscence materials, opportunities for people with dementia to participate in social interactions and take ownership of conversations, and a reduction of barriers due to motor deficits during interactions with media. Future studies should explore the types and content of media beneficial to individuals at different stages of dementia.

Differential effects of the anticonvulsant topiramate on neurobehavioral and histological outcomes following traumatic brain injury in rats

The efficacy of topiramate, a novel therapeutic agent approved for the treatment of seizure disorders, was evaluated in a model of traumatic brain injury (TBI). Adult male rats were anesthetized (sodium pentobarbital, 60 mg/kg, i.p.), subjected to lateral fluid percussion brain injury (n = 60) or sham injury (n = 47) and randomized to receive either topiramate or vehicle at 30 min (30 mg/kg, i.p.), and 8, 20 and 32 h postinjury (30 mg/kg, p.o.). In Study A, memory was evaluated using a Morris water maze at 48 h postinjury, after which brain tissue was evaluated for regional cerebral edema. In Study B, animals were evaluated for motor function at 48 h and 1, 2, 3, and 4 weeks postinjury using a composite neuroscore and the rotating pole test and for learning ability at 4 weeks. Brains were analyzed for hemispheric tissue loss and hippocampal CA3 cell loss. Topiramate had no effect on posttraumatic cerebral edema or histologic damage when compared to vehicle. At 48 h, topiramate treatment improved memory function in sham but not brain-injured animals, while at one month postinjury it impaired learning performance in brain-injured but not sham animals. Topiramate significantly improved composite neuroscores at 4 weeks postinjury and rotating pole performance at 1 and 4 weeks postinjury, suggesting a potentially beneficial effect on motor function following TBI.

Frailty: A Review of the First Decade of Research

Frailty is an emerging geriatric syndrome that refers to a state of increased vulnerability to adverse events including mortality, morbidity, disability, hospitalization, and nursing home admission. Despite its long conceptual and operational history in research and publications, frailty and mechanisms of frailty development are still poorly understood. In this review, we describe a number of conceptual models-reliability, allostatic load, and complexity-that have been put forward to explain the dynamic nature of frailty. We illustrate a consolidated pathophysiological model of frailty, taking into consideration the large and exponentially growing body of studies regarding predictors, indicators, and outcomes of frailty. The model addresses cellular (e.g., oxidative damage and telomere length) and systemic mechanisms (e.g., endocrinal, inflammatory, coagulatory, and metabolic deficiencies) of frailty, moderating or risk factors (e.g., ethnicity, lifestyle, and comorbidities), and outcomes (morbidity, disability, and cognitive decline). Finally, we identify the weaknesses of traditional epidemiological approaches for studying complex phenomena related to frailty and propose areas for future methodological and physiological inquiry.

Genetics and genomics in nursing: Evaluating Essentials implementation

The goal of the present study was to determine how well selected essential knowledge elements and practice indicators from the Essential Nursing Competencies and Curricula Guidelines in Genetics and Genomics (Essentials) were being achieved. A cross-sectional survey design was used. Eligible participants were recruited from a convenience sample of attendees at a national nursing conference in October 2008. Of the 200 surveys distributed, 47 usable surveys (24%) were returned. The majority of respondents were current nursing faculty (45.7%). Only 36% of all respondents had read the Essentials document. Less than 30% of respondents had attended any recent genetic/genomic content continuing education. There were significant associations between having read the Essentials document and obtaining both recent genomic continuing education and conducting genetic research (p<0.01). The results from this survey indicate that the Essentials have not been well disseminated outside of those primarily interested in the subject matter. They further indicate that respondents were not well prepared to respond to patient queries about genetic testing. Nurse educators must be adequately educated to address genomics as it will eventually become commonplace, with global applications in health promotion, disease prevention, and diagnostic and treatment strategies.

Development and validation of the mortality risk for trauma comorbidity index

Objective:The aim of this study was to develop and validate a comorbidity index to predict the risk of mortality associated with chronic health conditions following a traumatic injury. Summary Background Data:Currently available comorbidity adjustment tools do not account for certain chronic conditions, which may influence outcome following traumatic injury or they have not been fully validated for trauma. Controlling for comorbidity in trauma patients is becoming increasingly important as the population ages and elderly patients are more active, as well as to adjust for bias in trauma mortality studies. Methods:Cohort study using data from the National Study on the Costs and Outcome of Trauma. Subject pool (N = 4644/Weighted Number = 14,069) was randomly divided in half; the first half of subjects was used to derive the risk scale, the second to validate the instrument. To construct the Mortality Risk Score for Trauma (MoRT), univariate analysis and odds ratios were performed to determine relative risk of mortality at hospital discharge comparing those persons with a comorbid condition to those without. Conditions significantly associated with mortality (P < 0.05) were included in the multivariate model. The variables in the final model were used to build the MoRT. The predictive ability of the MoRT and the Charlson Comorbidity Index (CCI) for discharge and 1-year mortality were estimated using the c-statistic in the validation sample. Results:Six comorbidity factors were independently associated with the risk of mortality and formed the basis for the MoRT: severe liver disease, myocardial infarction, cerebrovascular disease, cardiac arrhythmias, dementia, and depression. The MoRT had a similar overall discrimination as the CCI for mortality at hospital discharge in injured adults (c-statistic: 0.56 vs. 0.56) although neither by itself performed well. The addition of age and gender improved the predictive ability of the MoRT (0.59; 95% CI: 0.56, 0.62) and the CCI (0.59; 0.56, 0.62). Similar results were seen at 1-year postinjury. The further addition of Injury Severity Score significantly improved the predictive ability of the MoRT (0.77, 95% CI: 0.74, 0.79) and the CCI (0.77, 95% CI: 0.75, 0.80). Conclusions:The MoRTs primary advantage over current instruments is its parsimony, containing only 6 items. In the present study, the comorbid conditions found to be predictive of mortality had some overlap with the CCI, but this study identified 2 novel predictors: cardiac arrhythmias and depression. Inclusion and reporting of these items within trauma registries would therefore be an important step to allow further validation and use of the MoRT.