Jane Topolovec-Vranic

The value of serum biomarkers in prediction models of outcome after mild traumatic brain injury.

BACKGROUND To determine, using a civilian model of mild traumatic brain injury (TBI), the added value of biomarker sampling upon prognostication of outcome at 1 week and 6 weeks postinjury. METHODS The Galveston Orientation and Amnesia test was administered, and blood samples for serum protein S100B and neuron-specific enolase (NSE) were collected from 141 emergency department patients within 4 hours of a suspected mild TBI (mTBI). The Rivermead Post-Concussion Symptoms Questionnaire (RPQ) was administered via telephone 3 days postinjury. Patients were assessed by a physician at 1 week (n = 113; 80%) and 6 weeks (n = 95; 67%) postinjury. Neurocognitive and postural stability measures were also administered at these follow-ups. RESULTS Levels of S100B and NSE were found to be abnormally elevated in 49% and 65% of patients with TBI, respectively. Sixty-eight percent and 38% of the patients were considered impaired at 1 week and 6 weeks postinjury, respectively. Stepwise logistic regression modeling identified admission Galveston Orientation and Amnesia test score, S100B level, and RPQ score at day 3 postinjury to be predictive of poor outcome at 1 week postinjury (c-statistic 0.877); female gender, loss of consciousness, NSE level, and RPQ score at day 3 postinjury were predictive of poor outcome at 6 weeks postinjury (c-statistic 0.895). The discriminative power of the biomarkers alone was limited. CONCLUSIONS Biomarkers, in conjunction with other readily available determinants of outcome assessed in the acute period after injury, add value in the early prognostication of patients with mTBI. Our findings are consistent with the notion that S100B and NSE point to biological mechanisms underlying poor outcome after mTBI.

Evaluation of an online cognitive behavioural therapy program by patients with traumatic brain injury and depression

Primary objective: The most frequently reported psychiatric symptom after traumatic brain injury (TBI) is depression. This study examined whether internet-delivered cognitive behaviour therapy (CBT) could be appropriate and effective for patients with mild or moderate TBI and depression. Methods and procedures: Patients were recruited for an at-home, 6-week internet-based CBT program (MoodGYM). Participants were assessed during this period by weekly telephone calls and at 12 months post-enrolment. Intervention completion rates, predictors of adherence, user feedback and changes in scores on validated depression scales were assessed. Main outcomes and results: Twenty-one patients were recruited: 64% and 43% completed the 6-week intervention and the 12-month follow-up, respectively. Adherence rates were not predicted by demographic or injury characteristics in this small sample. Patients identified reading, memory and comprehension requirements as limitations of the program. Scores on the depression scales were significantly decreased upon completion of the intervention and at the 12-month follow-up. Conclusions: The MoodGYM program may be effective for treating symptoms of depression in patients with TBI. While adherence rates were not predicted by age, education level or injury severity, demands upon memory and concentration which may already be compromised in these patients need to be considered.

Web-Based Intervention Programs for Depression: A Scoping Review and Evaluation

Background Although depression is known to affect millions of people worldwide, individuals seeking aid from qualified health care professionals are faced with a number of barriers to treatment including a lack of treatment resources, limited number of qualified service providers, stigma associated with diagnosis and treatment, prolonged wait times, cost, and barriers to accessibility such as transportation and clinic locations. The delivery of depression interventions through the Internet may provide a practical solution to addressing some of these barriers. Objective The purpose of this scoping review was to answer the following questions: (1) What Web-delivered programs are currently available that offer an interactive treatment component for depression?, (2) What are the contents, accessibility, and usability of each identified program?, and (3) What tools, supports, and research evidence are available for each identified program? Methods Using the popular search engines Google, Yahoo, and Bing (Canadian platforms), two reviewers independently searched for interactive Web-based interventions targeting the treatment of depression. The Beacon website, an information portal for online health applications, was also consulted. For each identified program, accessibility, usability, tools, support, and research evidence were evaluated and programs were categorized as evidence-based versus non-evidence-based if they had been the subject of at least one randomized controlled trial. Programs were scored using a 28-point rating system, and evidence- versus non-evidence-based programs were compared and contrasted. Although this review included all programs meeting exclusion and inclusion criteria found using the described search method, only English language Web-delivered depression programs were awarded an evaluation score. Results The review identified 32 programs meeting inclusion criteria. There was a great deal of variability among the programs captured in this evaluation. Many of the programs were developed for general adolescent or adult audiences, with few (n=2) focusing on special populations (eg, military personnel, older adults). Cognitive behavioral therapy was the most common therapeutic approach used in the programs described. Program interactive components included mood assessments and supplementary homework sheets such as activity planning and goal setting. Only 12 of the programs had published evidence in support of their efficacy and treatment of depressive symptoms. Conclusions There are a number of interactive depression interventions available through the Internet. Recommendations for future programs, or the adaptation of existing programs include offering a greater selection of alternative languages, removing registration restrictions, free trial periods for programs requiring user fees, and amending programs to meet the needs of special populations (eg, those with cognitive and/or visual impairments). Furthermore, discussion of specific and relevant topics to the target audience while also enhancing overall user control would contribute to a more accessible intervention tool.

Traumatic brain injury among people who are homeless: a systematic review

BackgroundHomelessness and poverty are important social problems, and reducing the prevalence of homelessness and the incidence of injury and illness among people who are homeless would have significant financial, societal, and individual implications. Recent research has identified high rates of traumatic brain injury (TBI) among this population, but to date there has not been a review of the literature on this topic. The objective of this systematic review was to review the current state of the literature on TBI and homelessness in order to identify knowledge gaps and direct future research.MethodsA systematic literature search was conducted in PsycINFO (1887–2012), Embase (1947–2012), and MEDLINE/Pubmed (1966–2012) to identify all published research studies on TBI and homelessness. Data on setting, sampling, outcome measures, and rate of TBI were extracted from these studies.ResultsEight research studies were identified. The rate of TBI among samples of persons who were homeless varied across studies, ranging from 8%-53%. Across the studies there was generally little information to adequately describe the research setting, sample sizes were small and consisted mainly of adult males, demographic information was not well described, and validated screening tools were rarely used. The methodological quality of the studies included was generally moderate and there was little information to illustrate that the studies were adequately powered or that study samples were representative of the source population. There was also an absence of qualitative studies in the literature.ConclusionsThe rate of TBI is higher among persons who are homeless as compared to the general population. Both descriptive and interventional studies of individuals who are homeless should include a psychometrically sound measure of history of TBI and related disability. Education of caregivers of persons who are at risk of becoming, or are homeless, should involve training on TBI. Dissemination of knowledge to key stakeholders such as people who are homeless, their families, and public policy makers is also advocated.

Depression and anxiety in parent versus spouse caregivers of adult patients with traumatic brain injury: A systematic review

A systematic review of studies which evaluated depression and anxiety in parent versus spouse caregivers of adults with traumatic brain injury (TBI) was conducted. Demographic variables of the TBI patients and caregivers, study design, measurement tools used, and outcomes reported were collected. Twenty-four studies met the inclusion criteria and were evaluated for methodological quality. While the majority of studies revealed no significant differences between caregiver types on measures of depression and/or anxiety, there was a great deal of variation in methodology and quality between the studies. Overall, high levels of caregiver distress were exposed, regardless of caregiver type (parent versus spouse). There is a need for qualitative and quantitative research designs in order to elucidate the factors that put caregivers at risk for depression and anxiety.

Detecting pain in traumatic brain-injured patients with different levels of consciousness during common procedures in the ICU: typical or atypical behaviors?

Purpose:Pain behaviors such as grimacing and muscle rigidity are recommended for pain assessment in nonverbal populations. However, these behaviors may not be appropriate for critically ill patients with a traumatic brain injury (TBI) depending on their level of consciousness (LOC). This study aimed to validate the use of behaviors for assessing pain of critically ill TBI adults with different LOC. Methods:Using a repeated measure within subject design, participants (N=45) were observed for 1 minute before (baseline), during, and 15 minutes after 2 procedures: (1) noninvasive blood pressure: NIBP (non-nociceptive); and (2) turning (nociceptive). A behavioral checklist combining 50 items from existing pain assessment tools and video recording were used to describe participants’ behaviors. Intrarater and interrater agreements of observed behaviors were also examined. Results:Overall, pain behaviors were observed more frequently during turning (median=4; T=−5.336; P⩽0.001) than at baseline (median=1), or during noninvasive blood pressure (median=0). TBI patients’ pain behaviors were mostly “atypical” and included uncommon responses such as flushing, sudden eye opening, eye weeping, and flexion of limbs. These behaviors were observed in ≥25.0% of TBI participants during turning independent of their LOC, and in 22.2% to 66.7% of conscious participants who reported the presence of pain. Agreements were >92% among and between the 2 raters. Conclusions:This study support previous findings that critically ill TBI patients could exhibit atypical behaviors when exposed to nociceptive procedures. As such, use of current recommended pain behaviors as part of standardized scales may not be optimal for assessing the analgesic needs of this vulnerable group.

Validation and evaluation of two observational pain assessment tools in a trauma and neurosurgical intensive care unit.

BACKGROUND Studies have demonstrated that patients in the intensive care unit experience high levels of pain. While many of these patients are nonverbal at some point during their stay, there are few valid tools available to assess pain in this group. OBJECTIVES To evaluate the validity and clinical utility of two pain assessment tools, the revised Adult Non-Verbal Pain Scale (NVPS-R) and the Critical Care Pain Observation Tool (CPOT), in a trauma and neurosurgical patient population. METHODS Patients were assessed using the NVPS-R and CPOT by trained intensive care unit nurses (n=23) and research assistants before, during and after two procedures: turning of the patient (nociceptive procedure) and noninvasive blood pressure cuff inflation (non-nociceptive procedure). Communicative patients were also asked to report their level of pain during each assessment. RESULTS A total of 66 patients (34 communicative, 32 noncommunicative) were included in the study. CPOT and NVPS-R scores increased significantly when participants were exposed to turning, but not during noninvasive blood pressure measurement (repeated measures ANOVA: CPOT, F=5.81, P=0.019; NVPS-R, F=5.32, P=0.025) supporting discriminant validity. CPOT and NVPS-R scores were significantly higher during the turning procedure for patients who had indicated that they were in pain versus those who were not, indicating criterion validity. Inter-rater reliability was generally higher for the CPOT than NVPS-R. Nurses rated the feasibility of the two tools as comparable but provided higher ratings of acceptability for the CPOT. CONCLUSIONS While the present study supports the use of the CPOT and the NVPS-R with critically ill trauma and neurosurgical patients, further research should explore the role of vital signs in pain.

antisaccadic eye Movements are correlated with corpus callosum White Matter Mean Diffusivity, stroop Performance, and symptom Burden in Mild Traumatic Brain injury and concussion

Antisaccades are thought to involve higher level inputs from neural centers involved in rapid eye movement inhibition and control. Previous work has demonstrated that performance on the antisaccade task can help in the assessment of injury in acute and/or chronic mild traumatic brain injury (mTBI). In this exploratory study, we performed cross-sectional and longitudinal comparisons of rapid eye movement, followed by correlations of antisaccade performance with assessments of symptom burden, diffusion tensor imaging, and a neuropsychological test of response inhibition. Significant deficits in antisaccade median latency, F(2, 31) = 3.65, p = 0.04 and prosaccade error mean duration, F(2, 31) = 3.63, p = 0.04 were found between patient groups and controls: the former was correlated with loss of white matter integrity in the splenium of the corpus callosum in acute mTBI, rho = 0.90, p = 0.0005. Furthermore, increased antisaccade median latency was also correlated with poor performance on an executive functioning task, r2 = 0.439, p = 0.03, and greater symptom burden, r2 = 0.480, p = 0.02 in the acute mTBI patients. Our preliminary research suggests that the antisaccade task could be useful as a neurological marker for mTBI and concussion, but more work is required.

Controlled blast exposure during forced explosive entry training and mild traumatic brain injury

BACKGROUND There is a paucity of data regarding the pathophysiology and short- and long-term neurologic consequences of primary blast injury in humans. The purpose of this investigation was to test the feasibility of implementing a research protocol in the context of a forced explosive entry training course. METHODS Instructors (n = 4) and students (n = 10) completing the Police Explosives Technicians-Forced Entry Instructors course were recruited to participate in the study. Participants underwent a physical examination, tests of postural stability and vestibular ataxia, and a neurocognitive battery 1 day before and 10 days following practical forced explosive entry exercises. RESULTS The instructors reported significantly more blast exposures in their careers than the students (p < 0.05). Seventy-five percent of the instructors and 50% of the students reported a history of trauma to the head. A minority of the participants had deficits on cranial nerve, vestibular ataxia, and neurocognitive tests which did not change significantly postexposure. All the instructors and most of the students (90%) demonstrated postural stability deficits at baseline which did not change significantly postexposure. CONCLUSIONS Studying the effects of blast exposure on the human brain in a controlled experimental setting is not possible. Forced explosive entry training courses afford an opportunity to begin examining this issue in real time in a controlled setting. This study underscores the importance of baseline testing of troops, of the consideration of subclinical implications of blast exposure, and of continued studies of the effects of blast exposures, including repeated exposures on the human brain.

Recognizing the Symptoms of Mental Illness following Concussions in the Sports Community: A Need for Improvement

Objective To evaluate the awareness of concussion-related symptoms amongst members of the sports community in Canada. Methods A cross-sectional national electronic survey was conducted. Youth athletes, parents, coaches and medical professionals across Canada were recruited through mailing lists from sports-related opt-in marketing databases. Participants were asked to identify, from a list of options, the symptoms of a concussion. The proportion of identified symptoms (categorized as physical, cognitive, mental health-related and overall) as well as participant factors associated with symptom recognition were analyzed. Results The survey elicited 6,937 responses. Most of the respondents (92.1%) completed the English language survey, were male (57.7%), 35–54 years of age (61.7%), with post-secondary education (58.2%), or high reported yearly household income (>