Michael Makley

Aggression after traumatic brain injury: prevalence and correlates

Aggression after traumatic brain injury (TBI) is common but not well defined. Sixty-seven participants with first-time TBI were evaluated for aggression within 3 months of injury. The prevalence of aggression was found to be 28.4%, predominantly verbal aggression. Post-TBI aggression was associated with new-onset major depression (p=0.02), poorer social functioning (p=0.04), and increased dependency in activities of daily living (p=0.03), but not with a history of substance abuse or adult/childhood behavioral problems. Implications of the study include early screening for aggression, evaluation for depression, and consideration of psychosocial support in aggressive patients.

Prevalence and types of sleep disturbances acutely after traumatic brain injury

Primary objective: To assess the prevalence of and risk factors for sleep disturbances in the acute post-traumatic brain injury (TBI) period. Research design: Longitudinal, observational study. Methods and procedures: Fifty-four first time closed-head injury patients were recruited and evaluated within 3 months after injury. Pre-injury and post-injury sleep disturbances were compared on the Medical Outcome Scale for Sleep. The subjects were also assessed on anxiety, depression, medical comorbidity and severity of TBI. Main outcomes and results: Subjects were worse on most sleep measures after TBI compared to before TBI. Anxiety disorder secondary to TBI was the most consistent significant risk factor to be associated with worsening sleep status. Conclusions: Anxiety is associated with sleep disturbances after TBI. Further studies need to be done to evaluate if this is a causal relationship.

Prevalence of Sleep Disturbance in Closed Head Injury Patients in a Rehabilitation Unit

Traumatic brain injury (TBI) is a leading cause of disability in young people in the United States. Disorders of arousal and attention are common in closed head injury (CHI). Daytime drowsiness impairs participation in rehabilitation, whereas nighttime wakefulness leads to falls and behavioral disturbances. Sleep disturbances in TBI reported in the literature have included excessive daytime somnolence, sleep phase cycle disturbance, narcolepsy, and sleep apnea. Although well known to the clinician treating these patients, the extent and prevalence of disrupted sleep in patients in an acute inpatient rehabilitation unit has not been described. Objective. To determine the prevalence of sleep wake cycle disturbance (SWCD) in patients with CHI in a TBI rehabilitation unit. Design. Prospective observational. Setting. Inpatient specialized brain injury rehabilitation unit. Patients. Thirty-one consecutive admissions to a brain injury rehabilitation unit with the diagnosis of CHI. Results. Twenty-one patients (68%) had aberrations of nighttime sleep. There was no significant difference in Glasgow Coma Score on admission to trauma nor was there any significant difference in age between the affected and unaffected groups. Patients with SWCD had longer stays in both the trauma center (P < .003) and the rehabilitation center (P < .03). Conclusions. There is a high prevalence of SWCD in CHI patients admitted to a brain injury rehabilitation unit. Patients with SWCD have longer stays in both acute and rehabilitation settings and may be a marker for more severe injury.

Predictors of New-Onset Depression After Mild Traumatic Brain Injury

Mild traumatic brain injury (TBI) is the most common form of TBI. Most people recover after mild TBI, but a small percentage continues to have persistent problems, predominantly depression. There is, however, minimal literature on the risk factors associated with mild TBI depression. In a sample of 43 mild TBI patients, followed longitudinally for 1 year, the prevalence of new-onset depression was found to be 18%. Older age and presence of frontal subdural hemorrhage were the only two significant findings noted in the depressed group compared with the nondepressed group. Identifying risk factors for mild TBI depression can aid in early diagnosis and treatment.

Cerebrospinal fluid evidence of increased extra-mitochondrial glucose metabolism implicates mitochondrial dysfunction in multiple sclerosis disease progression

In contrast to relapse, the mechanisms of multiple sclerosis (MS) disease progression are less understood and appear not to be exclusively inflammatory in nature. In this pilot study we investigated the relationship between disturbed CNS energy metabolism and MS disease progression. We tested the hypothesis that cerebrospinal fluid (CSF) concentrations of sorbitol, fructose, and lactate, all metabolites of extra-mitochondrial glucose metabolism, would be elevated in secondary progressive (SP) MS patients and would be associated with worsening neurologic disability. We measured metabolite concentrations by gas chromatographic/mass spectrometric and enzymatic methods in archived CSF samples from 85 MS patients [31 relapsing-remitting (RR) and 54 SP patients] and 18 healthy controls. We found that concentrations of all three metabolites, but not concentrations of glucose or myoinositol, were significantly increased in CSF from SP and, to a lesser degree, RR patients, compared to controls. Furthermore, CSF concentrations of sorbitol and fructose (polyol pathway metabolites), but not lactate (anaerobic glycolysis metabolite), correlated positively and significantly with Expanded Disability Status Scale (EDSS) score, an index of neurologic disability in MS patients. We conclude that extra-mitochondrial glucose metabolism is increased in MS patients and is associated with disease progression evidenced by increasing EDSS score. As extra-mitochondrial glucose metabolism increases with impaired mitochondrial metabolism of glucose, these findings implicate mitochondrial dysfunction in the pathogenesis of MS disease progression. CSF metabolic profiling may be useful in clarifying the role of mitochondrial pathology in progression and in targeting and monitoring therapies for disease progression that aim to preserve or boost mitochondrial glucose metabolism.

Manipulation of Central Nervous System Plasticity: A New Dimension in the Care of Neurologically Impaired Patients

Research in the neurosciences in recent decades has shown that the central nervous system is not a structurally static organ as was believed previously, but instead is a dynamic system that constantly undergoes structural and functional reorganization. The term brain plasticity refers to the constant cellular and intercellular modifications that occur during normal development and after neurologic injury and result in changes in neurologic function. The discovery that central nervous system plasticity after injury can be directed toward functional improvement with use of specific modalities has opened up a new dimension in the care of the neurologically impaired patient, termed restorative neurology.

A Hidden Reservoir of Methicillin-resistant Staphylococcus aureus and Vancomycin-resistant Enterococcus in Patients Newly Admitted to an Acute Rehabilitation Hospital

To find hidden reservoirs of methicillin‐resistant Staphylococcus aureus (MRSA) and vancomycin‐resistant Enterococcus (VRE) via active surveillance cultures for MRSA and VRE in newly admitted patients.

Treatment of Abulia with Carbidopa/Levodopa

Abulia is a clinical syndrome manifested by lack of spontaneity of action and speech, deficiency in initiation, apathy, inertia, mental and motor slowness, reduction in excur sion of motion, poor attention, and easy distractibility. Abulia has been conceptualized as laying in a continuum of motivational and emotional deficit in which apathy is at one extreme and akinetic mutism at the other, more severe extreme. Lesions in the frontal lobes have been most often implicated in the causality of abulia, but other areas of involvement have also been described. Some authors have reported the beneficial effect of dopaminergic agents in the treatment of abulia and other related disorders. We report on four patients with various disorders of the CNS and abulic symptoms who had a ben eficial response to administration of a carbidopa/levodopa (Sinemet) compound many months after the CNS insult responsible for the symptoms. We hypothesize that lev odopa may be beneficial in the treatment of abulia by increasing the availability of dopamine to the prefrontal cortex or related areas in the brain.