Trandur Ulfarsson

Pituitary Function and Functional Outcome in Adults after Severe Traumatic Brain Injury: The Long-Term Perspective

Post-traumatic hypopituitarism (PTHP) has been linked to disability and decreased quality of life. However, no studies have addressed the long-term consequences of PTHP in adults with severe traumatic brain injury (TBI) only. In this study, we evaluated the relationship between pituitary function, quality of life, and functioning in 51 patients (16-65 years of age) with severe TBI who were admitted to Sahlgrenska University Hospital, Gothenburg from 1999 to 2002. The patients were assessed once, 2-10 years after trauma. Data from the time of injury were collected retrospectively to adjust for injury severity. Outcome measures included hormonal testing, the Short Form-36 Health Survey, the Glasgow outcome scale-extended, and a self-report questionnaire specifically designed for this study and based on the International Classification of Functioning, Disability and Health. Of 51 patients, 14 (27.5%) presented with PTHP, and 11 (21.6%) had isolated growth hormone deficiency. Patients with PTHP were more often overweight at follow-up (p=0.01); the higher body mass index was partially explained by PTHP (R2 change=0.07, p=0.001). Otherwise no significant correlation was found among PTHP, functioning, or patient-reported quality of life. This study-which is unique in the homogeneity of the patients, the long follow-up time, and the use of injury severity as an outcome predictor-did not confirm results from previous studies linking PTHP to a worse outcome. Therefore, screening for PTHP might be restricted to specific subgroups such as overweight patients, indicating growth hormone deficiency.

Disorders of consciousness after severe traumatic brain injury: a Swedish-Icelandic study of incidence, outcomes and implications for optimizing care pathways.

BACKGROUND Very severe traumatic brain injury may cause disorders of consciousness in the form of coma, unresponsive wakefulness syndrome (also known as vegetative state) or minimally conscious state. Previous studies of outcome for these patients largely pre-date the 2002 definition of minimally conscious state. OBJECTIVES To establish the numbers of patients with disorder of consciousness at 3 weeks, 3 months and 1 year after severe traumatic brain injury, and to relate conscious state 3 weeks after injury to outcomes at 1 year. DESIGN Multi-centre, prospective, observational study of severe traumatic brain injury. INCLUSION CRITERIA lowest (non-sedated) Glasgow Coma Scale 3-8 during the first 24 h; requirement for neurosurgical intensive care; age 18-65 years; alive 3 weeks after injury. Diagnosis of coma, unresponsive wakefulness syndrome, minimally conscious state or emerged from minimally conscious state was based on clinical and Coma Recovery Scale Revised assessments 3 weeks, 3 months and 1 year after injury. One-year outcome was measured with Glasgow Outcome Scale Extended (GOSE). RESULTS A total of 103 patients was included in the study. Of these, 81% were followed up to 1 year (76% alive, 5% dead). Three weeks after injury 36 were in coma, unresponsive wakefulness syndrome or minimally conscious state and 11 were anaesthetized. Numbers of patients who had emerged from minimally conscious state 1 year after injury, according to status at 3 weeks were: coma (0/6), unresponsive wakefulness syndrome (9/17), minimally conscious state (13/13), anaesthetized (9/11). Outcome at 1 year was good (GOSE > 4) for half of patients in minimally conscious state or anaesthetized at 3 weeks, but for none of the patients in coma or unresponsive wakefulness syndrome. These differences in outcome were not revealed by prognostic predictions based on acute data. CONCLUSION Patients in minimally conscious state or anaesthetized 3 weeks after injury have a better prognosis than patients in coma or unresponsive wakefulness syndrome, which could not be explained by acute prognostic models.

Early intervention for patients at risk for persisting disability after mild traumatic brain injury: A randomized, controlled study

Study objective: To investigate the effect of an early intervention visit in addition to written information and treatment as usual for patients with an estimated high risk for persisting disability after a mild traumatic brain injury (MTBI). Research design: Randomized controlled trial. Methods: One hundred and seventy-three patients, aged 15–70 years with a Glasgow Coma Scale of 14–15 were included. All received written information about MTBI. Ninety-seven patients who reported three or more symptoms according to the Rivermead Post-Concussion Symptoms Questionnaire (RPQ) at 10 days after the injury were considered as high-risk patients and were randomized to either early visit to a doctor or to treatment as usual (TAU); all patients including the 76 low-risk patients were followed-up at 3 months. Completion rate was 83%. Outcome measures included RPQ and the Hospital Anxiety and Depression Scale. Results: RPQ symptoms decreased significantly in both randomized groups, but were not significantly different in the groups at 3 months. At 3 months, anxiety and depression scores did not differ between groups. Conclusions: An early intervention, offered to patients with an estimated high risk for persisting disability, had no additional effect on symptom level at 3 months after MTBI as compared to TAU.

Associations Between Care Pathways and Outcome 1 Year After Severe Traumatic Brain Injury

Objective:To assess associations between real-world care pathways for working-age patients in the first year after severe traumatic brain injury and outcomes at 1 year. Setting and Design:Prospective, observational study with recruitment from 6 neurosurgical centers in Sweden and Iceland. Follow-up to 1 year, independently of care pathways, by rehabilitation physicians and paramedical professionals. Participants:Patients with severe traumatic brain injury, lowest (nonsedated) Glasgow Coma Scale score 3 to 8 during the first 24 hours and requiring neurosurgical intensive care, age 18 to 65 years, and alive 3 weeks after injury. Main Measures:Length of stay in intensive care, time between intensive care discharge and rehabilitation admission, outcome at 1 year (Glasgow Outcome Scale Extended score), acute markers of injury severity, preexisting medical conditions, and post–acute complications. Logistic regression analyses were performed. Results:A multivariate model found variables significantly associated with outcome (odds ratio for good outcome [confidence interval], P value) to be as follows: length of stay in intensive care (0.92 [0.87-0.98], 0.014), time between intensive care discharge and admission to inpatient rehabilitation (0.97 [0.94-0.99], 0.017), and post–acute complications (0.058 [0.006-0.60], 0.017). Conclusions:Delays in rehabilitation admission were negatively associated with outcome. Measures to ensure timely rehabilitation admission may improve outcome. Further research is needed to evaluate possible causation.

Ten-year mortality after severe traumatic brain injury in western Sweden: A case control study

Abstract Primary objective: Life expectancy may be substantially reduced for many years after severe traumatic brain injury (TBI). This study investigated the patterns of the short- and long-term all-cause mortality and the rates of primary causes of death in patients with severe TBI. Subjects: This study was of 166 consecutive patients (6–82 years) with severe TBI admitted to Sahlgrenska University Hospital, Gothenburg, Sweden, from 1999–2002. The control group consisted of 809 subjects from the community, matched to the TBI cohort for age, gender and postcode area at the time of the injury. Methods: Survival outcome and cause of death were ascertained 10 years after the injury from the Swedish National Board of Health and Welfare register. The cumulative death rates and causes of death in cases and controls were compared. Results: The risk of death was increased for at least 10 years after severe TBI. The distribution of the causes of deaths differed between cases and controls in the first year of follow-up, but not between 1-year survivors and controls. Conclusion: Further research will be required to determine how to improve treatment so as to lower late mortality among survivors of severe TBI.

A history of unemployment or sick leave influences long-term functioning and health-related quality-of-life after severe traumatic brain injury

Abstract Primary objective: The consequences of pre-morbid factors in adults with severe traumatic brain injury have not been widely addressed. This study aimed to determine whether being unemployed or on sick leave before injury influences long-term health-related quality-of-life (HRQoL) and functioning in patients with severe traumatic brain injury. Subjects: Fifty-one consecutive patients were studied; aged 16–65 years, with severe traumatic brain injury who were admitted to Sahlgrenska University Hospital, Gothenburg, from 1999–2002. Methods: The patients were assessed once, 2–11 years after trauma. Data from the time of injury were combined into a validated prognostic model to adjust for injury severity. Data on sick leave and unemployment before injury were gathered from the Swedish social insurance agency. Outcomes were measured with the Short Form-36 Health Survey, the Glasgow Outcome Scale–Extended, and a self-report questionnaire specifically designed for this study to measure functioning. Results: In a multivariate analysis, a history of sick leave/unemployment predicted a worse long-term global outcome, more problems with personal activities of daily living and worse HRQoL. Conclusion: These results should be considered when refining outcome predictions and optimizing rehabilitation interventions for patients with severe traumatic brain injury.

Trajectories of Recovery and Outcome after Severe Traumatic Brain Injury : Design and baseline data from the "PROBRAIN" study

Endogenous free radical production by NADPH oxidase 2 contributes to the secondary injury cascade after traumatic brain injury in miceAccepted Abstracts from the International Brain Injury Association’s Ninth World Congress on Brain InjuryObjectives: Studies have shown that occupational therapy interventions for clients with cognitive impairment following acquired brain injury (CIABI) have a positive effect on performance of activities of daily living, although the exact nature of the interventions are not clearly described. A better understanding of current practice is therefore needed to move further in the search for evidence based occupational therapy for clients with CIABI. Research on occupational therapists’ (OTs’) practice can play an important role to explore and describe current practice and furthermore define and evaluate the effectiveness of different components in OT interventions. The aim of this study was to survey Swedish OTs’ practice patterns for clients having CIABI.Methods: The study had a cross-sectional design using a questionnaire developed in two former studies. A stratified random sample was done with 250 OTs each from the following areas: regional care, somatic county care, primary care and municipal eldercare. The questionnaire was sent out using on-line survey software and 462 participants responded. Data is currently analyzed by descriptive and comparative statistics.Results: Preliminary results show that the interventions targeted a wide range of cognitive impairments and its consequences. Interventions were both remedial and compensatory with graded activity as the most common remediating intervention. To compensate for activity limitations prescription, or recommendation, of assistive devices (AD) as well as supporting clients in finding internal strategies were used extensively. The ADs used consisted of both high and low technology devices. Eighty-two percent also included different specific interventions to improve clients’ decreased self-awareness in their practice. A vast majority of the OTs (94%) preferred to use observations in daily activities to assess both activity limitations and cognitive impairment. Almost all participants also used interviews and sixty-two percent used tests on impairment level. To support practice general Occupational Therapy models were widely used while theories focusing on cognitive impairments specifically were used less. The participants’ answers reflected a client-centered attitude with collaborative goal-setting and feedback discussions after each session. Eighty- four percent felt dependent on relatives to reach a successful outcome and most of them worked deliberately to involve relatives in the rehabilitation. The OTs responses were evenly distributed over the spheres of activity. Ninety-two percent of the participants worked in team and the most common diagnoses were stroke and traumatic brain injury. There were some differences in responses between the spheres.Conclusions: Preliminary conclusions are that the OTs practice patterns included interventions targeting most cognitive impairments and their consequences in daily activities. The use of daily activities as a mean was preferred irrespective of whether the interventions were remediative or compensatory. Interventions targeting decreased self-awareness as well as the use of ADs were common. A client-centered approach was dominating including collaboration with relatives.For personalcentered approach was dominating including collaborationwith relatives.Diagnosis of Disorders of Consciousness : Evoked Potentials and Behavioural Assessment in clinical practice

Cognitive recovery in the first 3 months after severe traumatic brain injury : preliminary data from "PROBRAIN'' study

Endogenous free radical production by NADPH oxidase 2 contributes to the secondary injury cascade after traumatic brain injury in miceAccepted Abstracts from the International Brain Injury Association’s Ninth World Congress on Brain InjuryObjectives: Studies have shown that occupational therapy interventions for clients with cognitive impairment following acquired brain injury (CIABI) have a positive effect on performance of activities of daily living, although the exact nature of the interventions are not clearly described. A better understanding of current practice is therefore needed to move further in the search for evidence based occupational therapy for clients with CIABI. Research on occupational therapists’ (OTs’) practice can play an important role to explore and describe current practice and furthermore define and evaluate the effectiveness of different components in OT interventions. The aim of this study was to survey Swedish OTs’ practice patterns for clients having CIABI.Methods: The study had a cross-sectional design using a questionnaire developed in two former studies. A stratified random sample was done with 250 OTs each from the following areas: regional care, somatic county care, primary care and municipal eldercare. The questionnaire was sent out using on-line survey software and 462 participants responded. Data is currently analyzed by descriptive and comparative statistics.Results: Preliminary results show that the interventions targeted a wide range of cognitive impairments and its consequences. Interventions were both remedial and compensatory with graded activity as the most common remediating intervention. To compensate for activity limitations prescription, or recommendation, of assistive devices (AD) as well as supporting clients in finding internal strategies were used extensively. The ADs used consisted of both high and low technology devices. Eighty-two percent also included different specific interventions to improve clients’ decreased self-awareness in their practice. A vast majority of the OTs (94%) preferred to use observations in daily activities to assess both activity limitations and cognitive impairment. Almost all participants also used interviews and sixty-two percent used tests on impairment level. To support practice general Occupational Therapy models were widely used while theories focusing on cognitive impairments specifically were used less. The participants’ answers reflected a client-centered attitude with collaborative goal-setting and feedback discussions after each session. Eighty- four percent felt dependent on relatives to reach a successful outcome and most of them worked deliberately to involve relatives in the rehabilitation. The OTs responses were evenly distributed over the spheres of activity. Ninety-two percent of the participants worked in team and the most common diagnoses were stroke and traumatic brain injury. There were some differences in responses between the spheres.Conclusions: Preliminary conclusions are that the OTs practice patterns included interventions targeting most cognitive impairments and their consequences in daily activities. The use of daily activities as a mean was preferred irrespective of whether the interventions were remediative or compensatory. Interventions targeting decreased self-awareness as well as the use of ADs were common. A client-centered approach was dominating including collaboration with relatives.For personalcentered approach was dominating including collaborationwith relatives.Diagnosis of Disorders of Consciousness : Evoked Potentials and Behavioural Assessment in clinical practice