BACKGROUND/AIMS: Inconsistency in the use of secondary brain injury prevention guidelines among US trauma centers after severe traumatic brain injury is prevalent in many literature sources. However, this phenomenon has not been thoroughly studied. The purpose of this DNP project is to identify the key barriers and challenges in compliance to the evidence-based guidelines for secondary brain injury prevention. DESIGN: An exploratory, emergent design was used to collect descriptive qualitative data through the use of a survey. SETTING: Six Phoenix Metropolitan Level 1 trauma centers. PARTICIPANTS: All survey participants who consented to survey completion, which had greater than six months of experience and directly worked with patients suffering from a severe TBI in the clinical setting. MEASUREMENTS: Participant demographics (work experience, area of work, job title), current awareness and use of Brain Trauma Foundation guidelines, and time duration for evidence based order set implementation. Narrative responses were also used to identify barriers to current use of the BTF guidelines and factors that may promote their use in the future. RESULTS: A total of 43 participants consented to the survey study, with completion by 35 participants. RNs (n=27), Physicians (n=2), NPs or PAs (n=5), with an average work experience of 6 to 14 years (42.86%). A total of n=22 (62%) of participants were unaware of the current BTF guidelines for severe TBI and only 25% (n=9) aware that their facility has a protocol based on the BTF guidelines for severe TBI, while 51% (n=18) were unsure if their facility had a protocol. Barriers were identified in narrative form and were consistent with awareness/education, provider congruence, communication, and order set/protocol process improvement. CONCLUSION: The understanding of current patient management for severe TBI based on the BTF guidelines is sporadic among the greater Phoenix area Level 1 trauma centers. Requiring proof of BTF guidelines compliance by the ACS at time of Level 1 certification may increase the consistent recommended use of the BTF guidelines for the care of severe TBIs.

Following a mild head injury (MHI), a person may report a variety of symptoms such as headache, memory disturbance, dizziness, and concentration difficulties. For most persons the symptoms are transient, but some suffer persistent symptoms that can have a major impact on everyday life. It remains poorly understood why some but not others have full recovery after MHI. The aim of this thesis was to investigate outcomes after MHI, with particular focus on neuropsychological functioning, fatigue, and risk of dementia. A related objective was to examine the potential association of a genetic factor, Apolipoprotein (APOE), with MHI outcome. The APOE є4 allele has been associated with unfavorable outcomes after moderate or severe head injury, but little is known about its influence on outcome after MHI. In Study I and II, data from a population-based longitudinal study were used to compare neuropsychological functioning and fatigue before and after MHI. The results from Study I showed a post-injury decline in neuropsychological performance for є4-carriers, whereas the performance remained unchanged for non-carriers. Study II showed an increase in self-reported fatigue after MHI for both є4-carriers and non-carriers, with a more pronounced increase for є4-carriers. In Study III, a case-control study was conducted to examine whether a history of MHI increased the risk of developing dementia later in life. It was found that MHI alone did not increase the risk, but the combination of MHI and APOE є4 was associated with increased risk of dementia. Taken together, the studies generally indicate a positive outcome after MHI, but in combination with APOE є4 even mild head injury may lead to long-lasting negative outcomes. Consideration of pre-injury level of functioning and genetic factors seems critical for a complete understanding of the impact of MHI.

No description available.

No description available.

Introduction: Older adults have been shown to be particularly vulnerable to the effects of mild traumatic brain injury (mTBI). However, limited research exists that examines the information and support received by older adults after a TBI, despite suggestions that input may be insufficient. We therefore aimed to evaluate the information and rehabilitative support received by individuals after mTBI, and to determine whether there were any age-related differences. Method: Adults (n = 250) who presented at the Christchurch Hospital Emergency Department over a 12 month period, with a diagnosis of mTBI were invited to participate in the study. Of these, 106 consented and 80 were able to be contacted for follow up. Participants were aged 18-85 years (M = 48) and evenly distributed into four age groups (18-30, 31-50, 51-65 and 66-85 years). Participants were interviewed over the phone using a questionnaire developed in a pilot study. Questions focussed on information and treatment received after the participants’ injury, as well as questions about cognitive and mood problems following the injury. Data was analysed both quantitatively and qualitatively. Results: There were no significant differences between age groups for the number of post-TBI symptoms reported by participants. However, as predicted, the post-injury information and assistance received were inconsistent and differed across groups: 25% of all participants did not receive any information after their TBI, and older adults were the least satisfied with the information received. Post-injury assistance was most commonly offered by friends, family and significant others, but this may not have been sufficient to encourage complete recovery. Participants made suggestions for assistance and support that they would have liked following their injury. Conclusions: The current study has significant implications for the treatment of mTBI as ill-informed and neglected patients are unlikely to return to pre-injury functioning and mental state. Furthermore, a rapidly increasing older population makes immediate attention to mTBI in older adults imperative.

Inledning: Bandy har en låg skadeincidens med cirka 7 skador per 1000 matchtimmar. Den vanligaste skadelokalisationen är ansiktet som står för ca en tredjedel av rapporterade skador. Eftersom antalet studier inom bandy är begränsat, finns anledning till att öka kunskapen om skadepanoramat, för att på sikt kunna arbeta förebyggande för att minska antalet skador. Syfte: Att med en kvantitativ ansats analysera rapporterade skador i elitseriebandy herrar 2007-2012. Metod: Resultatet av samtliga inrapporterade skador mellan 2007-2012 har analyserats. Materialet bestod av det totala antalet individer från lag som rapporterat skador, totalt 378 spelare. Resultat: Totalt rapporterades 97 skador under 2007-2012. Av dessa klassades 36 % (35/97) som allvarliga, det vill säga spelaren bedömdes avstå träning samt match mer än sju dagar. Ansiktsskador stod för 28 % (29/97) av skadorna. Slutsats: Studien visade i att ansiktsskador var den vanligaste skadelokalisationen, och att andelen allvarliga skador i likhet med tidigare studie inom elitbandy var hög. Nyckelord: ansiktsskada, bandy, retrospektiv, skadeprevention / Introduction: A low injury incidence has been reported from elite bandy (approximately 7 injuries/1000 game hours). The most common location was in the face, which represent about 30% of reported injuries. However, the studies are few and more knowledge is needed to support planning of preventive measures. Objective: To investigate injuries in Elite male bandy the years 2007-2012. Method: All reported injuries from participating teams in the Swedish professional 2007-2012 has been analysed. The participants consisted of 378 players followed between one and four seasons. Result: Totally, 97 injuries were reported during 2007-2012. Of those were 36 % (35/97) classified as severe, meaning that the player could not participate in training or games for at least 7 days. Facial injuries represent 29 % (28/97) of total injuries. Conclusion: Present study show similar results as previous report that face injuries is the most common injury in male elite bandy, and that the share of severe injuries is high. Key words: bandy, facial injury, injury prevention, retrospective

Traumatic Brain Injury (TBI) accounts for 1,000,000 hospital admissions in the European Union every year and is the leading cause of death in individuals under 45 years of age in both Europe and the United States. This thesis examines the consequences to both the brain and lung following TBI using the lateral fluid percussion injury (FPI) in an in-vivo murine model. In the murine FPI model, alongside cerebral inflammation (associated with neuronal damage and the infiltration of inflammatory cells), there is significant neutrophil accumulation within the pulmonary interstitium 6 and 24 hours after TBI. This was associated with pulmonary haemorrhage and increased vascular permeability. In an attempt to reduce pulmonary injury, 17-DMAG, an HSP90 inhibitor, was applied but proved to be nonprotective. Since patients with TBI show increased susceptibility to bacterial infection, microaspiration and ventilator-induced lung injury, a double-hit model was established whereby mice first received the head injury and then received a lung injury. This demonstrated worse lung injury following intra-tracheal administration of hydrochloric acid after TBI. Depleting neutrophils with an anti-LY-6G depleting antibody improved outcome in this model, indicating increased susceptibility to damage was neutrophil dependent. To test whether neutrophil accumulation within the pulmonary interstitium was specifically related to brain injury, lung tissue following other distant organ injury such as renal ischemia-reperfusion injury (IRI) and renal transplantation were assessed. Significant pulmonary interstitial neutrophil accumulation was seen following both models and was associated with significant pulmonary haemorrhage. Inducing HSP70 activity with an HSP90 inhibitor was shown to be protective by reducing the degree of pulmonary haemorrhage in these models. In an attempt to identify the mechanisms behind neutrophil accumulation in TBI, renal IRI and renal transplantation, ICAM-1 (CD54), a marker of the reverse transmigration of neutrophils was investigated. No differences in ICAM-1 expression were seen following TBI, indicating that another mechanism must be responsible. This mechanism is the focus of on going work within the laboratory. Hypoxia is believed to contribute towards the development of secondary brain injury however little is known regarding its direct contribution. Working alongside chemists at the University of Edinburgh, a number of novel fluorescent hypoxia probes were designed and tested, but none proved to be able to detect hypoxia in-vitro. In conclusion, this thesis has demonstrated that following mild TBI, the lungs are “primed” with a massive interstitial neutrophil influx and that a subsequent micro aspiration of acid induces exaggerated lung injury. The mechanism by which this occurs is the focus of on-going investigation. Pulmonary sequestration of neutrophils is also a predominant feature of other distant organ injuries.

Hypertonic saline (HS) is an accepted treatment for traumatic brain injury (TBI). However, the behavioral and cognitive consequences following HS administration have not thoroughly been examined. Recent preclinical evidence has suggested that nicotinamide (NAM) is beneficial for recovery of function following TBI. The first study compared the behavioral and cognitive consequences of HS and NAM as competitive therapeutic agents for the treatment of TBI. Following controlled cortical impact (CCI), bolus administrations of NAM (500 mg/kg), 7.5% HS, or 0.9% saline vehicle (1.0 mL/kg) were given at 2, 24, and 48 hrs post-CCI. Behavioral results revealed that animals treated with NAM and HS showed significant improvements in beam walk and locomotor placing compared to the Vehicle group. The Morris water maze (MWM) retrograde amnesia test was conducted on day 12 post-CCI and showed that all groups had significant retention of memory compared to injured, Vehicle-treated animals. Working memory was also assessed on days 18-20 using the MWM. The NAM and Vehicle groups quickly acquired the task; however, HS animals showed no acquisition of this task. Histological examinations revealed that the HS-treated animals lost significantly more cortical tissue than either the NAM or Vehicle-treated animals. HS-treated animals showed a greater loss of hippocampal tissue compared to the other groups. In general, NAM showed a faster rate of recovery than HS without this associated tissue loss. Study 1 suggested that future research into HS should include drug injection time course studies. Multiple injections may be responsible for the notable tissue damage. Therefore, it is possible that fewer injections will result in comparable behavioral recovery and less tissue damage that was observed. Due to the detrimental effects of 7.5% HS on cognition and hippocampal tissue following multiple administration in study 1, the proposed second study sought to study the behavioral and cognitive effects of HS using either single or multiple injection regime. The proposed study entailed a lengthier testing schedule than in study 1 and included the same histological examination to compare the different dosages. Additionally, edema formation was measured 24 hours following each drug endpoint in order to delineate the possible underlying mechanism of the observed deficits. In Study 2, HS tended to improve function on motor, sensorimotor and neurological tasks. Although this was a trend on all tests, animals treated with a single administration of HS overall performed better on all tasks compared to those receiving double or multiple injections. In the retrograde amnesia test, although not significant, the Sham, HS-2, and HS-24 animals showed improvement; whereas, the Vehicle and HS-48 animals showed no improvement in performance. This could possibly be linked to the additional hippocampal tissue loss that was noted in the HS-48 animals. In the working memory paradigm, the HS-2 and Vehicle groups had longer latencies to reach the platform than did the Sham group. However, after the first testing day, there were no significant differences between any of the groups. All animals treated with HS performed at the same rate and their performance either stayed the same over the three day testing period or became worse. It appears these animals were unable to learn and improve in the new memory acquisition task which is comparable to the results found in study 1. In study 1, there were again no observed hippocampal volume differences between the Sham and Vehicle-treated animals. However, there was extensive hippocampal tissue damage observed in all of the HS groups. Furthermore, animals treated with a single administration of HS had less hippocampal loss than those with double or multiple doses. Those animals receiving more than one dose of HS lost significantly more hippocampal tissue than the Vehicle group. The results of study 2 are comparable, and support, the results of study 1. Both studies support the strengths and weakness of HS therapy following TBI. Although there are potential benefits of HS therapy, there are also detrimental risks involved. Cognitive and structural damage could possible occur if the dosage amounts are not closely studied and monitored. Although the use of HS may be beneficial to reduce ICP following TBI, it appears that the use of HS may also lead to direct or indirect tissue loss possibly by chronic cellular dehydration. Stronger or more delineated effects may be noticed using higher doses or concentrations of HS in future studies. However, due to the nature of these results, caution should be advised with the use of all therapeutic usage of HS until further detailed studies are conducted.

Concussions are injuries that can result in debilitating symptoms, suffered by people of all ages, with children being at elevated risk for injury. Falls account for over 20% of head injuries worldwide, and up to 50% of concussive injuries in children. Following a concussion, children typically take longer for symptoms to resolve compared to adults. It is unknown whether or not children are more, less, or equally susceptible to concussive injury based on the mechanical response, with researchers divided on the subject. There is currently a paucity of published data for concussive injuries in children, with few studies investigating impact biomechanics and strain response in the brain using FE models. Those that exist typically rely on scaled adult models that do not capture age-dependent geometric properties, material properties of tissues, and the developmental stage of the brain reflected by the patterns of grey and white matter within the brain. Newer child models are being developed, however at present they are focused on car crash investigations that do not offer an accurate reflection of sports-related impacts, and those that could be experienced from day-to-day activities since impact characteristics (e.g. magnitude, duration, surface compliance) differ largely between these types of events. Strain magnitudes differ between events causing concussion in adults (falls, collisions, punches, and projectiles), so it follows that the unique impact characteristics of car crash events do not typically coincide with those associated with sports impacts. Car crash events can result in much longer impact durations compared to sporting impacts (100 ms duration in car crashes vs. 5-30 ms in sports impacts). The purpose of this thesis was to assess how the mechanical response of the brain in young children near 6 years old differs from an adult brain in cases resulting in concussive injury for sports impacts. Study one created a novel FE model of a 6-year-old brain, using medical images to extract an accurate representation of the geometry and tissues inside the head of a 6-year-old child. The developmental stage of the younger brain was captured using a highly-refined mesh to accurately represent the folds of white matter within the cerebrum. With no intracranial data for child cadavers available, published data of adult cadavers was used to validate the brain motion from impacts. Comparisons were made to a scaled adult model to highlight how the different model constructions influence brain motion and resulting strains. The new model showed higher correlation to the cadaver data compared to the scaled model, and yielded “good biofidelity” measures when assessed using a modified version of the normalized integral square error method. For young children, the new model was proposed to be more appropriate for concussion investigations as it captures age-appropriate geometry, material properties, and developmental stage of the brain, reflected in the patterns and volumes of grey and white matter within the brain. Study two tested the model for sensitivity across three levels of surface compliance and impact velocity consistent with sport impact events, and compared strain responses to a scaled adult model. The 6-year-old model showed unique strain responses compared to the scaled adult model with peak strains being lower across most impact events. Strain patterns also differed between models, with less strain being transmitted into the white matter in the 6-year-old model. Low compliance impacts yielded highest differences in strains (~30%), moderate compliance impacts yielded more similar strains (~9% lower), with high compliance impacts showing a location dependent response with frontal impacts being 14% lower, and side impacts being 9% higher than the scaled model. The sensitivity study characterized the model responses, allowing for better comparisons between the two different model constructions. Study three then compared the strain responses of reconstructed real-world concussive events for both children and adults. Forty cases of concussion from falls in children and adults (20 children aged 5-7, 20 adults) were reconstructed using physical models, with the measured impact kinematics used to load the FE models. Concussive cases of children showed lower strains than adults, finding a velocity driven relationship since the child concussions occurred at lower impact velocities compared to the adults. Lower peak strains, as well as cumulative strains in the child cases suggest that children are vulnerable to concussion at lower strain compared to adults. Protective strategies for children should address this vulnerability, no longer relying on product scaling to create head protection for youth.

A Thesis submitted to The University of Arizona College of Medicine - Phoenix in partial fulfillment of the requirements for the Degree of Doctor of Medicine.