Adolescence is a risk period for offending and head injury (HI), with rates of HI in young offender populations frequently exceeding those in the community. Poor parenting practices have been associated with increased risk of offending and development of reactive and proactive aggression. Preliminary research suggests HI may discriminate offender profiles within young offenders, but the influence of HI on offending alongside parenting and aggression is less well known. This study explored the relationships between parenting practices, reactive and proactive aggression, HI and offending in a sample of male young offenders from a Young Offender Institute (n=98) using self report data. A history of at least one HI was reported by 73.5%, with 61.1% reporting a knock out from their worst HI. Poor supervision emerged as a key predictor: predicting knock out history, indicators of offending and reactive and proactive aggression. Repeated HI was predictive of reactive aggression and a knock out history predicted earlier age of first offence. The impact of HI on outcomes via neuropsychological sequelea or as a “marker” for contextual risk factors such as poor supervision and reactive aggression are examined. Clinical implications for young offenders are discussed.

The purpose of this study was to examine the effects of aerobic fitness level on concussion risk, severity and recovery in high school football players. Participants (N=158) completed aerobic fitness (i.e., estimated VO2 max) and baseline neurocognitive tests (i.e., ImPACT). Concussed athletes completed ImPACT every 24-72 hours until they were asymptomatic or returned to baseline levels. A post-season questionnaire assessed unreported concussions and symptoms. Twenty players incurred concussions. Previously concussed athletes were 3.71 times more likely to be concussed than those with no concussion history. Severely concussed participants reported lingering symptoms. Previously concussed athletes high in aerobic fitness reported fewer symptoms than those low in aerobic fitness. Non-significant trends suggested that aerobic fitness might be related to faster recovery times and fewer symptoms. Twenty-eight percent (n= 38) of non-concussed participants reported a potential concussion and symptoms that were not recorded by medical staff during the season.

Chronic Traumatic Encephalopathy (CTE) is a neurodegenerative disease that is associated with repetitive traumatic brain injury like those sustained in sport, military combat, and other activities with repetitive head impact exposure. Repetitive head impacts typically cause mild traumatic brain injury (mTBI) resulting in both concussive and subconcussive injury. Repeated mTBIs injuries appear to cause an abnormal accumulation of proteins, including hyperphosphorylated tau (p-tau) and TDP-43, progressive axonal failure with gradual structural degradation, microvascular disruption, breach of blood-brain barrier, neuroinflammation and microglial activation; each of these manifestations lead to axonal degeneration and neuronal death, which impairs neuronal pathways and are likely to give rise to CTE symptoms. CTE can be microscopically characterized mainly by p-tau accumulation in perivascular spaces and at the depths of the cortical sulci. Clinical presentation of CTE may include behavioral, mood, cognitive, or motor symptoms. Some of the common symptoms include impulsivity, aggression, anxiety, depression, memory impairment, dementia, and suicidality. The Locus Coeruleus (LC), a nucleus in the pons of the brainstem, is suspected to be involved in CTE. The LC provides the main source of norepinephrine to the entire brain and is critical for its control over arousal, behaviors, attention, and memory. Dysfunction of the locus coeruleus has shown to cause a wide array of symptoms, many of which are similar to those seen in CTE. Furthermore, the LC is affected in many other neurodegenerative diseases and is believed to be responsible for the progressive and widespread nature of the various diseases and their clinical symptoms. Although the LC has been implicated in CTE there have been no studies examining LC pathology in relation to the disease progression or its symptoms. We hypothesize LC CTE pathology should increase with the severity of CTE. Furthermore, increased CTE pathology in the LC should create disturbances to the LC and the LC-NE system and manifest clinically. Specifically, LC CTE pathology may be associated with age of onset of general behavioral and cognitive symptoms as well as individual symptoms and outcomes including impulsivity, depression, depressed mood and death by suicide. To determine this, a postmortem study was performed on 184 individuals with a history of RHI and no comorbid diseases examining the relationship between AT8-immunopositive tau density in the LC and various clinical variables. The study found that LC AT8 density showed a significant positive correlation with duration of repetitive head impact (RHI) exposure when controlled for age. There also was a significant increase in LC AT8-immunoreactive tau in cases with stage III and IV CTE compared to those with no CTE and stage I and II CTE, and AT8 density was predictive of CTE stage when controlled for age. There were no significant relationships found between density of LC AT8-immunoreactive tau and age of any CTE symptom onset or individual symptom (impulsivity, depressed mood, MDD, death by suicide) presence. Future studies should continue to evaluate CTE pathology in the LC and its effects on both the pathological and clinical characteristics of the disease.

Design This is a cross-sectional study involving quantitative measures and qualitative interviews. Participants Sixteen brain injured men and four brain injured women participated. Eighteen of these had a close relative who also took part. Measures In addition to being interviewed, brain injured participants completed questionnaires on mood symptoms and fatigue, and a speed of information processing task. Relatives of brain injured people were interviewed and completed the symptom checklist. Correlational analysis was applied to the quantitative measures and- qualitative analysis was informed by the grounded theory approach. Results Quantitative measures suggest significant association of subjective perception of fatigue severity with mood and brain injury related symptoms. Relatives' objective perceptions of brain injured relatives' symptoms correlated significantly with subjective views. Subjective perception of fatigue did not correlate significantly with severity of brain injury or information processing speed. Qualitative analysis identified fatigue as a major problem for some people. Descriptions noting the impact of fatigue following injury included increased slowness, decreased energy, and lack of control. Fatigue was commonly considered to be more mental than physical, and was often linked with short temper. Conclusions Findings suggest that fatigue was related less to severity of injury than to psychological and emotional factors. The multidimensional nature of fatigue was confirmed. Links were made with low-mood, anxiety, lack of motivation, boredom, and having to cope with 'normal life' following brain injury. The possibility that 'fatigue' is an umbrella term used by some to describe a range of symptoms following brain injury was considered.

La patología de origen traumático, cuarta causa de mortalidad y primera en cuanto a años perdidos, es un relevante problema de salud, que ocasiona además una elevada morbilidad e incapacidad y un alto coste sanitario y social. El conocimiento de su abordaje se ha realizado mediante el análisis de bases de datos de pacientes y encuestas a profesionales. El presente trabajo de investigación va dirigido a conocer si la asistencia al paciente adulto con TCE en las UCI catalanas de referencia para esta patología es comparable en cuanto a epidemiología, abordaje y resultados, a los que muestra la literatura referente a otros países de nuestro entorno. Se planteó un estudio con un objetivo principal doble, por un aparte describir las características demográficas y clínicas de los pacientes y por otro analizar el abordaje terapéutico y la monitorización. Como objetivos secundarios se plantearon conocer la variabilidad de los apartados anteriores según la gravedad del TCE, conocer si la práctica clínica se adhería a las principales recomendaciones de las Guías de Práctica Clínica vigentes y conocer el resultado neurológico final de los pacientes, identificando las posibles variables epidemiológicas estudiadas que pudieran influir en el resultado neurológico y la presencia de de insultos secundarios que se producen. Se realizó un estudio observacional, multicéntrico y prospectivo en las 7 UCIs catalanas de referencia para esta patología. Se recogieron datos demográficos, clínicos, radiológicos, monitorización, terapéuticos, complicaciones y de resultado de los pacientes que ingresaban en una UCI afectos de un TCE, con o sin politraumatismo durante los primeros 15 días de estancia. Se incluyeron pacientes 370 pacientes durante un año.Los principales resultados muestran un predomina el sexo masculino, edad media de 40 años, causa principal el accidente de tráfico. Un 36% de los casos ingresaron directamente en el centro de referencia pero únicamente el 26% en los primeros 60 minutos. El perfil de gravedad del TCE fue un 53% Graves, 27% Moderados y 20% Leves, con una lesión encefálica predominante tipo II de Marshall (39%). La presencia de HSA fue del 49%. Se monitorizó la PIC en el 69% de los TCE grave, la SjO2 en el 27% y el DTC en el 50%. La intensidad de la monitorización y el uso de la terapéutica se incrementa de acuerdo a la mayor gravedad del paciente. Hay una alta adherencia para las recomendaciones de las guías de práctica clínica en lo que hace referencia a la utilización de monitorización sistémica y neurológica, la utilización de barbitúricos, y menor en cuanto a la utilización de corticoides, e hiperventilación. La tasa global de mortalidad en UCI fue del 22%, un 31 % para los graves. Las variables explicativas de "éxitus" fueron el estado de las pupilas, el tipo de lesión radiológica, el sexo y la gravedad del TCE. La presencia de complicaciones prehospitalarias (hipoxia, hipotensión, broncoaspiración, paro cardiorrespiratorio, hipotermia o convulsiones) se constata en el 15% de los pacientes y se asocia de forma acumulativa con un mal resultado.Como conclusión general este trabajo de investigación apoya la hipótesis inicial de que la atención al TCE en las UCI catalanas estudiadas es comparable en cuanto a epidemiología, abordaje y resultados, a los que muestra la literatura referente a otros países de nuestro entorno. Palabras clave:Head injury, traumatic brain injury, neurocritical care. / Trauma disease represents the fourth cause of mortality in frequency and the first one in terms of lifetime waste. It constitutes a significant health problem that provokes a high morbidity and incapacity in addition to striking health and social costs. Since now, its management approach has been done through patient data bases analysis and surveys directed to professionals. This research report attempts to elucidate epidemiologic, management and clinical results' comparability between actual adult BTI clinical practice in Catalan ICU's, which are of reference for this pathology, and practice shown in medical literature in our environment. The study was planned with a double main objective; for one part, to describe demographic and clinical patient characteristics, and for the second part, to analyse patient monitoring and therapeutic management. As secondary objectives we proposed to explore variability by BTI clinical severity, adherence rate to recommendations addressed in Clinical Practice Guidelines in force, and patient neurological outcome, identifying those epidemiologic parameters probably influencing neurological outcome, apart from secondary insults incidence. An observational and prospective study was conducted in 7 reference ICU's in Catalonia. Patient data collected covered demographic, clinical, radiological, monitoring and therapeutic aspects, besides complications and outcome variables for patients that were admitted in the ICU with a BTI diagnosis, with or without multiple trauma, that were followed in their length of stay for a 15-day period. A total of 370 patients were included in the study period of 1 year.Main results show a predominance of males with a mean age of 40, being traffic accident the main cause of BTI. 36% were directly admitted to the reference hospital, but only 26% were admitted in the first hour after the accident. The BTI severity profile was: 53% severe, 27% moderate and 20% mild, being the highest prevalence (39%) type II Marshall encephalic injury. The existence of SH was 49%. ICP was monitored in 69% of severe patients and SjO2 in 27% and TCD in 50%. Monitoring and therapeutic use was shown to increase depending on the higher patient severity. Close adherence to clinical guidelines recommendations was proven for systemic and neurological monitoring and barbiturate use, and was lesser the adherence for hyperventilation and corticoid utilization. ICU mortality rate was 22%, raising 31% for severe patients. Dependent variables for mortality were found to be pupil status, type of radiological finding, sex and BTI severity. Pre-hospital complications (hypoxia, hypotension, bronchial aspiration, cardiac arrest, hypothermia, convulsions) were found in 15% of patients, and are cumulative associated with a worse outcome.As a general conclusion, this research report supports the initial hypothesis that BTI clinical practice reviewed in reference Catalan ICU's, is comparable to practice in other countries of our environment, as is shown from the medical literature published.

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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.

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.

Concussions are a problem in competitive sports with growing concern over the acute and long-term consequences of repetitive head trauma. Participation in sport increases risk of concussion, particularly contact sports including rugby, hockey and football (Harmon et al., 2013). In rugby league, there are between 8.0-17.5 concussions/1000 player hours, representing roughly 10-15% of all injuries in the sport (Gardner et al., 2015). Shoulder, head, hip and knee are reported to be the most common regions that impact the head and are responsible for the greatest number of concussive injuries in rugby (Cusimano et al., 2013; Fuller et al., 2010; Gardner et al., 2014; Toth, Mcneil, & Feasby, 2005). In each of the common injury events reported in elite men’s rugby, there are unique combinations of impact conditions which include effective mass, compliance, velocity and location of impact. The head-to-head event represents a low mass, low compliance event, whereby the hip and shoulder-to-head collisions represents high mass, high compliance events. Scientists have conducted research in an effort to describe incidence and mechanisms of concussive injury in rugby, however, little is known about the biomechanics of head injury in the sport (Fréchède & Mcintosh, 2009; Fréchède & McIntosh, 2007; McIntosh et al., 2000). The purpose of this thesis is to characterize dynamic response and brain tissue deformation for (1) hip-to-head, (2) shoulder-to-head, (3) knee-to-head, and (4) head-to-head concussion events in men’s rugby. Twenty-nine (29) impact videos of diagnosed concussive injuries associated with the four common injury events were reconstructed in the Neurotrauma Impact Science Lab. Head-to-head impacts were reconstructed in this study using a pendulum system, while hip, shoulder and knee to head impacts were reconstructed using the pneumatic linear impactor. Results of this study demonstrate that the common injury events resulting in concussion in elite men’s rugby have different dynamic response characteristics. Head-to-head events produced significantly greater peak linear and peak rotational acceleration, however no significant differences in maximum principal strain between the injury events. Results of this study can be useful in reducing rates and severity of concussive injury in rugby.