Editor’s Letter
A big Thank You to all the nurses, doctors, support staff, and blood donors that gave of themselves to help the victims in Aurora, CO last month. Our thoughts are with you.
This month I am focusing my attention on traumatic brain injuries. The field is huge, so I am spotlighting a few things of interest. TBI, or traumatic brain injury, has been a hot topic in the news lately because of several contributing factors that I will mention in this introduction but not go into great detail about, specifically. The first of which is the state of our returning combat veterans and wounded military personnel; TBI is being called the signature injury for the wars in Iraq and Afghanistan by the VA, with 20% of returning veterans suffering TBI’s. Secondly, there are the random acts of violence we read in the headlines almost daily such as the shooting of US Representative Gabrielle Giffords and the severe beating of the young Florida girl, Josie Lou Ratley, by a fellow student. Lastly, there have been news reports about chronic traumatic encephalopathy (CTE), the longterm effects to the brain caused by concussive injuries sustained by athletes young and old. The media has focused on professional athletes like Ray Easterling, Junior Seau, and Dave Duerson that took their own lives and donated their brains for study. Combat soldiers injured in blasts, and athletes involved in impact sports both show characteristics of CTE. CTE can cause dementia like symptoms, emotional and personality changes, and memory disturbances, among other potential symptoms.
I hope you enjoy reading this month’s newsletter as much as I enjoyed putting it together. As always, if you have a topic of interest that you would like to see included in our newsletter, a story you would like to share, or if you know someone who might like to receive our newsletter, please contact me at newsletter@nurserecruiter.com.
Christine Thompson
Editor, NurseRecruiter.com Newsletter
What is TBI?
There are many avenues to a traumatic brain injury (TBI): skull penetrating forces like bullets, brain swelling caused by diseases like meningitis, cerebrovascular accidents (CVAs), concussive forces like explosions, blunt force trauma, car accidents of varying degrees, and the more recently studied cause of TBI, impact sports, like football, where damage is often the cumulative effect of repeated trauma.
These types of injuries can be minor to severe and can happen when a person is rear ended in a car accident, for example, even at 30 MPH. The head is thrown forward and back again with such force it actually causes the brain, like a soggy sponge, to impact the sides of the skull causing direct injury to the brain.
A closed head injury can be difficult to initially assess because there is not an obvious wound to be treated and damage occurs quickly once the brain begins to swell. Once the damage is done, the prognosis is poor for total recovery, but advances in research, treatment, and rehabilitation help improve the lives of patients.
The brain is not the unknowable black box it used to be, but there is much that is still not known about the effects of disease and injury on the brain. This is why studies like the Human Brain Project spotlighted in the June 2012 copy of Scientific American, and other brain research studies are so important.
The Human Brain Project is a collaborative effort to create a digital human brain. Researchers will then sign up for time to use the program (kind of like astrophysicists share the Very Large Array in New Mexico) to run their specific experiments.
More than 20% of US combat soldiers returning home from Iraq and Afghanistan suffer from TBI’s. It is due in large part to this high number of affected individuals that research hospitals are turning their focus to the studies of brain injuries and rehabilitation of patients.
The Michael E. DeBakey VA Medical Center in Houston, Texas was awarded a large research grant by the VA Office of Research and Development to create a VA Rehabilitation Research Center of Excellence with the central focus on mild traumatic brain injuries. The Center, led by Harvey Levin, PhD has several ongoing studies evaluating service members and veterans of Operation Enduring Freedom (OEF), Operation Iraqi Freedom (OIF), and Operation New Dawn (OND).
Rehabilitation Hospitals, like TIRR in Houston Texas, and Craig Hospital in Englewood Colorado, are 2 among 16 hospitals renowned for their model systems of care by the National Institute on Disability and Rehabilitation Research (NIDRR). These facilities are participating in what is being called “The first prospective, longitudinal multi center study ever conducted which examines the course of recovery and outcomes following the delivery of a coordinated system of acute neurotrauma, and inpatient rehabilitation”. The study also includes a large scale follow-up that monitors participants 20 years post injury.
Head injuries cause mild to drastic changes in thinking, sensation, language, and emotion. Changes can be cursory or life long. Traumatic brain injuries are also correlated with patients developing issues later in life such as CVA’s (strokes), Parkinson’s Disease, seizure disorders like epilepsy, Alzheimer’s Disease, and chronic traumatic encephalopathy (CTE), which is thought to stem from repeated head injuries that lead to permanent cognitive impairments over time. CTE is a neuro-degenerative disease that is only diagnosable postmortem when a brain biopsy can be performed.
Chronic traumatic encephalopathy. (2012, July 27). In Wikipedia, The Free Encyclopedia. Retrieved 20:07, July 14, 2012, from http://en.wikipedia.org/w/index.php?title=Chronic_traumatic_encephalopathy&oldid=504485138
http://www.houston.va.gov/TBI.asp
http://www.memorialhermann.org/newsroom/content.aspx?id=10941
http://www.craighospital.org/
http://articles.nydailynews.com/2012-05-17/news/31753323_1_brain-injuries-brain-tissue-signature-injury
http://www.stripes.com/news/new-study-links-exposure-to-even-a-single-bomb-blast-to-serious-lifelong-brain-disease-1.177400
http://edition.cnn.com/2012/05/16/health/concussion-brain-disease-vets/index.htm
http://www.defense.gov/News/NewsArticle.aspx?ID=67990
Federation of American Societies for Experimental Biology (FASEB) (2012, April 22). Estrogen hormone reveals protective ability after traumatic brain injury. ScienceDaily. Retrieved July 19, 2012, from http://www.sciencedaily.com/releases/2012/04/120422162212.htm
Monash University (2012, July 19). Better management of traumatic brain injury.ScienceDaily. Retrieved July 21, 2012, from http://www.sciencedaily.com/releases/2012/07/120719212739.htm
SUNY Downstate Medical Center (2010, September 18). Drug combination may treat traumatic brain injury. ScienceDaily. Retrieved July 27, 2012, from http://www.sciencedaily.com/releases/2010/09/100917183029.htm
American Academy of Neurology (2012, February 19). New treatment for traumatic brain injury shows promise in animals. ScienceDaily. Retrieved July 27, 2012, from http://www.sciencedaily.com/releases/2012/02/120220090616.htm
Current TBI Research
Scientists all over the world are looking for ways to minimize the extent of damage to the brain when a head injury occurs. In Australia, researchers Professor Robert Medcalf and Dr Maithili Sashindranath at Monash University’s Australian Centre for Blood Diseases (ACBD), in conjunction with researchers at University of Geneva in Switzerland and the University of Michigan in the United States, have identified that by inhibiting certain enzymes that occur post trauma, can actually reduce the severity of the head injury. The researchers published their results from the 5 year collaborative study in the July 2012 edition of the neurology journal, Brain.
The two enzymes the researcher identified were tissue plasminogen activator (t-PA) which functions to break down blood clots, and matrix metalloproteinase-3 (MMP-3) which functions to break down extra cellular matrices. The two enzymes acting together after a head injury promote further damage to the brain tissue. Doctor Robert Medcalf reported, “…we found that the process of t-PA inactivation by one of its natural inhibitors actually contributed to brain injury, because it leads to the activation of MMP-3.” According to the study it is the MMP-3 that does the damage to the brain tissues. “Now we know that if we block MMP-3 with an inhibitor, we can protect the brain following TBI,” Professor Medcalf said.
Another area of TBI research involving novel-therapies and bio-markers is being conducted by Dr. Joshua Gatson, Assistant Professor of Surgery at the University of Texas Southwestern Medical Center in Dallas. Dr. Gatson’s most recent study involving TBI demonstrates that estrone, a naturally occurring estrogen in the body, provides anti-inflammatory and antioxidant capabilities.
The study was conducted on male rats. It compared giving either 0.5 mg of estrone or a placebo to rats 30 minutes after they sustained brain injury. The study showed that estrone is involved in promoting the brain-derived neurotrophic factor (BDNF), a protein, which acts on certain neurons to promote survival and growth of neurons. BDNF also is involved in long-term memory, learning, and executive brain functions. Dr. Gatson reported that, “BDNF, one of the main growth factors that regulates repair following injury, is actually increased following treatment with estrone after brain injury…So if you give this drug shortly after injury, it is thought to increase repair mechanisms.”
Scientists at Northwestern University were recently granted a patent for a potentially life saving medication currently referred to as MW151. MW151 is in Phase one human clinical trials. In experiments on lab mice MW151 showed that if it was given shortly after the head injury it worked to block “glial activation”.
Glial cells in the central nervous system act as a support team for neurons. They maintain a stable environment (homeostasis), make myelin (which insulates electrical pulses for the proper conduction of information in nerve cells), and generally protects neurons by destroying pathogens. The problem arises after a TBI when the glial cells release pro-inflammatory cytokines. Inflammation in the brain after an injury leads to further damage so, if inflammation could be reduced or prevented, devastating long term effects might be avoidable.
“If you took a drug like this early on after traumatic brain injury or a even a stroke, you could possibly prevent the long-term complications of that injury including the risk of seizures, cognitive impairment and, perhaps, mental health issues,” reported Mark Wainright, M.D. rom Northwestern University’s Feinberg School
New research in the field of traumatic brain injuries is vital for developing new treatments for brain injuries and improving the long term prognosis for patients.
Monash University (2012, July 19). Better management of traumatic brain injury.ScienceDaily. Retrieved July 21, 2012, from http://www.sciencedaily.com.
Tissue plasminogen activator. (2012, July 14). In Wikipedia, The Free Encyclopedia. Retrieved 19:13, July 28, 2012, from http://en.wikipedia.org/w/index.php?title=Tissue_plasminogen_activator&oldid=502268315
MMP3. (2012, July 23). In Wikipedia, The Free Encyclopedia. Retrieved 19:12, July 28, 2012, from http://en.wikipedia.org/w/index.php?title=MMP3&oldid=503780264
Federation of American Societies for Experimental Biology (FASEB) (2012, April 22). Estrogen hormone reveals protective ability after traumatic brain injury. ScienceDaily. Retrieved July 30, 2012, from http://www.sciencedaily.com-/releases/2012/04/120422162212.htm
Northwestern University (2012, July 24). New drug could treat Alzheimer’s, multiple sclerosis and brain injury. ScienceDaily. Retrieved July 30, 2012, from http://www.sciencedaily.com-/releases/2012/07/120724171302.htm
Neuroglia. (2012, July 20). In Wikipedia, The Free Encyclopedia. Retrieved 19:11, July 28, 2012, from http://en.wikipedia.org/w/index.php?title=Neuroglia&oldid=503301041
Multifaceted TBI Rehabilitation
Rehabilitation after a traumatic brain injury is very important to the personal independence and recovery of patients. Typically rehabilitation falls into one of a couple of categories and can be inpatient or outpatient in nature. Individuals who suffer brain injuries may receive rehabilitative treatments such as physical therapy, occupational therapy, speech therapy, and cognitive therapy, among others.
When an individual has suffered a significant TBI and the acute care hospital has determined them to be stable, the patient can then be transferred to a rehabilitation hospital where they will continue to receive care. They will work in a rehabilitation setting to recover and rebuild skills lost due to the TBI. Hospitals such as TIRR in Texas and Craig Hospital in Colorado work closely with individuals recovering from TBI, and also provide support for the affected family members. Once the patient is discharged from the rehabilitation hospital they will often continue rehabilitation by re-learning activities of daily living as well as learning compensatory strategies to improve independence and overall quality of life. Outpatient vocational rehabilitation programs are widely available to train, or retrain individuals so they are able to return to the workforce.
Multifaceted rehabilitation is important in recovery from TBI. In a recent study published in the January 2012, Journal of Neurotrauma, scientists asked the question, “Does an early onset and continuous chain of rehabilitation improve the long-term functional outcome of patients with severe traumatic brain injury?” The study was led by Nada Andelic, M.D., Ph.D. at the Department of Physical Medicine and Rehabilitation Oslo University Hospital Ulleval in Norway. Researchers evaluated whether patients who experienced a continuous rehabilitation chain starting in the acute phase of a severe TBI (which is hours to a few days after the injury) compared to the long-term functional outcomes of individuals who in the past had received non-continous rehabilitative treatments that started in the sub-acute phase of a TBI (which is from 4 to 21 days post injury). The study found that a continuous chain of rehabilitative treatment beginning early, such as in the acute phase of TBI, actually improved long-term functional outcomes for patients.
Nada Andelic, Erik Bautz-Holter, Pal Ronning, Kjell Olafsen, Solrun Sigurdardottir, Anne-Kristine Schanke, Unni Sveen, Sveinung Tornas, Maria Sandhaug, and Cecilie Roe. Journal of Neurotrauma. January 1, 2012, 29(1): 66-74. doi:10.1089/neu.2011.1811.
http://www.theinjuryco-op.com/bisubacute.html