Trauma to the mandible can potentially increase our predictive accuracy for intracranial injuries (ICIs) because of the mandible's strength, anatomic proximity, and direct connection to the skull base. Our goals were to: 1) investigate the association of mandible fractures with traumatic brain injury (TBI) and intracranial lesions (ICLs); and 2) determine predictors of ICIs in a level 1 Canadian trauma center with distinct patient demographics and fracture etiologies.
A retrospective chart review was performed of medical records of mandible-fracture patients treated at our institution from 1997 to 2003. Patients who had undergone postinjury computed tomography (CT) of the head with a minimum of 4 weeks' follow-up were considered eligible. Data collected included patient and fracture characteristics, neurologic evaluation, and the presence of concomitant injuries.
One hundred eighty-one patients were reviewed, of whom 86 were found eligible, with demographics representative of an urban-trauma population. The incidence of TBI was 68.6%, and of ICLs, 27%. Logistic regression identified alcohol (odds ratio [OR], 3.97), concomitant facial fracture (OR, 2.77), and other systemic injury (OR, 2.59) as independent predictors of an ICI in mandibular fracture patients. Importantly, ICIs were observed in 19% of mandible-fracture patients, satisfying the criteria for mild TBI, and in 17% of patients without any evidence of TBI.
Some authors have advocated treating mandible fractures on an outpatient basis, with a focused workup. Our results of significant concomitant ICI in mandible-fracture patients, conversely, suggest that such management may inadvertently result in the oversight of potentially life-threatening injuries. Thus, we recommend mandatory intracranial CT imaging if the patient's neurologic status at time of injury is unknown or meets the criteria of TBI, or if positive predictors for ICL are present.
This brief clinical report demonstrates the necessity of supplementary examination methods for precise maxillofacial trauma diagnostics, especially in patients with combined injury. It describes the unusual case of mandibular fracture in a young lady on the day of her wedding.
Cerebral ischemia-reperfusion (I/R) injury initiates a cascade of events, generating nitric oxide (NO) and superoxide(O2•-) to form peroxynitrite (ONOO-), a potent oxidant. Arctic ground squirrels (AGS; Urocitellus parryii) show high tolerance to I/R injury. However, the underlying mechanism remains elusive. We hypothesize that tolerance to I/R modeled in an acute hippocampal slice preparation in AGS is modulated by reduced oxidative and nitrative stress. Hippocampal slices (400µm) from rat and AGS were subjected to oxygen glucose deprivation (OGD) using a novel microperfusion technique. Slices were exposed to NO, O2.- donors with and without OGD; pretreatment with inhibitors of NO, O2.- and ONOO- followed by OGD. Perfusates collected every 15min were analyzed for LDH release, a marker of cell death. 3-nitrotyrosine (3NT) and 4-hydroxynonenal (4HNE) were measured to assess oxidative and nitrative stress. Results show that NO/O2.- alone is not sufficient to cause ischemic-like cell death, but with OGD enhances cell death more in rat than in AGS. A NOS inhibitor, SOD mimetic and ONOO- inhibitor attenuates OGD injury in rat but has no effect in AGS. Rats also show a higher level of 3NT and 4HNE with OGD than AGS suggesting the greater level of injury in rat is via formation of ONOO-.
Cites: Free Radic Res Commun. 1993;18(4):195-9 PMID 8396550
Cutoff scores suggested by Millis, Putnam, Adams, and Ricker (1995) for detecting suboptimal performance on indices from the California Verbal Learning Test (CVLT) were evaluated using data from 193 compensation-seeking participants. All participants claimed to have suffered a blow to the head in an accident causing subsequent deterioration in cognitive function. The participants were divided into those with negligible or possible mild brain injuries and those with clear evidence of moderate to severe brain injuries. In addition to the CVLT, all participants were administered the Computerized Assessment of Response Bias (CARB), a two-alternative forced choice test of recognition memory that is used to detect feigned cognitive impairment. For all CVLT indices, the distributions of outcome (valid vs. suboptimal performance) was unrelated to age and brain injury severity, and only weakly associated with education. However, a significantly higher proportion of males than females obtained scores in the suboptimal performance range. The CVLT indices were not fully redundant with each other with respect to binary participant classifications; substantial disagreement between pairwise classifications was found among those participants who obtained at least one score in the suboptimal performance range. CVLT index classifications were also found to be non-redundant with classifications based on CARB scores. The CVLT may thus add useful data over and above that obtained from symptom validity testing. However, the data suggest that the use of the strategy where any one or more below-cutoff CVLT scores are considered a positive indicator of suboptimal performance may be associated with a higher than acceptable false-positive error rate.
To investigate the characteristics and inpatient rehabilitation outcomes of persons who sustained a traumatic brain injury (TBI) resulting from physical assault - a form of intentional TBI - and compare these outcomes to those of persons with TBI resulting from other aetiologies.
A prospective population-based cohort study using inpatient rehabilitation data from Canadian population-based administrative databases for the fiscal years 2001-2006. Outcome measures were measures of functional independence (motor and cognitive), as measured by the FIM™ Instrument, and discharge destinations.
Characteristics associated with intentional TBI were being male, younger in age and unemployed; living alone and having a greater likelihood of alcohol/drug abuse prior to admission. The intentional TBI group showed poorer total functional gains at discharge from inpatient rehabilitation. Multivariate regression analyses showed that persons with intentional injury were less likely to be discharged home.
Persons with TBI from physical assault are a distinct clinical group in Canadian inpatient rehabilitation settings. These findings can support clinicians in determining proper assessment, management, discharge planning and post-rehabilitation care that target specific needs of persons with TBI resulting from physical assault.
Clinicians should have appropriate training to properly assess the mental health status of this patient group. Inpatient rehabilitation facilities should be prepared to provide services targeting psychosocial, substance abuse and interpersonal relationship issues to persons with a TBI from physical assault while patients are still within a hospital setting. Follow-up clinical care and community support services are warranted for those with intentional TBIs, including provision of occupational rehabilitation services, such as vocational rehabilitation. The discharge team should be responsible for ensuring appropriate discharge to community in the absence of family or other advocates on behalf of the patient.
Community integration is considered an ultimate goal for rehabilitation after traumatic brain injury (TBI).
To determine (a) whether differences exist in rehabilitation outcomes between intentional and unintentional TBI populations and (b) whether TBI from assault is a predictor of community integration following inpatient rehabilitation.
Retrospective cohort study using population-based data from Canadian hospital administration records, 2001 to 2006. Outcome measure was the Reintegration to Normal Living Index (RNLI).
From a sample of 243 persons, 24 (9.9%) had sustained TBI from physical assault. Persons with TBI from physical assault reported significantly lower scores on two items on the RNLI's Daily Functioning subscale: "recreation" and "family role."
These findings suggest that targeted intervention in these specific areas could be beneficial, which are often primarily addressed by occupational therapists in both inpatient rehabilitation and community settings.
Information concerning all deaths resulting from head injuries in children aged 0-15 years in the County of Ringkøbing during the period 1.1.1982-31.8.1989 was reviewed retrospectively. As might be anticipated, the great majority of accidents occurred in traffic (77.1%). Young children who were pedestrians were struck by motor vehicles while the older children were struck while cycling. Where pedestrians were concerned, there was, as a rule, insufficient supervision when the accident occurred. Children who were killed while cycling had not employed bicycle helmets. Relatively many children were killed on farms (17.1%) and the common feature of these accidents was that simple safety rules had not been observed. It is concluded that nearly half of all the accidents could have been avoided if simple prophylactic measures such as supervision and screening of machines and working areas had been observed.
Discharge against medical advice (DAMA) have consistently been reported as causing adverse outcomes for both patients and service providers. However, little is known about the DAMA of patients with traumatic brain injury (TBI). The objectives of this study were to develop a risk profile of DAMA patients in the TBI population, to examine factors associated with DAMA occurrence, and to examine specifically whether injury intention (unintentional vs. intentional) is a significant predictor of DAMA.
A retrospective cohort study was conducted using hospital discharge data obtained from the Minimal Data Set (MDS) of the Ontario Trauma Registry for the years 1993/1994 and 2000/2001 on TBI patients aged 15 to 64 years.
The MDS review yielded 15,684 cases of TBI with an average length of stay of 2.7 days. Of these, 446 (2.84%) had recorded DAMA events. When compared with patients with unintentional TBI, DAMA was significantly associated with intentional injuries in those with self-inflicted TBI (adjusted odds ratio [aOR] = 1.97; 95% confidence interval [CI], 1.36-2.84) and other-inflicted TBI (aOR = 2.00; CI, 1.53-2.62). DAMA was also associated with younger age and a history of alcohol/drug abuse (aOR = 3.50; CI, 2.85-4.30).
TBI patients who leave hospital against medical advice are a high-risk population. Early identification of these patients could allow implementation of better prevention and management strategies, thus improving health outcomes and enhancing healthcare delivery.
Fifty former amateur boxers were examined and compared with two control groups of soccer players and track and field athletes. All subjects were interviewed regarding their sports career, medical history, and social variables. They underwent a physical and a neurologic examination. Personality traits were investigated and related to the platelet monoamine oxidase activity. Cerebral morphologic changes were evaluated using computed tomography and magnetic resonance imaging. Further, clinical neurophysiologic tests were made as well as neuropsychologic tests. No significant differences were found between the groups in any of the physical or neurologic examinations or in platelet monoamine oxidase activity. Socially, the boxers had a lower degree of education and had chosen less intellectual professions, but they were less impulsive and more socialized. The computed tomography images and magnetic resonance imaging studies showed no significant differences between the groups. There was a significantly higher incidence of slight or moderate electroencephalography deviations among the boxers. Neuropsychologically, the boxers had an inferior finger-tapping performance. Thus, no signs of serious chronic brain damage were found among any of the groups studied. However, the electroencephalography and finger-tapping differences between the groups might indicate slight brain dysfunction in some of the amateur boxers.
Comment In: Am J Sports Med. 1993 Sep-Oct;21(5):7648238728