Neurosurgery & Trauma

CHICAGO — Decompression of the spinal cord within 24 hours of injury is safe and is associated with improved neurologic recovery, results from an ongoing, prospective, multicenter study suggest.

“Certainly we're not going to be getting a home run with early surgery, but the concept here is to try for the best outcome we can,” Dr. Michael G. Fehlings said of the 1-year results of the Surgical Treatment of Acute Spinal Cord Injury Study (STASCIS).

The study included 170 patients who had a subaxial cervical spinal cord injury (SCI) and evidence of spinal cord or canal compression on MRI or CT. Of these, 44% were defined as an American Spinal Injury Association (ASIA) Impairment grade A with no motor or sensory function preserved; 22% were rated as grade B, 16% as grade C, and 18% as grade D.

Patients received decompression by surgery or traction within 7 days of SCI, and were stratified as “early” if it was within 24 hours of injury or “delayed” if it was after 24 hours.

A total of 94 patients, mean age 40 years, had early decompression surgery, and 76 patients, mean age 42 years, underwent delayed decompression. The investigators assessed outcomes in 108 patients at 6 months, and in 64 patients at 1 year.

At 6 months, 24% of early decompression patients had a 2-grade or greater improvement on the ASIA scale, compared with 4% who had delayed decompression, said Dr. Fehlings, head of the Krembil Neuroscience Centre at the University Health Network in Toronto. There weren't enough patients at 1 year to segregate the data by ASIA grade, but significantly more patients in the early group had a combined 1- and 2-grade improvement on the ASIA scale, compared with those in the delayed-compression group.

Complications, particularly respiratory complications and length of stay in the ICU, were reduced by about 15% in the early decompression group versus the delayed-treatment group (37% vs. 49%).

Dr. Fehlings and coinvestigators hypothesized that traction would be one of the primary means of achieving decompression, but it was used in only 29% of the early group and in 21% of the delayed group. Traction was also not as successful as was anticipated, with only a 50% success rate.

The Spine Study Trauma Group, a group of the world's top 40 spine surgeons, will publish in the next year consensus-based recommendations that patients with acute spinal cord injury without other life-threatening conditions should have early decompression surgery within 24 hours, Dr. Fehlings said in an interview at the annual meeting of the American Association of Neurological Surgeons.

Presentation discussant Christopher Shields of the Kentucky Spinal Cord Injury Research Center in Louisville suggested 8–12 hours may have been a more appropriate cutoff point for early intervention. Dr. Fehlings said that animal studies suggest the time window for optimal decompression after spinal cord injury occurs within 8–24 hours after SCI. Based on the differences in metabolic rate between rats and humans, an 8- to 12-hour window roughly translates into 24 hours for humans. Also, the logistics are substantial in terms of transferring a patient to an SCI treatment facility, and getting that patient medically optimized, imaged, taken to surgery, and decompressed.

“The Spine Trauma Study Group has deemed that 24 hours is the cutoff for early surgical intervention, although my colleagues and I try hard in every case to minimize this time,” said Dr. Fehlings, professor of neurosurgery at the University of Toronto.

CHICAGO — Decompression of the spinal cord within 24 hours of injury is safe and is associated with improved neurologic recovery, results from an ongoing, prospective, multicenter study suggest.

“Certainly we're not going to be getting a home run with early surgery, but the concept here is to try for the best outcome we can,” Dr. Michael G. Fehlings said of the 1-year results of the Surgical Treatment of Acute Spinal Cord Injury Study (STASCIS).

The study included 170 patients who had a subaxial cervical spinal cord injury (SCI) and evidence of spinal cord or canal compression on MRI or CT. Of these, 44% were defined as an American Spinal Injury Association (ASIA) Impairment grade A with no motor or sensory function preserved; 22% were rated as grade B, 16% as grade C, and 18% as grade D.

Patients received decompression by surgery or traction within 7 days of SCI, and were stratified as “early” if it was within 24 hours of injury or “delayed” if it was after 24 hours.

A total of 94 patients, mean age 40 years, had early decompression surgery, and 76 patients, mean age 42 years, underwent delayed decompression. The investigators assessed outcomes in 108 patients at 6 months, and in 64 patients at 1 year.

At 6 months, 24% of early decompression patients had a 2-grade or greater improvement on the ASIA scale, compared with 4% who had delayed decompression, said Dr. Fehlings, head of the Krembil Neuroscience Centre at the University Health Network in Toronto. There weren't enough patients at 1 year to segregate the data by ASIA grade, but significantly more patients in the early group had a combined 1- and 2-grade improvement on the ASIA scale, compared with those in the delayed-compression group.

Complications, particularly respiratory complications and length of stay in the ICU, were reduced by about 15% in the early decompression group versus the delayed-treatment group (37% vs. 49%).

Dr. Fehlings and coinvestigators hypothesized that traction would be one of the primary means of achieving decompression, but it was used in only 29% of the early group and in 21% of the delayed group. Traction was also not as successful as was anticipated, with only a 50% success rate.

The Spine Study Trauma Group, a group of the world's top 40 spine surgeons, will publish in the next year consensus-based recommendations that patients with acute spinal cord injury without other life-threatening conditions should have early decompression surgery within 24 hours, Dr. Fehlings said in an interview at the annual meeting of the American Association of Neurological Surgeons.

Presentation discussant Christopher Shields of the Kentucky Spinal Cord Injury Research Center in Louisville suggested 8–12 hours may have been a more appropriate cutoff point for early intervention. Dr. Fehlings said that animal studies suggest the time window for optimal decompression after spinal cord injury occurs within 8–24 hours after SCI. Based on the differences in metabolic rate between rats and humans, an 8- to 12-hour window roughly translates into 24 hours for humans. Also, the logistics are substantial in terms of transferring a patient to an SCI treatment facility, and getting that patient medically optimized, imaged, taken to surgery, and decompressed.

“The Spine Trauma Study Group has deemed that 24 hours is the cutoff for early surgical intervention, although my colleagues and I try hard in every case to minimize this time,” said Dr. Fehlings, professor of neurosurgery at the University of Toronto.

CHICAGO — Decompression of the spinal cord within 24 hours of injury is safe and is associated with improved neurologic recovery, results from an ongoing, prospective, multicenter study suggest.

“Certainly we're not going to be getting a home run with early surgery, but the concept here is to try for the best outcome we can,” Dr. Michael G. Fehlings said of the 1-year results of the Surgical Treatment of Acute Spinal Cord Injury Study (STASCIS).

The study included 170 patients who had a subaxial cervical spinal cord injury (SCI) and evidence of spinal cord or canal compression on MRI or CT. Of these, 44% were defined as an American Spinal Injury Association (ASIA) Impairment grade A with no motor or sensory function preserved; 22% were rated as grade B, 16% as grade C, and 18% as grade D.

Patients received decompression by surgery or traction within 7 days of SCI, and were stratified as “early” if it was within 24 hours of injury or “delayed” if it was after 24 hours.

A total of 94 patients, mean age 40 years, had early decompression surgery, and 76 patients, mean age 42 years, underwent delayed decompression. The investigators assessed outcomes in 108 patients at 6 months, and in 64 patients at 1 year.

At 6 months, 24% of early decompression patients had a 2-grade or greater improvement on the ASIA scale, compared with 4% who had delayed decompression, said Dr. Fehlings, head of the Krembil Neuroscience Centre at the University Health Network in Toronto. There weren't enough patients at 1 year to segregate the data by ASIA grade, but significantly more patients in the early group had a combined 1- and 2-grade improvement on the ASIA scale, compared with those in the delayed-compression group.

Complications, particularly respiratory complications and length of stay in the ICU, were reduced by about 15% in the early decompression group versus the delayed-treatment group (37% vs. 49%).

Dr. Fehlings and coinvestigators hypothesized that traction would be one of the primary means of achieving decompression, but it was used in only 29% of the early group and in 21% of the delayed group. Traction was also not as successful as was anticipated, with only a 50% success rate.

The Spine Study Trauma Group, a group of the world's top 40 spine surgeons, will publish in the next year consensus-based recommendations that patients with acute spinal cord injury without other life-threatening conditions should have early decompression surgery within 24 hours, Dr. Fehlings said in an interview at the annual meeting of the American Association of Neurological Surgeons.

Presentation discussant Christopher Shields of the Kentucky Spinal Cord Injury Research Center in Louisville suggested 8–12 hours may have been a more appropriate cutoff point for early intervention. Dr. Fehlings said that animal studies suggest the time window for optimal decompression after spinal cord injury occurs within 8–24 hours after SCI. Based on the differences in metabolic rate between rats and humans, an 8- to 12-hour window roughly translates into 24 hours for humans. Also, the logistics are substantial in terms of transferring a patient to an SCI treatment facility, and getting that patient medically optimized, imaged, taken to surgery, and decompressed.

“The Spine Trauma Study Group has deemed that 24 hours is the cutoff for early surgical intervention, although my colleagues and I try hard in every case to minimize this time,” said Dr. Fehlings, professor of neurosurgery at the University of Toronto.

CORONADO, CALIF. — Reports are challenging the validity of the five National Emergency X-Radiography Utilization Study criteria to diagnose spine injury in children.

The criteria (posterior midline cervical tenderness; no evidence of intoxication; normal level of alertness; no focal neurologic deficit; and no painful, distracting injury) were established in a study of 34,069 trauma victims (N. Engl. J. Med. 2000;343:94–9). Of these, 818 (2.4%) had cervical spine injury.

The researchers reported the criteria were 99% sensitive for cervical spine injury and 99.6% sensitive for clinically significant cervical spine injury in adults. Specificity was 12.9% in both groups.

In a subset analysis of 3,065 children from the National Emergency X-Radiography Utilization Study (NEXUS) study, 30 had cervical spine injuries (Pediatrics 2001;108:E20). The NEXUS criteria for detecting cervical spine injury were 100% sensitive and only 19.9% specific. However, none of the children studied were less than 2 years old and only 817 (27%) were younger than age 8 years.

“Until we come up with pediatric-specific criteria, it's reasonable to apply the NEXUS criteria to awake and alert patients,” Dr. Julie C. Leonard said at a meeting sponsored by the American College of Emergency Physicians. “However, if you have a high index of suspicion by either mechanism or self-reported pain, you should use your clinical acumen.”

A recent 20-year review that applied the NEXUS criteria to 190 children with cervical spine injury found the criteria were 94% sensitive among children aged less than 8 and 100% sensitive in those older than 8 (Neurosurgery 2008;62:700–8). A Pediatric Emergency Care Applied Research Network study found the NEXUS criteria were 83% sensitive among 539 children with spinal injury who presented to the emergency department. Of the 90 children missed by the NEXUS criteria, 58 (64%) were younger than 8 years of age.

Dr. Leonard, of Washington University, St. Louis, said a risk-stratification system is needed. High-risk populations also must be considered, like those with Down syndrome or juvenile idiopathic arthritis.

Dr. Leonard disclosed no conflicts.

CORONADO, CALIF. — Reports are challenging the validity of the five National Emergency X-Radiography Utilization Study criteria to diagnose spine injury in children.

The criteria (posterior midline cervical tenderness; no evidence of intoxication; normal level of alertness; no focal neurologic deficit; and no painful, distracting injury) were established in a study of 34,069 trauma victims (N. Engl. J. Med. 2000;343:94–9). Of these, 818 (2.4%) had cervical spine injury.

The researchers reported the criteria were 99% sensitive for cervical spine injury and 99.6% sensitive for clinically significant cervical spine injury in adults. Specificity was 12.9% in both groups.

In a subset analysis of 3,065 children from the National Emergency X-Radiography Utilization Study (NEXUS) study, 30 had cervical spine injuries (Pediatrics 2001;108:E20). The NEXUS criteria for detecting cervical spine injury were 100% sensitive and only 19.9% specific. However, none of the children studied were less than 2 years old and only 817 (27%) were younger than age 8 years.

“Until we come up with pediatric-specific criteria, it's reasonable to apply the NEXUS criteria to awake and alert patients,” Dr. Julie C. Leonard said at a meeting sponsored by the American College of Emergency Physicians. “However, if you have a high index of suspicion by either mechanism or self-reported pain, you should use your clinical acumen.”

A recent 20-year review that applied the NEXUS criteria to 190 children with cervical spine injury found the criteria were 94% sensitive among children aged less than 8 and 100% sensitive in those older than 8 (Neurosurgery 2008;62:700–8). A Pediatric Emergency Care Applied Research Network study found the NEXUS criteria were 83% sensitive among 539 children with spinal injury who presented to the emergency department. Of the 90 children missed by the NEXUS criteria, 58 (64%) were younger than 8 years of age.

Dr. Leonard, of Washington University, St. Louis, said a risk-stratification system is needed. High-risk populations also must be considered, like those with Down syndrome or juvenile idiopathic arthritis.

Dr. Leonard disclosed no conflicts.

CORONADO, CALIF. — Reports are challenging the validity of the five National Emergency X-Radiography Utilization Study criteria to diagnose spine injury in children.

The criteria (posterior midline cervical tenderness; no evidence of intoxication; normal level of alertness; no focal neurologic deficit; and no painful, distracting injury) were established in a study of 34,069 trauma victims (N. Engl. J. Med. 2000;343:94–9). Of these, 818 (2.4%) had cervical spine injury.

The researchers reported the criteria were 99% sensitive for cervical spine injury and 99.6% sensitive for clinically significant cervical spine injury in adults. Specificity was 12.9% in both groups.

In a subset analysis of 3,065 children from the National Emergency X-Radiography Utilization Study (NEXUS) study, 30 had cervical spine injuries (Pediatrics 2001;108:E20). The NEXUS criteria for detecting cervical spine injury were 100% sensitive and only 19.9% specific. However, none of the children studied were less than 2 years old and only 817 (27%) were younger than age 8 years.

“Until we come up with pediatric-specific criteria, it's reasonable to apply the NEXUS criteria to awake and alert patients,” Dr. Julie C. Leonard said at a meeting sponsored by the American College of Emergency Physicians. “However, if you have a high index of suspicion by either mechanism or self-reported pain, you should use your clinical acumen.”

A recent 20-year review that applied the NEXUS criteria to 190 children with cervical spine injury found the criteria were 94% sensitive among children aged less than 8 and 100% sensitive in those older than 8 (Neurosurgery 2008;62:700–8). A Pediatric Emergency Care Applied Research Network study found the NEXUS criteria were 83% sensitive among 539 children with spinal injury who presented to the emergency department. Of the 90 children missed by the NEXUS criteria, 58 (64%) were younger than 8 years of age.

Dr. Leonard, of Washington University, St. Louis, said a risk-stratification system is needed. High-risk populations also must be considered, like those with Down syndrome or juvenile idiopathic arthritis.

Dr. Leonard disclosed no conflicts.

SAN DIEGO — Two studies represent “an opportunity to do some useful intervention research in shaken baby syndrome or abusive head trauma,” Janet Saul, Ph.D., said at a conference sponsored by Rady Children's Hospital, San Diego.

The first, led by Dr. Mark S. Dias, a pediatric neurosurgeon at Pennsylvania State University, Hershey, will test the efficacy of a hospital-based intervention. Components include a video and brochure about shaken baby syndrome, discussion about it with a clinician, posters, and a commitment statement for new parents to sign.

Parents receive four messages: crying is normal; there are ways to calm a baby; there are ways to calm yourself; it's important to select other caregivers.

Also, half the counties in Central Pennsylvania will receive a “booster” session for parents who come to pediatric offices for 2-, 4-, and 6-month immunization visits.

In North Carolina, researchers led by Dr. Desmond Runyan of the department of social medicine at the University of North Carolina at Chapel Hill are conducting a statewide preventive intervention that prepares parents to deal safely and explicitly with crying. Nurses in charge of nurseries in hospitals and birthing centers will show parents a DVD about the normalcy of crying and the ways to respond. The DVD will be given to parents to be shared with baby sitters and day care providers.

Pediatricians and family physicians also are being asked to deliver the same DVD and information to mothers at either prenatal care visits or the first postnatal visit. A mass media campaign to address infant crying and parent's response to crying is also being developed by the National Center on Shaken Baby Syndrome, said Dr. Saul, a psychologist who is chief of the prevention development and evaluation branch in the division of violence prevention at the CDC's National Center for Injury Prevention and Control, Atlanta.

On the day of injury, a small subdural hemorrhage and subtle edema are seen.

Four weeks later, atrophy is seen, due to brain damage sustained by the injury. Images Courtesy Dr. Mark S. Dias

SAN DIEGO — Two studies represent “an opportunity to do some useful intervention research in shaken baby syndrome or abusive head trauma,” Janet Saul, Ph.D., said at a conference sponsored by Rady Children's Hospital, San Diego.

The first, led by Dr. Mark S. Dias, a pediatric neurosurgeon at Pennsylvania State University, Hershey, will test the efficacy of a hospital-based intervention. Components include a video and brochure about shaken baby syndrome, discussion about it with a clinician, posters, and a commitment statement for new parents to sign.

Parents receive four messages: crying is normal; there are ways to calm a baby; there are ways to calm yourself; it's important to select other caregivers.

Also, half the counties in Central Pennsylvania will receive a “booster” session for parents who come to pediatric offices for 2-, 4-, and 6-month immunization visits.

In North Carolina, researchers led by Dr. Desmond Runyan of the department of social medicine at the University of North Carolina at Chapel Hill are conducting a statewide preventive intervention that prepares parents to deal safely and explicitly with crying. Nurses in charge of nurseries in hospitals and birthing centers will show parents a DVD about the normalcy of crying and the ways to respond. The DVD will be given to parents to be shared with baby sitters and day care providers.

Pediatricians and family physicians also are being asked to deliver the same DVD and information to mothers at either prenatal care visits or the first postnatal visit. A mass media campaign to address infant crying and parent's response to crying is also being developed by the National Center on Shaken Baby Syndrome, said Dr. Saul, a psychologist who is chief of the prevention development and evaluation branch in the division of violence prevention at the CDC's National Center for Injury Prevention and Control, Atlanta.

On the day of injury, a small subdural hemorrhage and subtle edema are seen.

Four weeks later, atrophy is seen, due to brain damage sustained by the injury. Images Courtesy Dr. Mark S. Dias

SAN DIEGO — Two studies represent “an opportunity to do some useful intervention research in shaken baby syndrome or abusive head trauma,” Janet Saul, Ph.D., said at a conference sponsored by Rady Children's Hospital, San Diego.

The first, led by Dr. Mark S. Dias, a pediatric neurosurgeon at Pennsylvania State University, Hershey, will test the efficacy of a hospital-based intervention. Components include a video and brochure about shaken baby syndrome, discussion about it with a clinician, posters, and a commitment statement for new parents to sign.

Parents receive four messages: crying is normal; there are ways to calm a baby; there are ways to calm yourself; it's important to select other caregivers.

Also, half the counties in Central Pennsylvania will receive a “booster” session for parents who come to pediatric offices for 2-, 4-, and 6-month immunization visits.

In North Carolina, researchers led by Dr. Desmond Runyan of the department of social medicine at the University of North Carolina at Chapel Hill are conducting a statewide preventive intervention that prepares parents to deal safely and explicitly with crying. Nurses in charge of nurseries in hospitals and birthing centers will show parents a DVD about the normalcy of crying and the ways to respond. The DVD will be given to parents to be shared with baby sitters and day care providers.

Pediatricians and family physicians also are being asked to deliver the same DVD and information to mothers at either prenatal care visits or the first postnatal visit. A mass media campaign to address infant crying and parent's response to crying is also being developed by the National Center on Shaken Baby Syndrome, said Dr. Saul, a psychologist who is chief of the prevention development and evaluation branch in the division of violence prevention at the CDC's National Center for Injury Prevention and Control, Atlanta.

On the day of injury, a small subdural hemorrhage and subtle edema are seen.

Four weeks later, atrophy is seen, due to brain damage sustained by the injury. Images Courtesy Dr. Mark S. Dias

Susceptibility-weighted imaging (SWI) is a T2* MRI technique that takes advantage of both magnitude and phase to enhance contrast. The signal changes result from disturbances in a homogeneous magnetic field caused by paramagnetic, ferromagnetic, or diamagnetic substances, said E. Mark Haacke, Ph.D., professor of radiology at Wayne State University, Detroit, and director of the Magnetic Resonance Imaging Institute for Biomedical Research in Detroit.

Application of a magnetic field to the brain generates an induced field that depends on the applied magnetic field and the magnetic susceptibility of molecules within the brain. Signal intensity changes are dependent on several factors, including hematocrit, deoxyhemoglobin concentration, and the presence of hemosiderin and other paramagnetic or diamagnetic substances. The technique is very sensitive in detecting intravascular venous deoxygenated blood and extravascular blood products. Most blood products are paramagnetic (deoxyhemoglobin, intracellular methemoglobin, and hemosiderin), letting SWI take advantage of magnetic susceptibility effects.

In brain trauma, the identification of smaller hemorrhages and their locations provides useful data about the mechanism of injury and potential clinical outcome. In this case, SWI showed several bleeds, including shearing of the confluence of the medullary veins into the septal vein. The bleeds appear as black areas, visibile because of the iron in hemosiderin, which accumulated postbleeding.

The join between veins and venules tends to be an area of weakness susceptible to bleeding in brain trauma. In fact, for this patient, “almost all of these bleeds were on the venous side,” said Dr. Haacke. “It's well known biomechanically that the veins are weaker than the arteries, but usually you end up seeing tearing and shearing of both arteries and veins when you have bad trauma.” One of the veins running to the front of the brain—to nerve-containing tissue—also seems to have bled, which could account for this man's headaches.

Iron deposited from bleeding tends to stay in the brain. “Odds are that if we imaged 5 years later, we'd probably still see the major bleeding,” said Dr. Haacke.

The long-term goal is to correlate the imaging with motor and cognitive effects of trauma. “If you could eventually come up with a treatment that helped resolve some of the bleeding, for example, then you would potentially be able to watch and see with MRI if the person is getting better,” said Dr. Haacke.

Conventional MRI (left) hints at a possible bleed in the left front brain. SWI (right) reveals several bleeds from trauma. Photos courtesy Zahid Latif/Detroit Medical Center/Wayne State University

Susceptibility-weighted imaging (SWI) is a T2* MRI technique that takes advantage of both magnitude and phase to enhance contrast. The signal changes result from disturbances in a homogeneous magnetic field caused by paramagnetic, ferromagnetic, or diamagnetic substances, said E. Mark Haacke, Ph.D., professor of radiology at Wayne State University, Detroit, and director of the Magnetic Resonance Imaging Institute for Biomedical Research in Detroit.

Application of a magnetic field to the brain generates an induced field that depends on the applied magnetic field and the magnetic susceptibility of molecules within the brain. Signal intensity changes are dependent on several factors, including hematocrit, deoxyhemoglobin concentration, and the presence of hemosiderin and other paramagnetic or diamagnetic substances. The technique is very sensitive in detecting intravascular venous deoxygenated blood and extravascular blood products. Most blood products are paramagnetic (deoxyhemoglobin, intracellular methemoglobin, and hemosiderin), letting SWI take advantage of magnetic susceptibility effects.

In brain trauma, the identification of smaller hemorrhages and their locations provides useful data about the mechanism of injury and potential clinical outcome. In this case, SWI showed several bleeds, including shearing of the confluence of the medullary veins into the septal vein. The bleeds appear as black areas, visibile because of the iron in hemosiderin, which accumulated postbleeding.

The join between veins and venules tends to be an area of weakness susceptible to bleeding in brain trauma. In fact, for this patient, “almost all of these bleeds were on the venous side,” said Dr. Haacke. “It's well known biomechanically that the veins are weaker than the arteries, but usually you end up seeing tearing and shearing of both arteries and veins when you have bad trauma.” One of the veins running to the front of the brain—to nerve-containing tissue—also seems to have bled, which could account for this man's headaches.

Iron deposited from bleeding tends to stay in the brain. “Odds are that if we imaged 5 years later, we'd probably still see the major bleeding,” said Dr. Haacke.

The long-term goal is to correlate the imaging with motor and cognitive effects of trauma. “If you could eventually come up with a treatment that helped resolve some of the bleeding, for example, then you would potentially be able to watch and see with MRI if the person is getting better,” said Dr. Haacke.

Conventional MRI (left) hints at a possible bleed in the left front brain. SWI (right) reveals several bleeds from trauma. Photos courtesy Zahid Latif/Detroit Medical Center/Wayne State University

Susceptibility-weighted imaging (SWI) is a T2* MRI technique that takes advantage of both magnitude and phase to enhance contrast. The signal changes result from disturbances in a homogeneous magnetic field caused by paramagnetic, ferromagnetic, or diamagnetic substances, said E. Mark Haacke, Ph.D., professor of radiology at Wayne State University, Detroit, and director of the Magnetic Resonance Imaging Institute for Biomedical Research in Detroit.

Application of a magnetic field to the brain generates an induced field that depends on the applied magnetic field and the magnetic susceptibility of molecules within the brain. Signal intensity changes are dependent on several factors, including hematocrit, deoxyhemoglobin concentration, and the presence of hemosiderin and other paramagnetic or diamagnetic substances. The technique is very sensitive in detecting intravascular venous deoxygenated blood and extravascular blood products. Most blood products are paramagnetic (deoxyhemoglobin, intracellular methemoglobin, and hemosiderin), letting SWI take advantage of magnetic susceptibility effects.

In brain trauma, the identification of smaller hemorrhages and their locations provides useful data about the mechanism of injury and potential clinical outcome. In this case, SWI showed several bleeds, including shearing of the confluence of the medullary veins into the septal vein. The bleeds appear as black areas, visibile because of the iron in hemosiderin, which accumulated postbleeding.

The join between veins and venules tends to be an area of weakness susceptible to bleeding in brain trauma. In fact, for this patient, “almost all of these bleeds were on the venous side,” said Dr. Haacke. “It's well known biomechanically that the veins are weaker than the arteries, but usually you end up seeing tearing and shearing of both arteries and veins when you have bad trauma.” One of the veins running to the front of the brain—to nerve-containing tissue—also seems to have bled, which could account for this man's headaches.

Iron deposited from bleeding tends to stay in the brain. “Odds are that if we imaged 5 years later, we'd probably still see the major bleeding,” said Dr. Haacke.

The long-term goal is to correlate the imaging with motor and cognitive effects of trauma. “If you could eventually come up with a treatment that helped resolve some of the bleeding, for example, then you would potentially be able to watch and see with MRI if the person is getting better,” said Dr. Haacke.

Conventional MRI (left) hints at a possible bleed in the left front brain. SWI (right) reveals several bleeds from trauma. Photos courtesy Zahid Latif/Detroit Medical Center/Wayne State University

HONOLULU — Disappointing clinical trial results should not suggest that outcomes cannot be improved in traumatic brain injury, only that study methodologies may need to be refined, Dr. D. James Cooper said during a plenary address at the annual congress of the Society of Critical Care Medicine.

To be sure, various interventions have had hopeful improvements in animal models, but not in human trials.

But the heterogeneity of the traumatic brain injury (TBI) population and “huge differences” in the specific trauma suffered may make study results look unfairly pessimistic, said Dr. Cooper, deputy director of the intensive care unit at Alfred Hospital, Melbourne.

Experimental treatments may be initiated too late because of logistical and informed-consent dilemmas, and older patients may be so unlikely to benefit that they skew results. And follow-up assessment periods may be too brief, because it appears that Glasgow Outcome Scale scores improve greatly over time, but very slowly, he said.

A number of lessons have indeed been learned, even from negative clinical trials, and several promising approaches are currently under review.

Serious doubt has been cast on the efficacy of early high-dose steroids, for example, following the curtailment of the 10,000-patient randomized controlled MRC-CRASH (Corticosteroid Randomisation After Significant Head Injury) trial in the United Kingdom after excess deaths were reported in the steroid arm.

“It seems clear from the study that the use of an agent that has been very widely used, particularly in the developing world, clearly and unambiguously increases mortality, accounting for an absolute number of 3% excess deaths. I think it's abundantly clear … [that the] use of high-dose steroids should cease,” said Dr. Cooper, associate director for Australia's National Trauma Research Institute.

Because they lower vasopressor requirements in TBI patients, lower-dose steroids are used commonly in the intensive care environment, he noted. “There are no randomized controlled trials at all in this area, and it's clear to me, [based on the MRC-CRASH results,] there needs to be … a reevaluation” of this practice, said Dr. Cooper.

Another unexpected finding stemmed from the Australian SAFE-TBI (Saline Versus Albumin Fluid Evaluation-Traumatic Brain Injury) study, in which Dr. Cooper participated. That study of nearly 500 patients confirmed that albumin is independently tied to mortality in TBI patients when it is used for intravascular fluid resuscitation in the first 28 days. In contrast, saline was associated with lower mortality and better neurologic outcomes in patients with moderate to severe TBI.

The reasons remain unclear, although Dr. Cooper hypothesized that albumin may increase brain edema, prompting the use of other agents that could contribute to mortality; that it may increase bleeding or cause more coagulopathy; or that it may be the result of hemodilution.

The possibility remains that albumin's negative effect on survival may be a class effect of colloids, he said.

A recent analysis of data from both the SAFE-TBI study and the earlier ATBIS (Australasian Traumatic Brain Injury Study) “[adds] to our strong feeling that saline alone might be worthwhile,” he said.

As a final note, Dr. Cooper outlined two ongoing international clinical trials of early decompressive craniectomy to reduce intracranial pressure.

The absolute risk of mortality was halved with early decompressive craniectomy versus medical therapy alone in a recent, 38-patient French study; but the trial was concluded early because of slow recruitment.

Dr. Cooper's DECRA (Early Decompression Craniectomy in Patients With Severe Traumatic Brain Injury) trial at 21 sites is enrolling only patients younger than 60 years with blunt diffuse brain injuries—strict criteria that may be more conducive to interpreting results, he said.

So far, 112 patients have been enrolled of 165 anticipated, already more than the largest study ever conducted of early decompressive craniectomy, Dr. Cooper noted.

Among the first 42 patients who received surgery, the complication rate has been less than 10%, he said.

HONOLULU — Disappointing clinical trial results should not suggest that outcomes cannot be improved in traumatic brain injury, only that study methodologies may need to be refined, Dr. D. James Cooper said during a plenary address at the annual congress of the Society of Critical Care Medicine.

To be sure, various interventions have had hopeful improvements in animal models, but not in human trials.

But the heterogeneity of the traumatic brain injury (TBI) population and “huge differences” in the specific trauma suffered may make study results look unfairly pessimistic, said Dr. Cooper, deputy director of the intensive care unit at Alfred Hospital, Melbourne.

Experimental treatments may be initiated too late because of logistical and informed-consent dilemmas, and older patients may be so unlikely to benefit that they skew results. And follow-up assessment periods may be too brief, because it appears that Glasgow Outcome Scale scores improve greatly over time, but very slowly, he said.

A number of lessons have indeed been learned, even from negative clinical trials, and several promising approaches are currently under review.

Serious doubt has been cast on the efficacy of early high-dose steroids, for example, following the curtailment of the 10,000-patient randomized controlled MRC-CRASH (Corticosteroid Randomisation After Significant Head Injury) trial in the United Kingdom after excess deaths were reported in the steroid arm.

“It seems clear from the study that the use of an agent that has been very widely used, particularly in the developing world, clearly and unambiguously increases mortality, accounting for an absolute number of 3% excess deaths. I think it's abundantly clear … [that the] use of high-dose steroids should cease,” said Dr. Cooper, associate director for Australia's National Trauma Research Institute.

Because they lower vasopressor requirements in TBI patients, lower-dose steroids are used commonly in the intensive care environment, he noted. “There are no randomized controlled trials at all in this area, and it's clear to me, [based on the MRC-CRASH results,] there needs to be … a reevaluation” of this practice, said Dr. Cooper.

Another unexpected finding stemmed from the Australian SAFE-TBI (Saline Versus Albumin Fluid Evaluation-Traumatic Brain Injury) study, in which Dr. Cooper participated. That study of nearly 500 patients confirmed that albumin is independently tied to mortality in TBI patients when it is used for intravascular fluid resuscitation in the first 28 days. In contrast, saline was associated with lower mortality and better neurologic outcomes in patients with moderate to severe TBI.

The reasons remain unclear, although Dr. Cooper hypothesized that albumin may increase brain edema, prompting the use of other agents that could contribute to mortality; that it may increase bleeding or cause more coagulopathy; or that it may be the result of hemodilution.

The possibility remains that albumin's negative effect on survival may be a class effect of colloids, he said.

A recent analysis of data from both the SAFE-TBI study and the earlier ATBIS (Australasian Traumatic Brain Injury Study) “[adds] to our strong feeling that saline alone might be worthwhile,” he said.

As a final note, Dr. Cooper outlined two ongoing international clinical trials of early decompressive craniectomy to reduce intracranial pressure.

The absolute risk of mortality was halved with early decompressive craniectomy versus medical therapy alone in a recent, 38-patient French study; but the trial was concluded early because of slow recruitment.

Dr. Cooper's DECRA (Early Decompression Craniectomy in Patients With Severe Traumatic Brain Injury) trial at 21 sites is enrolling only patients younger than 60 years with blunt diffuse brain injuries—strict criteria that may be more conducive to interpreting results, he said.

So far, 112 patients have been enrolled of 165 anticipated, already more than the largest study ever conducted of early decompressive craniectomy, Dr. Cooper noted.

Among the first 42 patients who received surgery, the complication rate has been less than 10%, he said.

HONOLULU — Disappointing clinical trial results should not suggest that outcomes cannot be improved in traumatic brain injury, only that study methodologies may need to be refined, Dr. D. James Cooper said during a plenary address at the annual congress of the Society of Critical Care Medicine.

To be sure, various interventions have had hopeful improvements in animal models, but not in human trials.

But the heterogeneity of the traumatic brain injury (TBI) population and “huge differences” in the specific trauma suffered may make study results look unfairly pessimistic, said Dr. Cooper, deputy director of the intensive care unit at Alfred Hospital, Melbourne.

Experimental treatments may be initiated too late because of logistical and informed-consent dilemmas, and older patients may be so unlikely to benefit that they skew results. And follow-up assessment periods may be too brief, because it appears that Glasgow Outcome Scale scores improve greatly over time, but very slowly, he said.

A number of lessons have indeed been learned, even from negative clinical trials, and several promising approaches are currently under review.

Serious doubt has been cast on the efficacy of early high-dose steroids, for example, following the curtailment of the 10,000-patient randomized controlled MRC-CRASH (Corticosteroid Randomisation After Significant Head Injury) trial in the United Kingdom after excess deaths were reported in the steroid arm.

“It seems clear from the study that the use of an agent that has been very widely used, particularly in the developing world, clearly and unambiguously increases mortality, accounting for an absolute number of 3% excess deaths. I think it's abundantly clear … [that the] use of high-dose steroids should cease,” said Dr. Cooper, associate director for Australia's National Trauma Research Institute.

Because they lower vasopressor requirements in TBI patients, lower-dose steroids are used commonly in the intensive care environment, he noted. “There are no randomized controlled trials at all in this area, and it's clear to me, [based on the MRC-CRASH results,] there needs to be … a reevaluation” of this practice, said Dr. Cooper.

Another unexpected finding stemmed from the Australian SAFE-TBI (Saline Versus Albumin Fluid Evaluation-Traumatic Brain Injury) study, in which Dr. Cooper participated. That study of nearly 500 patients confirmed that albumin is independently tied to mortality in TBI patients when it is used for intravascular fluid resuscitation in the first 28 days. In contrast, saline was associated with lower mortality and better neurologic outcomes in patients with moderate to severe TBI.

The reasons remain unclear, although Dr. Cooper hypothesized that albumin may increase brain edema, prompting the use of other agents that could contribute to mortality; that it may increase bleeding or cause more coagulopathy; or that it may be the result of hemodilution.

The possibility remains that albumin's negative effect on survival may be a class effect of colloids, he said.

A recent analysis of data from both the SAFE-TBI study and the earlier ATBIS (Australasian Traumatic Brain Injury Study) “[adds] to our strong feeling that saline alone might be worthwhile,” he said.

As a final note, Dr. Cooper outlined two ongoing international clinical trials of early decompressive craniectomy to reduce intracranial pressure.

The absolute risk of mortality was halved with early decompressive craniectomy versus medical therapy alone in a recent, 38-patient French study; but the trial was concluded early because of slow recruitment.

Dr. Cooper's DECRA (Early Decompression Craniectomy in Patients With Severe Traumatic Brain Injury) trial at 21 sites is enrolling only patients younger than 60 years with blunt diffuse brain injuries—strict criteria that may be more conducive to interpreting results, he said.

So far, 112 patients have been enrolled of 165 anticipated, already more than the largest study ever conducted of early decompressive craniectomy, Dr. Cooper noted.

Among the first 42 patients who received surgery, the complication rate has been less than 10%, he said.

Emergency on-call coverage from specialist physicians is “unraveling” at hospitals across the country, resulting in delayed treatment, patient transfers, permanent injuries, and even death, according to a study from the Center for Studying Health System Change, a nonpartisan policy research group in Washington.

While the problem is predominantly an issue for hospital emergency departments, it also is becoming increasingly problematic for inpatients who need urgent specialty care, according to the report. The findings are based on 2007 data from 12 nationally representative communities: Boston; Cleveland; Greenville, S.C.; Indianapolis; Lansing, Mich.; Little Rock, Ark.; Miami; Northern New Jersey; Orange County, Calif; Phoenix; Seattle; and Syracuse, N.Y.

The picture is particularly grim because overall ED utilization rates have risen by 7% in the past decade, from 36.9 to 39.6 visits per 100 people, according to the report. While insured people account for the vast majority of ED visits, “the proportion of visits by uninsured people is rising at a relatively higher rate,” the researchers wrote.

Citing a 2006 paper from the American College of Emergency Physicians, the study reported that 73% of emergency departments in the United States report inadequate on-call coverage by specialist physicians. In particularly short supply are neurologists, neurosurgeons, orthopedic surgeons, plastic surgeons, trauma surgeons, hand surgeons, obstetrician-gynecologists, ophthalmologists, and dermatologists. While an actual shortage of such physicians may sometimes be to blame, “physician unwillingness to take call appears to be a more pressing issue for many hospitals,” the authors said.

Although unwillingness to accept on-call duty is largely influenced by quality of life issues, the requirement to provide on-call coverage has traditionally been mandated by hospitals under the Emergency Medical Treatment and Labor Act. However, many specialists are now shifting their practices away from the hospital, and are no longer obligated by medical staff privileges, noted the report's authors.

Many physicians also believe payment for on-call care is inadequate, especially when caring for the uninsured. Specialists also worry that providing emergency care may increase their exposure to medical liability and drive up the cost of their malpractice premiums, the report stated.

One study found 21% of patient deaths or permanent injuries related to ED treatment delays are attributed to lack of specialists' availability. Complete lack of access to specialty care in some EDs is forcing either travel or transfer of patients. And for the physicians who continue to provide on-call coverage, increasing workload and decreasing morale may put patients further at risk.

Crisis May Drive Physicians Away

“It's not a surprise that we're having this problem—it's a surprise to me that we have any on-call specialists at all,” Dr. Todd Taylor, previously an emergency physician and speaker for the ACEP Council, said in an interview. Dr. Taylor left clinical medicine last summer to work in the computer industry because of the risks of liability.

“The liability issue has become the overriding barrier to physicians being willing to put themselves at risk,” he said. “Unless you solve the liability crisis in emergency care and health care in general, nothing else you do matters.”

More troubling than the lack of emergency on-call specialists, he added, is the lack of emergency physicians in general—a newer phenomenon reported earlier this year in the 2007 Daniel Stern & Associates Emergency Medicine Compensation and Benefits Survey.

“This has applied to on-call specialists for years, but the phenomenon is now spreading to core emergency physicians, who are increasingly seeking alternative careers,” Dr. Taylor said, noting 30% of study respondents were considering leaving medicine because of the malpractice climate.

Most on-call specialists have a private practice outside of the emergency department—they don't need the ED—so it's not suprising that they were first to leave, he explained. “But now that core emergency physicians, who were trained to practice only emergency medicine, are making the same choices, that should be a wake-up call,” Dr. Taylor said. “That's what's different now compared to 2 or 3 years ago.”

On-Call Shortage Cripples Trauma Care

Lack of optimal on-call coverage is what will ultimately “cripple” trauma and emergency care, agreed Dr. L.D. Britt, professor of surgery at the Eastern Virginia Medical School in Norfolk. “Some of the specialists are asking for unbelievably exorbitant fees to provide coverage, and hospitals are being held hostage. That's unsustainable for many hospitals—it's a major crisis,” he said in an interview.

While Dr. Britt sympathizes with physicians' struggles with payment and liability issues, he believes the true bottom line is simply that obligations are being overlooked.

“It cannot be everyone saying, 'I can't do this.' Something has to give,” Dr. Britt said. “I consider it my obligation to provide emergency coverage if I am on call. I know that's my responsibility—and I'm a chairman of a department. Some people can find ways out of it, but I'm saying we cannot have all those options out there.”

In addition, high fees charged by specialists and paid by hospitals for on-call coverage are not justified based on the premise that on-call coverage increases a physician's liability exposure, he said. “Being on call doesn't give you more litigation than being in general surgery—that's well documented,” he said.

Dr. Taylor disagreed. “The literature is very clear that emergency care is one of the highest liability environments in health care,” he said. “You only have to look at what's happened to emergency physician malpractice premiums relative to others not involved in emergency care. Mine almost doubled the last 3 years I worked.”

Dr. Britt pointed out that no other country “is spending what we're spending on health care, and yet we're not getting what we should.” But he doubted more spending could solve the problem. “We have an obligation to provide care for the injured and the ill—and if the specialists, rightly or wrongly, say they can't provide that, then we need to come up with a different idea.”

Emergency on-call coverage from specialist physicians is “unraveling” at hospitals across the country, resulting in delayed treatment, patient transfers, permanent injuries, and even death, according to a study from the Center for Studying Health System Change, a nonpartisan policy research group in Washington.

While the problem is predominantly an issue for hospital emergency departments, it also is becoming increasingly problematic for inpatients who need urgent specialty care, according to the report. The findings are based on 2007 data from 12 nationally representative communities: Boston; Cleveland; Greenville, S.C.; Indianapolis; Lansing, Mich.; Little Rock, Ark.; Miami; Northern New Jersey; Orange County, Calif; Phoenix; Seattle; and Syracuse, N.Y.

The picture is particularly grim because overall ED utilization rates have risen by 7% in the past decade, from 36.9 to 39.6 visits per 100 people, according to the report. While insured people account for the vast majority of ED visits, “the proportion of visits by uninsured people is rising at a relatively higher rate,” the researchers wrote.

Citing a 2006 paper from the American College of Emergency Physicians, the study reported that 73% of emergency departments in the United States report inadequate on-call coverage by specialist physicians. In particularly short supply are neurologists, neurosurgeons, orthopedic surgeons, plastic surgeons, trauma surgeons, hand surgeons, obstetrician-gynecologists, ophthalmologists, and dermatologists. While an actual shortage of such physicians may sometimes be to blame, “physician unwillingness to take call appears to be a more pressing issue for many hospitals,” the authors said.

Although unwillingness to accept on-call duty is largely influenced by quality of life issues, the requirement to provide on-call coverage has traditionally been mandated by hospitals under the Emergency Medical Treatment and Labor Act. However, many specialists are now shifting their practices away from the hospital, and are no longer obligated by medical staff privileges, noted the report's authors.

Many physicians also believe payment for on-call care is inadequate, especially when caring for the uninsured. Specialists also worry that providing emergency care may increase their exposure to medical liability and drive up the cost of their malpractice premiums, the report stated.

One study found 21% of patient deaths or permanent injuries related to ED treatment delays are attributed to lack of specialists' availability. Complete lack of access to specialty care in some EDs is forcing either travel or transfer of patients. And for the physicians who continue to provide on-call coverage, increasing workload and decreasing morale may put patients further at risk.

Crisis May Drive Physicians Away

“It's not a surprise that we're having this problem—it's a surprise to me that we have any on-call specialists at all,” Dr. Todd Taylor, previously an emergency physician and speaker for the ACEP Council, said in an interview. Dr. Taylor left clinical medicine last summer to work in the computer industry because of the risks of liability.

“The liability issue has become the overriding barrier to physicians being willing to put themselves at risk,” he said. “Unless you solve the liability crisis in emergency care and health care in general, nothing else you do matters.”

More troubling than the lack of emergency on-call specialists, he added, is the lack of emergency physicians in general—a newer phenomenon reported earlier this year in the 2007 Daniel Stern & Associates Emergency Medicine Compensation and Benefits Survey.

“This has applied to on-call specialists for years, but the phenomenon is now spreading to core emergency physicians, who are increasingly seeking alternative careers,” Dr. Taylor said, noting 30% of study respondents were considering leaving medicine because of the malpractice climate.

Most on-call specialists have a private practice outside of the emergency department—they don't need the ED—so it's not suprising that they were first to leave, he explained. “But now that core emergency physicians, who were trained to practice only emergency medicine, are making the same choices, that should be a wake-up call,” Dr. Taylor said. “That's what's different now compared to 2 or 3 years ago.”

On-Call Shortage Cripples Trauma Care

Lack of optimal on-call coverage is what will ultimately “cripple” trauma and emergency care, agreed Dr. L.D. Britt, professor of surgery at the Eastern Virginia Medical School in Norfolk. “Some of the specialists are asking for unbelievably exorbitant fees to provide coverage, and hospitals are being held hostage. That's unsustainable for many hospitals—it's a major crisis,” he said in an interview.

While Dr. Britt sympathizes with physicians' struggles with payment and liability issues, he believes the true bottom line is simply that obligations are being overlooked.

“It cannot be everyone saying, 'I can't do this.' Something has to give,” Dr. Britt said. “I consider it my obligation to provide emergency coverage if I am on call. I know that's my responsibility—and I'm a chairman of a department. Some people can find ways out of it, but I'm saying we cannot have all those options out there.”

In addition, high fees charged by specialists and paid by hospitals for on-call coverage are not justified based on the premise that on-call coverage increases a physician's liability exposure, he said. “Being on call doesn't give you more litigation than being in general surgery—that's well documented,” he said.

Dr. Taylor disagreed. “The literature is very clear that emergency care is one of the highest liability environments in health care,” he said. “You only have to look at what's happened to emergency physician malpractice premiums relative to others not involved in emergency care. Mine almost doubled the last 3 years I worked.”

Dr. Britt pointed out that no other country “is spending what we're spending on health care, and yet we're not getting what we should.” But he doubted more spending could solve the problem. “We have an obligation to provide care for the injured and the ill—and if the specialists, rightly or wrongly, say they can't provide that, then we need to come up with a different idea.”

Emergency on-call coverage from specialist physicians is “unraveling” at hospitals across the country, resulting in delayed treatment, patient transfers, permanent injuries, and even death, according to a study from the Center for Studying Health System Change, a nonpartisan policy research group in Washington.

While the problem is predominantly an issue for hospital emergency departments, it also is becoming increasingly problematic for inpatients who need urgent specialty care, according to the report. The findings are based on 2007 data from 12 nationally representative communities: Boston; Cleveland; Greenville, S.C.; Indianapolis; Lansing, Mich.; Little Rock, Ark.; Miami; Northern New Jersey; Orange County, Calif; Phoenix; Seattle; and Syracuse, N.Y.

The picture is particularly grim because overall ED utilization rates have risen by 7% in the past decade, from 36.9 to 39.6 visits per 100 people, according to the report. While insured people account for the vast majority of ED visits, “the proportion of visits by uninsured people is rising at a relatively higher rate,” the researchers wrote.

Citing a 2006 paper from the American College of Emergency Physicians, the study reported that 73% of emergency departments in the United States report inadequate on-call coverage by specialist physicians. In particularly short supply are neurologists, neurosurgeons, orthopedic surgeons, plastic surgeons, trauma surgeons, hand surgeons, obstetrician-gynecologists, ophthalmologists, and dermatologists. While an actual shortage of such physicians may sometimes be to blame, “physician unwillingness to take call appears to be a more pressing issue for many hospitals,” the authors said.

Although unwillingness to accept on-call duty is largely influenced by quality of life issues, the requirement to provide on-call coverage has traditionally been mandated by hospitals under the Emergency Medical Treatment and Labor Act. However, many specialists are now shifting their practices away from the hospital, and are no longer obligated by medical staff privileges, noted the report's authors.

Many physicians also believe payment for on-call care is inadequate, especially when caring for the uninsured. Specialists also worry that providing emergency care may increase their exposure to medical liability and drive up the cost of their malpractice premiums, the report stated.

One study found 21% of patient deaths or permanent injuries related to ED treatment delays are attributed to lack of specialists' availability. Complete lack of access to specialty care in some EDs is forcing either travel or transfer of patients. And for the physicians who continue to provide on-call coverage, increasing workload and decreasing morale may put patients further at risk.

Crisis May Drive Physicians Away

“It's not a surprise that we're having this problem—it's a surprise to me that we have any on-call specialists at all,” Dr. Todd Taylor, previously an emergency physician and speaker for the ACEP Council, said in an interview. Dr. Taylor left clinical medicine last summer to work in the computer industry because of the risks of liability.

“The liability issue has become the overriding barrier to physicians being willing to put themselves at risk,” he said. “Unless you solve the liability crisis in emergency care and health care in general, nothing else you do matters.”

More troubling than the lack of emergency on-call specialists, he added, is the lack of emergency physicians in general—a newer phenomenon reported earlier this year in the 2007 Daniel Stern & Associates Emergency Medicine Compensation and Benefits Survey.

“This has applied to on-call specialists for years, but the phenomenon is now spreading to core emergency physicians, who are increasingly seeking alternative careers,” Dr. Taylor said, noting 30% of study respondents were considering leaving medicine because of the malpractice climate.

Most on-call specialists have a private practice outside of the emergency department—they don't need the ED—so it's not suprising that they were first to leave, he explained. “But now that core emergency physicians, who were trained to practice only emergency medicine, are making the same choices, that should be a wake-up call,” Dr. Taylor said. “That's what's different now compared to 2 or 3 years ago.”

On-Call Shortage Cripples Trauma Care

Lack of optimal on-call coverage is what will ultimately “cripple” trauma and emergency care, agreed Dr. L.D. Britt, professor of surgery at the Eastern Virginia Medical School in Norfolk. “Some of the specialists are asking for unbelievably exorbitant fees to provide coverage, and hospitals are being held hostage. That's unsustainable for many hospitals—it's a major crisis,” he said in an interview.

While Dr. Britt sympathizes with physicians' struggles with payment and liability issues, he believes the true bottom line is simply that obligations are being overlooked.

“It cannot be everyone saying, 'I can't do this.' Something has to give,” Dr. Britt said. “I consider it my obligation to provide emergency coverage if I am on call. I know that's my responsibility—and I'm a chairman of a department. Some people can find ways out of it, but I'm saying we cannot have all those options out there.”

In addition, high fees charged by specialists and paid by hospitals for on-call coverage are not justified based on the premise that on-call coverage increases a physician's liability exposure, he said. “Being on call doesn't give you more litigation than being in general surgery—that's well documented,” he said.

Dr. Taylor disagreed. “The literature is very clear that emergency care is one of the highest liability environments in health care,” he said. “You only have to look at what's happened to emergency physician malpractice premiums relative to others not involved in emergency care. Mine almost doubled the last 3 years I worked.”

Dr. Britt pointed out that no other country “is spending what we're spending on health care, and yet we're not getting what we should.” But he doubted more spending could solve the problem. “We have an obligation to provide care for the injured and the ill—and if the specialists, rightly or wrongly, say they can't provide that, then we need to come up with a different idea.”

After 18 months, the functional and aesthetic outcomes of the first human face transplantation are satisfactory and “encouraging,” according to the physicians who performed the surgery.

It appears that face transplantation “can offer hope” to selected patients who have severe facial disfigurement, they reported in the New England Journal of Medicine.

Dr. Jean-Michel Dubernard of the University of Lyons, France, and his associates previously published the initial results of the partial face transplantation, which they performed in a 38-year-old woman in November 2005. They now report longer-term outcomes.

The woman had been mauled by a dog in May of that year, with her distal nose, upper and lower lips, her entire chin, and the adjacent areas of both cheeks amputated. She received a graft of the lower face from a 46-year-old donor who had the same blood type and all but one of the same HLA antigens.

The recipient's sensory discrimination recovered quickly in the entire skin surface and the oral mucosa, although it remains subnormal. Heat and cold sensation was nearly normal at 4 months and normal at 6 months over the entire graft.

Motor recovery was slower. The patient was unable to close her mouth completely until 6 months post transplant, when that milestone greatly improved pronunciation and mastication. The smile was asymmetrical until 10 months, but became normal by 18 months.

The patient experienced two episodes of acute graft rejection, one 18 days after transplantation and the other 7 months later.

Initial treatment with a standard regimen of oral prednisone, tacrolimus, and mycophenolate mofetil were ineffective, but intravenous boluses of methylprednisolone reversed both of the episodes of rejection.

Extracorporeal photochemotherapy was started to reduce the risk of further graft rejection, and the treatment has been well tolerated.

The woman also developed two infectious complications: type 1 herpes simplex virus of the lips responded to oral valacyclovir and topical acyclovir, and molluscum contagiosum on the cheeks—affecting both the patient's own skin and the allograft skin—was treated by curettage.

The patient's initial immunosuppressive regimen impaired her renal function. This dysfunction was attributed to tacrolimus, which was replaced by sirolimus. Renal function has improved since the switch.

Although the patient has not undergone formal psychological testing, she has gradually resumed a normal social life.

“The progressive return of [facial] expressiveness correlated well with psychological acceptance of the foreign graft,” Dr. Dubernard and his associates said (N. Engl. J. Med. 2007;357:2451–60).

“She is not afraid of walking in the street or meeting people at a party, and she is very satisfied with the aesthetic and functional results,” they noted.

After 18 months, the functional and aesthetic outcomes of the first human face transplantation are satisfactory and “encouraging,” according to the physicians who performed the surgery.

It appears that face transplantation “can offer hope” to selected patients who have severe facial disfigurement, they reported in the New England Journal of Medicine.

Dr. Jean-Michel Dubernard of the University of Lyons, France, and his associates previously published the initial results of the partial face transplantation, which they performed in a 38-year-old woman in November 2005. They now report longer-term outcomes.

The woman had been mauled by a dog in May of that year, with her distal nose, upper and lower lips, her entire chin, and the adjacent areas of both cheeks amputated. She received a graft of the lower face from a 46-year-old donor who had the same blood type and all but one of the same HLA antigens.

The recipient's sensory discrimination recovered quickly in the entire skin surface and the oral mucosa, although it remains subnormal. Heat and cold sensation was nearly normal at 4 months and normal at 6 months over the entire graft.

Motor recovery was slower. The patient was unable to close her mouth completely until 6 months post transplant, when that milestone greatly improved pronunciation and mastication. The smile was asymmetrical until 10 months, but became normal by 18 months.

The patient experienced two episodes of acute graft rejection, one 18 days after transplantation and the other 7 months later.

Initial treatment with a standard regimen of oral prednisone, tacrolimus, and mycophenolate mofetil were ineffective, but intravenous boluses of methylprednisolone reversed both of the episodes of rejection.

Extracorporeal photochemotherapy was started to reduce the risk of further graft rejection, and the treatment has been well tolerated.

The woman also developed two infectious complications: type 1 herpes simplex virus of the lips responded to oral valacyclovir and topical acyclovir, and molluscum contagiosum on the cheeks—affecting both the patient's own skin and the allograft skin—was treated by curettage.

The patient's initial immunosuppressive regimen impaired her renal function. This dysfunction was attributed to tacrolimus, which was replaced by sirolimus. Renal function has improved since the switch.

Although the patient has not undergone formal psychological testing, she has gradually resumed a normal social life.

“The progressive return of [facial] expressiveness correlated well with psychological acceptance of the foreign graft,” Dr. Dubernard and his associates said (N. Engl. J. Med. 2007;357:2451–60).

“She is not afraid of walking in the street or meeting people at a party, and she is very satisfied with the aesthetic and functional results,” they noted.

After 18 months, the functional and aesthetic outcomes of the first human face transplantation are satisfactory and “encouraging,” according to the physicians who performed the surgery.

It appears that face transplantation “can offer hope” to selected patients who have severe facial disfigurement, they reported in the New England Journal of Medicine.

Dr. Jean-Michel Dubernard of the University of Lyons, France, and his associates previously published the initial results of the partial face transplantation, which they performed in a 38-year-old woman in November 2005. They now report longer-term outcomes.

The woman had been mauled by a dog in May of that year, with her distal nose, upper and lower lips, her entire chin, and the adjacent areas of both cheeks amputated. She received a graft of the lower face from a 46-year-old donor who had the same blood type and all but one of the same HLA antigens.

The recipient's sensory discrimination recovered quickly in the entire skin surface and the oral mucosa, although it remains subnormal. Heat and cold sensation was nearly normal at 4 months and normal at 6 months over the entire graft.

Motor recovery was slower. The patient was unable to close her mouth completely until 6 months post transplant, when that milestone greatly improved pronunciation and mastication. The smile was asymmetrical until 10 months, but became normal by 18 months.

The patient experienced two episodes of acute graft rejection, one 18 days after transplantation and the other 7 months later.

Initial treatment with a standard regimen of oral prednisone, tacrolimus, and mycophenolate mofetil were ineffective, but intravenous boluses of methylprednisolone reversed both of the episodes of rejection.

Extracorporeal photochemotherapy was started to reduce the risk of further graft rejection, and the treatment has been well tolerated.

The woman also developed two infectious complications: type 1 herpes simplex virus of the lips responded to oral valacyclovir and topical acyclovir, and molluscum contagiosum on the cheeks—affecting both the patient's own skin and the allograft skin—was treated by curettage.

The patient's initial immunosuppressive regimen impaired her renal function. This dysfunction was attributed to tacrolimus, which was replaced by sirolimus. Renal function has improved since the switch.

Although the patient has not undergone formal psychological testing, she has gradually resumed a normal social life.

“The progressive return of [facial] expressiveness correlated well with psychological acceptance of the foreign graft,” Dr. Dubernard and his associates said (N. Engl. J. Med. 2007;357:2451–60).

“She is not afraid of walking in the street or meeting people at a party, and she is very satisfied with the aesthetic and functional results,” they noted.

WASHINGTON — All traumatic brain injuries are not equal. Soldiers who experience blast-induced brain trauma manifest significantly greater emotional upheaval than do soldiers with brain injuries caused by car accidents, judging from preliminary data on soldiers wounded while deployed in Iraq.

In presenting the data at a meeting sponsored by the Institute of Medicine, Louis French, Psy.D., said, “At least one of the things that differentiates blast-induced brain injury from other types of mechanically induced brain injury is how emotionally traumatic the event is for these people. Perhaps blast as a mechanism is a more difficult way to get hurt emotionally.”

Dr. French presented some preliminary data from 144 soldiers who returned from Iraq with traumatic brain injury (TBI) who had completed the neurobehavioral symptom inventory prior to deployment. Most (141) were men, and the average age was 30.5 years. The symptoms included emotional, cognitive, and functional. The soldiers rated the symptoms as to how problematic they were.

A total of 130 patients had suffered closed head injuries, and 108 (75%) were injured from a blast. A total of 62 patients were classified as having mild TBI. In those 62 patients, the most common problems were sleep disturbances (94%–-of which 33% have reported very severe sleep disturbances), forgetfulness (89%), and irritability (81%). The soldiers were treated at Walter Reed Army Medical Center in Washington, where Dr. French is on the staff of the Defense and Veterans Brain Injury Center.

There may be something different about a blast injury that introduces a certain type of symptom, he said.

The people who have been injured from blast were endorsing higher levels of symptom severity than were people who were injured through other ways, he noted.

The three statistically significant symptoms that differentiated the blast injury patients were anxiety, depression, and frustration tolerance, all of which came out of the emotional cluster of symptoms.

Soldiers with TBI are dealing with more than neurologic impairment and emotional symptoms resulting from their TBI. They also are facing problems such as chronic pain, stress, ongoing physical rehabilitation, and dramatic lifestyle changes all brought on by the TBI, Dr. French said in an interview.

During his presentation, Dr. French also offered data to highlight the epidemiology of TBI in military personnel, along with some sample characteristics, symptoms, and tips for how community neurologists might evaluate and treat these patients once they leave intensive care facilities. “While there has been a lot of attention to brain injuries in the military, we need to be cautious about making a diagnosis based on symptoms without knowing the timing of an event,” he said.

For a patient's symptoms to be related to a TBI, he or she needs to experience a traumatic event—such as a car accident or a blast injury—that creates an external force to the head and causes an alteration in brain function, at least a brief feeling of being dazed and confused, or a complete loss of consciousness.

Although some symptoms may manifest much later than the TBI, there will be some symptoms that occur immediately at the time of the TBI, if that is the true cause of the symptoms, Dr. French explained.

Depression is a good example of a symptom experienced by many soldiers that may or may not be related to their TBI. “We know that depression is a fairly common symptom following TBI. However, the depression may be related to the blow to the head itself or to the fact that someone can't work for a while or can't return to fighting,” Dr. French said.

Explosion and blast-related injuries are a significant problem among military returning from the war in Iraq, accounting for 68% of injuries among 433 wounded soldiers treated at Walter Reed between January 2003 and April 2005, Dr. French said. Of these, 89% were closed head injuries; 43% of the patients suffered posttraumatic amnesia of less than 24 hours (J. Neurotrauma 2005;22:1178).

Complications among the TBI patients while they were treated at Walter Reed included skull fractures (25%), subdural hematoma (18.7%), shock (14%), and hypoxia (9.5%). In addition, 91% reported postconcussive symptoms including headache (47%), forgetfulness (46%), irritability (45%), and problems concentrating (41%). Overall, 43% had psychiatric symptoms, 27% of which were depression related.

Dr. French and his colleagues developed a blast injury protocol to evaluate the soldiers with follow-ups at various intervals. The protocol calls for not only basic medical care but also physical therapy and psychotherapy, as well as treatment for cognitive problems and chronic pain.

“It's important to remember [that soliders who have returned from Iraq with blast-induced TBI face] issues of chronic pain, ongoing physical rehab, ongoing stress symptoms, and a change in life roles,” Dr. French said, adding basic medical care, such as treating headaches and sleep problems, can go a long way toward making these patients more comfortable during a lengthy, ongoing recover.

High Pressure Is the Driving Force in Blast Injury

Blast injuries are caused by the explosion's blast waves—fronts of high pressure that compress the surrounding air, said Dr. Ibolja Cernak at a meeting sponsored by the Institute of Medicine.

Behind the blast wave is the blast wind, which causes a massive displacement of air that can reach hurricane proportions, said Dr. Cernak, medical director of the Johns Hopkins University Applied Physics Laboratory in Laurel, Md.

The interaction of the blast wave and blast wind in a battleground setting can cause several types of brain injury:

▸ Primary. Injury caused by the direct effect of blast pressure on the brain tissue.

▸ Secondary. Injury that occurs when the blast propels flying objects (such as shrapnel) into a person.

▸ Tertiary. Injury that occurs when the blast propels a person through the air to strike an object (similar to when someone is thrown from a car during a car accident).

▸ Quaternary. Injury caused by other effects of a blast, such as burns from thermal bombs or crush injuries caused by falling debris after a blast.

Dr. Cernak noted research findings have shown that blast injuries are part of a complex trauma as the whole body responds to a dramatic environment, she said. Blast injuries to the brain can be direct (when the force of the blast causes the brain to impact the skull or spine) or indirect (when the brain responds to the shock of impact on other parts of the body).

Soldiers in combat settings regularly are exposed to blasts. Even if they do not immediately and obviously show signs of a traumatic brain injury, repeated exposure to low-level blasts may cause brain injuries to develop over time, Dr. Cernak noted.

WASHINGTON — All traumatic brain injuries are not equal. Soldiers who experience blast-induced brain trauma manifest significantly greater emotional upheaval than do soldiers with brain injuries caused by car accidents, judging from preliminary data on soldiers wounded while deployed in Iraq.

In presenting the data at a meeting sponsored by the Institute of Medicine, Louis French, Psy.D., said, “At least one of the things that differentiates blast-induced brain injury from other types of mechanically induced brain injury is how emotionally traumatic the event is for these people. Perhaps blast as a mechanism is a more difficult way to get hurt emotionally.”

Dr. French presented some preliminary data from 144 soldiers who returned from Iraq with traumatic brain injury (TBI) who had completed the neurobehavioral symptom inventory prior to deployment. Most (141) were men, and the average age was 30.5 years. The symptoms included emotional, cognitive, and functional. The soldiers rated the symptoms as to how problematic they were.

A total of 130 patients had suffered closed head injuries, and 108 (75%) were injured from a blast. A total of 62 patients were classified as having mild TBI. In those 62 patients, the most common problems were sleep disturbances (94%–-of which 33% have reported very severe sleep disturbances), forgetfulness (89%), and irritability (81%). The soldiers were treated at Walter Reed Army Medical Center in Washington, where Dr. French is on the staff of the Defense and Veterans Brain Injury Center.

There may be something different about a blast injury that introduces a certain type of symptom, he said.

The people who have been injured from blast were endorsing higher levels of symptom severity than were people who were injured through other ways, he noted.

The three statistically significant symptoms that differentiated the blast injury patients were anxiety, depression, and frustration tolerance, all of which came out of the emotional cluster of symptoms.

Soldiers with TBI are dealing with more than neurologic impairment and emotional symptoms resulting from their TBI. They also are facing problems such as chronic pain, stress, ongoing physical rehabilitation, and dramatic lifestyle changes all brought on by the TBI, Dr. French said in an interview.

During his presentation, Dr. French also offered data to highlight the epidemiology of TBI in military personnel, along with some sample characteristics, symptoms, and tips for how community neurologists might evaluate and treat these patients once they leave intensive care facilities. “While there has been a lot of attention to brain injuries in the military, we need to be cautious about making a diagnosis based on symptoms without knowing the timing of an event,” he said.

For a patient's symptoms to be related to a TBI, he or she needs to experience a traumatic event—such as a car accident or a blast injury—that creates an external force to the head and causes an alteration in brain function, at least a brief feeling of being dazed and confused, or a complete loss of consciousness.

Although some symptoms may manifest much later than the TBI, there will be some symptoms that occur immediately at the time of the TBI, if that is the true cause of the symptoms, Dr. French explained.

Depression is a good example of a symptom experienced by many soldiers that may or may not be related to their TBI. “We know that depression is a fairly common symptom following TBI. However, the depression may be related to the blow to the head itself or to the fact that someone can't work for a while or can't return to fighting,” Dr. French said.

Explosion and blast-related injuries are a significant problem among military returning from the war in Iraq, accounting for 68% of injuries among 433 wounded soldiers treated at Walter Reed between January 2003 and April 2005, Dr. French said. Of these, 89% were closed head injuries; 43% of the patients suffered posttraumatic amnesia of less than 24 hours (J. Neurotrauma 2005;22:1178).

Complications among the TBI patients while they were treated at Walter Reed included skull fractures (25%), subdural hematoma (18.7%), shock (14%), and hypoxia (9.5%). In addition, 91% reported postconcussive symptoms including headache (47%), forgetfulness (46%), irritability (45%), and problems concentrating (41%). Overall, 43% had psychiatric symptoms, 27% of which were depression related.

Dr. French and his colleagues developed a blast injury protocol to evaluate the soldiers with follow-ups at various intervals. The protocol calls for not only basic medical care but also physical therapy and psychotherapy, as well as treatment for cognitive problems and chronic pain.

“It's important to remember [that soliders who have returned from Iraq with blast-induced TBI face] issues of chronic pain, ongoing physical rehab, ongoing stress symptoms, and a change in life roles,” Dr. French said, adding basic medical care, such as treating headaches and sleep problems, can go a long way toward making these patients more comfortable during a lengthy, ongoing recover.

High Pressure Is the Driving Force in Blast Injury

Blast injuries are caused by the explosion's blast waves—fronts of high pressure that compress the surrounding air, said Dr. Ibolja Cernak at a meeting sponsored by the Institute of Medicine.

Behind the blast wave is the blast wind, which causes a massive displacement of air that can reach hurricane proportions, said Dr. Cernak, medical director of the Johns Hopkins University Applied Physics Laboratory in Laurel, Md.

The interaction of the blast wave and blast wind in a battleground setting can cause several types of brain injury:

▸ Primary. Injury caused by the direct effect of blast pressure on the brain tissue.

▸ Secondary. Injury that occurs when the blast propels flying objects (such as shrapnel) into a person.

▸ Tertiary. Injury that occurs when the blast propels a person through the air to strike an object (similar to when someone is thrown from a car during a car accident).

▸ Quaternary. Injury caused by other effects of a blast, such as burns from thermal bombs or crush injuries caused by falling debris after a blast.

Dr. Cernak noted research findings have shown that blast injuries are part of a complex trauma as the whole body responds to a dramatic environment, she said. Blast injuries to the brain can be direct (when the force of the blast causes the brain to impact the skull or spine) or indirect (when the brain responds to the shock of impact on other parts of the body).

Soldiers in combat settings regularly are exposed to blasts. Even if they do not immediately and obviously show signs of a traumatic brain injury, repeated exposure to low-level blasts may cause brain injuries to develop over time, Dr. Cernak noted.

WASHINGTON — All traumatic brain injuries are not equal. Soldiers who experience blast-induced brain trauma manifest significantly greater emotional upheaval than do soldiers with brain injuries caused by car accidents, judging from preliminary data on soldiers wounded while deployed in Iraq.

In presenting the data at a meeting sponsored by the Institute of Medicine, Louis French, Psy.D., said, “At least one of the things that differentiates blast-induced brain injury from other types of mechanically induced brain injury is how emotionally traumatic the event is for these people. Perhaps blast as a mechanism is a more difficult way to get hurt emotionally.”

Dr. French presented some preliminary data from 144 soldiers who returned from Iraq with traumatic brain injury (TBI) who had completed the neurobehavioral symptom inventory prior to deployment. Most (141) were men, and the average age was 30.5 years. The symptoms included emotional, cognitive, and functional. The soldiers rated the symptoms as to how problematic they were.

A total of 130 patients had suffered closed head injuries, and 108 (75%) were injured from a blast. A total of 62 patients were classified as having mild TBI. In those 62 patients, the most common problems were sleep disturbances (94%–-of which 33% have reported very severe sleep disturbances), forgetfulness (89%), and irritability (81%). The soldiers were treated at Walter Reed Army Medical Center in Washington, where Dr. French is on the staff of the Defense and Veterans Brain Injury Center.

There may be something different about a blast injury that introduces a certain type of symptom, he said.

The people who have been injured from blast were endorsing higher levels of symptom severity than were people who were injured through other ways, he noted.

The three statistically significant symptoms that differentiated the blast injury patients were anxiety, depression, and frustration tolerance, all of which came out of the emotional cluster of symptoms.

Soldiers with TBI are dealing with more than neurologic impairment and emotional symptoms resulting from their TBI. They also are facing problems such as chronic pain, stress, ongoing physical rehabilitation, and dramatic lifestyle changes all brought on by the TBI, Dr. French said in an interview.

During his presentation, Dr. French also offered data to highlight the epidemiology of TBI in military personnel, along with some sample characteristics, symptoms, and tips for how community neurologists might evaluate and treat these patients once they leave intensive care facilities. “While there has been a lot of attention to brain injuries in the military, we need to be cautious about making a diagnosis based on symptoms without knowing the timing of an event,” he said.

For a patient's symptoms to be related to a TBI, he or she needs to experience a traumatic event—such as a car accident or a blast injury—that creates an external force to the head and causes an alteration in brain function, at least a brief feeling of being dazed and confused, or a complete loss of consciousness.

Although some symptoms may manifest much later than the TBI, there will be some symptoms that occur immediately at the time of the TBI, if that is the true cause of the symptoms, Dr. French explained.

Depression is a good example of a symptom experienced by many soldiers that may or may not be related to their TBI. “We know that depression is a fairly common symptom following TBI. However, the depression may be related to the blow to the head itself or to the fact that someone can't work for a while or can't return to fighting,” Dr. French said.

Explosion and blast-related injuries are a significant problem among military returning from the war in Iraq, accounting for 68% of injuries among 433 wounded soldiers treated at Walter Reed between January 2003 and April 2005, Dr. French said. Of these, 89% were closed head injuries; 43% of the patients suffered posttraumatic amnesia of less than 24 hours (J. Neurotrauma 2005;22:1178).

Complications among the TBI patients while they were treated at Walter Reed included skull fractures (25%), subdural hematoma (18.7%), shock (14%), and hypoxia (9.5%). In addition, 91% reported postconcussive symptoms including headache (47%), forgetfulness (46%), irritability (45%), and problems concentrating (41%). Overall, 43% had psychiatric symptoms, 27% of which were depression related.

Dr. French and his colleagues developed a blast injury protocol to evaluate the soldiers with follow-ups at various intervals. The protocol calls for not only basic medical care but also physical therapy and psychotherapy, as well as treatment for cognitive problems and chronic pain.

“It's important to remember [that soliders who have returned from Iraq with blast-induced TBI face] issues of chronic pain, ongoing physical rehab, ongoing stress symptoms, and a change in life roles,” Dr. French said, adding basic medical care, such as treating headaches and sleep problems, can go a long way toward making these patients more comfortable during a lengthy, ongoing recover.

High Pressure Is the Driving Force in Blast Injury

Blast injuries are caused by the explosion's blast waves—fronts of high pressure that compress the surrounding air, said Dr. Ibolja Cernak at a meeting sponsored by the Institute of Medicine.

Behind the blast wave is the blast wind, which causes a massive displacement of air that can reach hurricane proportions, said Dr. Cernak, medical director of the Johns Hopkins University Applied Physics Laboratory in Laurel, Md.

The interaction of the blast wave and blast wind in a battleground setting can cause several types of brain injury:

▸ Primary. Injury caused by the direct effect of blast pressure on the brain tissue.

▸ Secondary. Injury that occurs when the blast propels flying objects (such as shrapnel) into a person.

▸ Tertiary. Injury that occurs when the blast propels a person through the air to strike an object (similar to when someone is thrown from a car during a car accident).

▸ Quaternary. Injury caused by other effects of a blast, such as burns from thermal bombs or crush injuries caused by falling debris after a blast.

Dr. Cernak noted research findings have shown that blast injuries are part of a complex trauma as the whole body responds to a dramatic environment, she said. Blast injuries to the brain can be direct (when the force of the blast causes the brain to impact the skull or spine) or indirect (when the brain responds to the shock of impact on other parts of the body).

Soldiers in combat settings regularly are exposed to blasts. Even if they do not immediately and obviously show signs of a traumatic brain injury, repeated exposure to low-level blasts may cause brain injuries to develop over time, Dr. Cernak noted.

WASHINGTON — High intelligence may be protective against brain injury-associated cognitive dysfunction, judging from follow-up data on veterans injured during the war in Vietnam, Jordan Grafman, Ph.D., said at a meeting sponsored by the Institute of Medicine.

Dr. Grafman, chief of the cognitive neurosciences section of the National Institute of Neurological Disorders and Stroke, presented new data from 35 years of following Vietnam War veterans with traumatic brain injury (TBI). The study is the most recent phase in the ongoing Vietnam Head Injury Study, a long-term follow-up of veterans who suffered head injuries in combat. The cohort included 199 men with TBI and 55 controls; their average age at most recent follow up was 59 years.

Participants completed a variation of a U.S. Army classification test used to assess mental ability. The test was similar to an intelligence test that the soldiers took when they first enlisted. Overall, 4.5% of the participants scored less than 24 on the Mini-Mental State Examination, but those who scored lower also had below-average baseline intelligence scores.

The controls showed a cognitive decline with age, and the soldiers with penetrating head injuries showed a slightly greater decline, even when investigators controlled for a host of variables.

“But if you look at subgroups, those with the lowest preinjury intelligence scores had the most cognitive decline from preinjury to follow-up, and the difference was statistically significant, compared with controls,” Dr. Grafman said. He also noted that soldiers with head injuries who show exacerbated cognitive decline as they age may be mistakenly diagnosed with dementia, when in fact their increased cognitive decline results from a combination of aging and the size of their lesions.

Based in part on these findings, Dr. Grafman does not believe that TBI is always a precursor to Alzheimer's disease. But the long-term findings suggest that the location of the injury contributes to late-life cognitive decline and other symptoms.

“Lesions of the caudate nucleus of the brain significantly and consistently predicted late-life cognitive decline, and may indicate the importance of certain neurotransmitters in maintaining functions as we age,” Dr. Grafman said.

By contrast, the location of a TBI can be protective, too. Posttraumatic stress is clearly part of the experience of war, especially if someone experiences combat, Dr. Grafman said. But none the men with injuries to the amygdala showed signs of posttraumatic stress disorder, whereas 18% of those men with ventromedial prefrontal cortex lesions and more than 40% of patients with lesions elsewhere in the brain had developed PTSD over time since their injuries.

Dr. Grafman emphasized the importance of longitudinal studies for brain injury patients in general, and for veterans in particular, because baseline data are often available. “Preinjury intelligence is by far the best predictor of outcome, no matter what other variables you throw in,” Dr. Grafman said, based on the 35-year data and data from the same group of veterans at 5 and 15 years' follow-up. Data gathered on the cohort at 10 years showed individuals who scored higher on baseline intelligence tests were more likely to be working years later, and they were more able to handle daily activities, compared with those who had lower baseline intelligence scores.

Veterans are an outstanding patient group, and a systematic plan is needed to keep them from being lost in the medical system, Dr. Grafman noted, adding, “There needs to be a well-run centralized database for the registry of head-injured soldiers with a small number of manageable variables.”

WASHINGTON — High intelligence may be protective against brain injury-associated cognitive dysfunction, judging from follow-up data on veterans injured during the war in Vietnam, Jordan Grafman, Ph.D., said at a meeting sponsored by the Institute of Medicine.

Dr. Grafman, chief of the cognitive neurosciences section of the National Institute of Neurological Disorders and Stroke, presented new data from 35 years of following Vietnam War veterans with traumatic brain injury (TBI). The study is the most recent phase in the ongoing Vietnam Head Injury Study, a long-term follow-up of veterans who suffered head injuries in combat. The cohort included 199 men with TBI and 55 controls; their average age at most recent follow up was 59 years.

Participants completed a variation of a U.S. Army classification test used to assess mental ability. The test was similar to an intelligence test that the soldiers took when they first enlisted. Overall, 4.5% of the participants scored less than 24 on the Mini-Mental State Examination, but those who scored lower also had below-average baseline intelligence scores.

The controls showed a cognitive decline with age, and the soldiers with penetrating head injuries showed a slightly greater decline, even when investigators controlled for a host of variables.

“But if you look at subgroups, those with the lowest preinjury intelligence scores had the most cognitive decline from preinjury to follow-up, and the difference was statistically significant, compared with controls,” Dr. Grafman said. He also noted that soldiers with head injuries who show exacerbated cognitive decline as they age may be mistakenly diagnosed with dementia, when in fact their increased cognitive decline results from a combination of aging and the size of their lesions.

Based in part on these findings, Dr. Grafman does not believe that TBI is always a precursor to Alzheimer's disease. But the long-term findings suggest that the location of the injury contributes to late-life cognitive decline and other symptoms.

“Lesions of the caudate nucleus of the brain significantly and consistently predicted late-life cognitive decline, and may indicate the importance of certain neurotransmitters in maintaining functions as we age,” Dr. Grafman said.

By contrast, the location of a TBI can be protective, too. Posttraumatic stress is clearly part of the experience of war, especially if someone experiences combat, Dr. Grafman said. But none the men with injuries to the amygdala showed signs of posttraumatic stress disorder, whereas 18% of those men with ventromedial prefrontal cortex lesions and more than 40% of patients with lesions elsewhere in the brain had developed PTSD over time since their injuries.

Dr. Grafman emphasized the importance of longitudinal studies for brain injury patients in general, and for veterans in particular, because baseline data are often available. “Preinjury intelligence is by far the best predictor of outcome, no matter what other variables you throw in,” Dr. Grafman said, based on the 35-year data and data from the same group of veterans at 5 and 15 years' follow-up. Data gathered on the cohort at 10 years showed individuals who scored higher on baseline intelligence tests were more likely to be working years later, and they were more able to handle daily activities, compared with those who had lower baseline intelligence scores.

Veterans are an outstanding patient group, and a systematic plan is needed to keep them from being lost in the medical system, Dr. Grafman noted, adding, “There needs to be a well-run centralized database for the registry of head-injured soldiers with a small number of manageable variables.”

WASHINGTON — High intelligence may be protective against brain injury-associated cognitive dysfunction, judging from follow-up data on veterans injured during the war in Vietnam, Jordan Grafman, Ph.D., said at a meeting sponsored by the Institute of Medicine.

Dr. Grafman, chief of the cognitive neurosciences section of the National Institute of Neurological Disorders and Stroke, presented new data from 35 years of following Vietnam War veterans with traumatic brain injury (TBI). The study is the most recent phase in the ongoing Vietnam Head Injury Study, a long-term follow-up of veterans who suffered head injuries in combat. The cohort included 199 men with TBI and 55 controls; their average age at most recent follow up was 59 years.

Participants completed a variation of a U.S. Army classification test used to assess mental ability. The test was similar to an intelligence test that the soldiers took when they first enlisted. Overall, 4.5% of the participants scored less than 24 on the Mini-Mental State Examination, but those who scored lower also had below-average baseline intelligence scores.

The controls showed a cognitive decline with age, and the soldiers with penetrating head injuries showed a slightly greater decline, even when investigators controlled for a host of variables.

“But if you look at subgroups, those with the lowest preinjury intelligence scores had the most cognitive decline from preinjury to follow-up, and the difference was statistically significant, compared with controls,” Dr. Grafman said. He also noted that soldiers with head injuries who show exacerbated cognitive decline as they age may be mistakenly diagnosed with dementia, when in fact their increased cognitive decline results from a combination of aging and the size of their lesions.

Based in part on these findings, Dr. Grafman does not believe that TBI is always a precursor to Alzheimer's disease. But the long-term findings suggest that the location of the injury contributes to late-life cognitive decline and other symptoms.

“Lesions of the caudate nucleus of the brain significantly and consistently predicted late-life cognitive decline, and may indicate the importance of certain neurotransmitters in maintaining functions as we age,” Dr. Grafman said.

By contrast, the location of a TBI can be protective, too. Posttraumatic stress is clearly part of the experience of war, especially if someone experiences combat, Dr. Grafman said. But none the men with injuries to the amygdala showed signs of posttraumatic stress disorder, whereas 18% of those men with ventromedial prefrontal cortex lesions and more than 40% of patients with lesions elsewhere in the brain had developed PTSD over time since their injuries.

Dr. Grafman emphasized the importance of longitudinal studies for brain injury patients in general, and for veterans in particular, because baseline data are often available. “Preinjury intelligence is by far the best predictor of outcome, no matter what other variables you throw in,” Dr. Grafman said, based on the 35-year data and data from the same group of veterans at 5 and 15 years' follow-up. Data gathered on the cohort at 10 years showed individuals who scored higher on baseline intelligence tests were more likely to be working years later, and they were more able to handle daily activities, compared with those who had lower baseline intelligence scores.

Veterans are an outstanding patient group, and a systematic plan is needed to keep them from being lost in the medical system, Dr. Grafman noted, adding, “There needs to be a well-run centralized database for the registry of head-injured soldiers with a small number of manageable variables.”

BOSTON — Botulinum toxin injections are significantly more effective than oral tizanidine in reducing muscle tone and normalizing the appearance of spastic upper limbs in patients who have experienced a stroke or traumatic brain injury.

In fact, Dr. David Simpson reported at the annual meeting of the American Academy of Neurology, tizanidine—a first-line therapy for cerebral spasticity—was significantly less effective than placebo, suggesting it's time for physicians “to reconsider our first-line treatment for these patients, “said Dr. Simpson, professor of neurology at the Mount Sinai School of Medicine, New York.

Allergan Inc. sponsored the trial; Dr. Simpson and some of his coinvestigators have received research support and personal compensation from the company.

He presented the initial results of an 18-week three-way study of botulinum toxin, tizanidine, and placebo in 60 patients with increased upper limb tone secondary to stroke or traumatic brain injury.

Patients were randomized to either botulinum toxin injection plus oral placebo; tizanidine plus placebo injections; or oral placebo-placebo injections. All botulinum toxin patients received a mandatory injection of 50 units in the wrist flexors; providers could also inject additional toxin in other upper limb muscles, at doses deemed therapeutic. The maximum botulinum exposure was 500 units. Dilutions above the elbow were 2 cm

Tizanidine was titrated according to the label indications: 4 mg/day, escalating 4 mg every 3–4 days based on frequent consultation and patient reaction, to a maximum of 36 mg/day. If adverse events occurred, patients were permitted to slow their titration.

At baseline, all patients had a modified Ashworth score of at least 3 (0 indicates normal tone, whereas 5 indicates rigidity). By week 3, patients receiving the toxin showed significantly more wrist flexor relaxation than the other groups (−1.25 vs. −0.25 for tizanidine and −0.67 for placebo). The results were similar at week 6. By week 18, the toxin group was moving back toward its baseline scores.

Finger tone was also significantly more improved in patients in the toxin group than in those in the tizanidine or placebo groups (−1.32 vs. −0.22 and −0.69).

“In fact, the placebo group did significantly better than the tizanidine group in both categories,” he said.

Only limb posture cosmesis was significantly improved in the Disability Assessment Score, he said. The greatest improvement occurred in the botulinum toxin group.

BOSTON — Botulinum toxin injections are significantly more effective than oral tizanidine in reducing muscle tone and normalizing the appearance of spastic upper limbs in patients who have experienced a stroke or traumatic brain injury.

In fact, Dr. David Simpson reported at the annual meeting of the American Academy of Neurology, tizanidine—a first-line therapy for cerebral spasticity—was significantly less effective than placebo, suggesting it's time for physicians “to reconsider our first-line treatment for these patients, “said Dr. Simpson, professor of neurology at the Mount Sinai School of Medicine, New York.

Allergan Inc. sponsored the trial; Dr. Simpson and some of his coinvestigators have received research support and personal compensation from the company.

He presented the initial results of an 18-week three-way study of botulinum toxin, tizanidine, and placebo in 60 patients with increased upper limb tone secondary to stroke or traumatic brain injury.

Patients were randomized to either botulinum toxin injection plus oral placebo; tizanidine plus placebo injections; or oral placebo-placebo injections. All botulinum toxin patients received a mandatory injection of 50 units in the wrist flexors; providers could also inject additional toxin in other upper limb muscles, at doses deemed therapeutic. The maximum botulinum exposure was 500 units. Dilutions above the elbow were 2 cm

Tizanidine was titrated according to the label indications: 4 mg/day, escalating 4 mg every 3–4 days based on frequent consultation and patient reaction, to a maximum of 36 mg/day. If adverse events occurred, patients were permitted to slow their titration.

At baseline, all patients had a modified Ashworth score of at least 3 (0 indicates normal tone, whereas 5 indicates rigidity). By week 3, patients receiving the toxin showed significantly more wrist flexor relaxation than the other groups (−1.25 vs. −0.25 for tizanidine and −0.67 for placebo). The results were similar at week 6. By week 18, the toxin group was moving back toward its baseline scores.

Finger tone was also significantly more improved in patients in the toxin group than in those in the tizanidine or placebo groups (−1.32 vs. −0.22 and −0.69).

“In fact, the placebo group did significantly better than the tizanidine group in both categories,” he said.

Only limb posture cosmesis was significantly improved in the Disability Assessment Score, he said. The greatest improvement occurred in the botulinum toxin group.

BOSTON — Botulinum toxin injections are significantly more effective than oral tizanidine in reducing muscle tone and normalizing the appearance of spastic upper limbs in patients who have experienced a stroke or traumatic brain injury.

In fact, Dr. David Simpson reported at the annual meeting of the American Academy of Neurology, tizanidine—a first-line therapy for cerebral spasticity—was significantly less effective than placebo, suggesting it's time for physicians “to reconsider our first-line treatment for these patients, “said Dr. Simpson, professor of neurology at the Mount Sinai School of Medicine, New York.

Allergan Inc. sponsored the trial; Dr. Simpson and some of his coinvestigators have received research support and personal compensation from the company.

He presented the initial results of an 18-week three-way study of botulinum toxin, tizanidine, and placebo in 60 patients with increased upper limb tone secondary to stroke or traumatic brain injury.

Patients were randomized to either botulinum toxin injection plus oral placebo; tizanidine plus placebo injections; or oral placebo-placebo injections. All botulinum toxin patients received a mandatory injection of 50 units in the wrist flexors; providers could also inject additional toxin in other upper limb muscles, at doses deemed therapeutic. The maximum botulinum exposure was 500 units. Dilutions above the elbow were 2 cm

Tizanidine was titrated according to the label indications: 4 mg/day, escalating 4 mg every 3–4 days based on frequent consultation and patient reaction, to a maximum of 36 mg/day. If adverse events occurred, patients were permitted to slow their titration.

At baseline, all patients had a modified Ashworth score of at least 3 (0 indicates normal tone, whereas 5 indicates rigidity). By week 3, patients receiving the toxin showed significantly more wrist flexor relaxation than the other groups (−1.25 vs. −0.25 for tizanidine and −0.67 for placebo). The results were similar at week 6. By week 18, the toxin group was moving back toward its baseline scores.

Finger tone was also significantly more improved in patients in the toxin group than in those in the tizanidine or placebo groups (−1.32 vs. −0.22 and −0.69).

“In fact, the placebo group did significantly better than the tizanidine group in both categories,” he said.

Only limb posture cosmesis was significantly improved in the Disability Assessment Score, he said. The greatest improvement occurred in the botulinum toxin group.