[Infantile acquired brain injury, a personal experience. Demands from the socio-familial point of view]. / Daño cerebral sobrevenido infantil, una experiencia personal. Reclamaciones desde el punto de vista sociofamiliar.

We report on the experience of a family in which the youngest child has acquired brain injury and the struggle undertaken by the family to improve the neurorehabilitation resources in the public health service. The article outlines the main demands, from the socio-familial point of view, as regards the improvement of neurological rehabilitation and the resources needed to deliver it.

TITLE: Daño cerebral sobrevenido infantil, una experiencia personal. Reclamaciones desde el punto de vista sociofamiliar.Se describe la experiencia de una familia en la que el hijo menor tiene daño cerebral sobrevenido y la lucha emprendida por la familia para mejorar los recursos neurorrehabilitadores de la sanidad publica. Se recogen las principales reclamaciones, desde el punto de vista sociofamiliar, en cuanto a la mejora en la atencion neurorrehabilitadora y los recursos necesarios.

Validación de un programa de estimulación neuropsicológico NEUROPROTENIC en pacientes con daño cerebral adquirido / Validation of a neuropsychological stimulation program NEUROPROTENIC in patients with acquired brain injury

El objetivo de la presente investigación fue realizar el diseño de un software de estimulación neuropsicológica denominado NEUROPROTENIC y validación de las actividades incluidas en el software, como proyecto de grado para el programa de Maestría en Neuropsicología Clínica de la Facultad de Psicología de la Universidad de San Buenaventura. Esta es la primera fase general del estudio que posteriormente será sistematizado e implementado en pacientes que han presentado daño cerebral adquirido, específicamente aquellos con las etiologías correspondiente a accidente cerebrovascular y trauma cráneo encefálico. En el contexto actual de investigaciones sobre rehabilitación neuropsicológica y/o estimulación neuropsicológica, se ha iniciado una tendencia mayor al uso de nuevas herramientas tecnológicas, por tanto es quizás por esto la gran oportunidad de NEUROPROTENIC de ser un software pionero en Colombia que se somete a validación las actividades de rehabilitación, consiguiendo un alto índice de validez en las actividades diseñadas lo que garantiza en una gran parte que realmente que las personas con Daño Cerebral Adquirido que participen de la estimulación neuropsicológica mediante presenten una mejoría significativa en la curva de recuperación espontanea...

The objective of this research is to design software called NEUROPROTENIC neuropsychological stimulation, as degree project for Master of Clinical Neuropsychology, Faculty of Psychology at the University of San Buenaventura. This generally is the first phase of the study which will later be systematized and implemented in patients who have acquired brain injury, specifically those corresponding to the stroke etiologies and Traumatic Brain Injury. In the current context of neuropsychological rehabilitation research and / or neuropsychological stimulation, has started a greater tendency to use new technological tools, so it is perhaps for this NEUROPROTENIC the great opportunity to be a pioneer in Colombia that software undergoes validation rehabilitation activities, achieving high level of validity in activities designed which guarantees really much that people with Acquired Brain Injury to participate by presenting neuropsychological stimulation significantly improved the spontaneous recovery curve...

Factores de riesgos prevalentes en pacientes ingresados por enfermedad cerebrovascular / Prevailing risk factors in hospitalized patients with cerebrovascular disease

INTRODUCCIÓN: la enfermedad cerebrovascular en la actualidad es uno de los problemas de salud más importantes, no solo en Cuba, sino en los países desarrollados del mundo. Ocupa el segundo lugar como causa de discapacidad permanente en el adulto y muerte, solo es superada por las enfermedades cardiovasculares y el cáncer, lo que determina su relevancia médica, económica y social por el costo en la rehabilitación y los cuidados que requieren los pacientes con importantes daños neurológicos. OBJETIVO: caracterizar los factores de riesgos prevalecientes en los pacientes ingresados por enfermedad cerebrovascular. MÉTODOS: estudio descriptivo y longitudinal en una muestra de 144 pacientes ingresados por enfermedad cerebrovascular en el servicio de urgencias del Hospital Clinicoquirúrgico Docente "Dr. Octavio de la Concepción y de la Pedraja" entre enero y diciembre de 2012. Se aplicó una encuesta que exploró diferentes variables y los datos obtenidos se codificaron manualmente. RESULTADOS: el tipo de enfermedad cerebrovascular que prevaleció fue la hemorragia subaracnoidea, seguida por la hemorragia cerebral. Los factores de riesgo modificables que se identificaron con mayor frecuencia fueron la hipertensión arterial y la diabetes mellitus. Se constató insuficiente control de los factores de riesgo en la atención primaria de salud. CONCLUSIONES: los factores de riesgo mayormente asociados a la enfermedad cerebrovascular fueron la hipertensión arterial y la edad avanzada, seguidos por el tabaquismo y la diabetes mellitus, en correspondencia con un control deficiente de estas enfermedades.

INTRODUCTION: cerebrovascular diseases are presently one of the most important health problems not only in Cuba but in the developed countries as well. It holds the second place in the list of causes of permanent disability and of death in adults, just preceded by cancer and cardiovascular diseases, which determines its medical, economic and social relevance due to the cost of rehabilitation and of care that patients having significant neurological damage require. OBJECTIVE: to characterize the prevailing risk factors in hospitalized patients with cerebrovascular disease. METHODS: longitudinal and descriptive study of a sample of 144 patients with cerebrovascular disease, who were admitted to the emergency service of "Dr Octavio de la Concepcion y de la Pedraja" teaching, clinical and surgical hospital from January through December, 2012. A survey was conducted to explore different variables and the collected data were manually coded. RESULTS: the predominant type of cerebrovascular disease was subararachnoid hemorrhage followed by brain hemorrhage. The most frequently modifiable risk factors were blood hypertension and diabetes mellitus. It was observed that the control of risk factors was poor at the primary health care setting. CONCLUSIONS: the risk factors mainly associated to cerebrovascular disease were blood hypertension and advanced age, followed by tabaquismo and diabetes mellitus, in correspondence with a deficient control of these illnesses.

Severe stroke: which medicine for which results?

In face of any severe stroke, the questions for health professionals in charge of the patient are: will the handicap be acceptable for the patient? But can we predict an acceptable handicap for the patient? For his family? When we know that the cognitive disorders, consequences of severe stroke often modify, in a major way, the behaviour of these patients? Given these difficulties for estimate vital and functional prognosis and even more the quality of life of patients with severe stroke, collective reflexions between physicians and nurses are essential, reflexions taking into account preferences and values of patients. Use of resuscitation resources for severe stroke patients implies to offer them the best rehabilitation. So, questions about health pathways for severe stroke are essential: which structures for these patients, which technologies, which medical, medico-social and social supports, which human accompaniment the society can propose to the patients and to their family, so that they have an acceptable quality of life.

Bimanuality is improved by hand surgery in children with brain lesions: preliminary results in 18 children.

The present study was performed to investigate if, in a short term perspective, bimanual hand function in children with brain damage improves as an effect of hand surgery. Assisting Hand Assessment (AHA), Goal Achievement Scale, consolidated House Functional Classification, Zancolli Classification, and the active range of motion were measured before surgery and 5-14 months after surgery in 18 children, aged 6-16 years, mean of 11 years. AHA improved from 44.5 AHA units (range 20-66) to 52.5 AHA units (range 25-69) (P<0.005) on a 0-100 AHA unit scale. Active motion improved (P<0.005). Rating of selected goals improved from 2.6 to 6.4, on a 10-grade scale. On a short term, hand surgery improved not only the grip, but also the ability to use the hemiplegic hand in bimanual activities.

Habilidades funcionais de criança com síndrome da imunodeficiência adquirida / Functional abilities of children with Acquired Immunodeficiency Syndrome

A encefalopatia associada ao vírus da imunodeficiência humana é uma conseqüência importante das infecções neurológicas que atingem crianças com a síndrome da imunodeficiência adquirida. Tal conseqüência pode gerar perdas no desenvolvimento neuropsicomotorlevando a dificuldades em atividades fundamentais para a independênciada criança. O objetivo do estudo é descrever os ganhos funcionaisnas áreas de auto-cuidado e mobilidade de uma criança com síndrome da imunodeficiência adquirida. Foi aplicado junto ao cuidador da criança o Inventário de Avaliação Pediátrica de Incapacidade(PEDI), antes e após o processo de reabilitação com intervalo de 12meses. Os resultados demonstram que houve melhora funcional nos aspectos avaliados. Na área de auto-cuidado houve alteração de escores de 53,65 na primeira avaliação para 60,06 na segunda avaliação. Na área de mobilidade a criança passou de um escore de 24,29 para 38,66. Os resultados sugerem que as estratégias utilizadas no processo de reabilitação, bem como atuação da equipe ultidisciplinar permitiram o desenvolvimento de habilidades para melhor desempenho ocupacional da criança.

Encephalopathy associated with human immunodeficiency virus is an important consequence of neurological infections that affect children with acquired immunodeficiency syndrome. Such a result can generate large losses in neuropsychomotor development leading to difficulties in activities fundamental to the independence of the child. The objective here was to describe the functional gains in the areas of self-care and mobility of a child with acquired immunodeficiency syndrome. The Pediatric Evaluation of Disability Inventory (PEDI) was made with the child’s caregiver, before and after the rehabilitation process with an interval of 12 months. The results show that there were significant improvements in the functional aspects evaluated. In the area of self-care there scoring changed from53.65 to 60.06 in the first and second assessments, respectively. In the areaof mobility, the child’s score went from 24.29 to 38.66. The results suggestthat strategies used in the rehabilitation process, along with the help of amultidisciplinary team, enabled the development of occupational skills forbetter performance.

Reversing brain damage in former NFL players: implications for traumatic brain injury and substance abuse rehabilitation.

Brain injuries are common in professional American football players. Finding effective rehabilitation strategies can have widespread implications not only for retired players but also for patients with traumatic brain injury and substance abuse problems. An open label pragmatic clinical intervention was conducted in an outpatient neuropsychiatric clinic with 30 retired NFL players who demonstrated brain damage and cognitive impairment. The study included weight loss (if appropriate); fish oil (5.6 grams a day); a high-potency multiple vitamin; and a formulated brain enhancement supplement that included nutrients to enhance blood flow (ginkgo and vinpocetine), acetylcholine (acetyl-l-carnitine and huperzine A), and antioxidant activity (alpha-lipoic acid and n-acetyl-cysteine). The trial average was six months. Outcome measures were Microcog Assessment of Cognitive Functioning and brain SPECT imaging. In the retest situation, corrected for practice effect, there were statistically significant increases in scores of attention, memory, reasoning, information processing speed and accuracy on the Microcog. The brain SPECT scans, as a group, showed increased brain perfusion, especially in the prefrontal cortex, parietal lobes, occipital lobes, anterior cingulate gyrus and cerebellum. This study demonstrates that cognitive and cerebral blood flow improvements are possible in this group with multiple interventions.

Current trends in the length of stay in neurological early rehabilitation.

BACKGROUND: Neurological early rehabilitation (phase B) is an integral component of the phase model of the German Federal Rehabilitation Council (Bundesarbeitsgemeinschaft für Rehabilitation, BAR). We studied the current trend in patients' length of stay. METHODS: This study included 2060 cases of the BDH-Klinik Hessisch Oldendorf (a neurological rehabilitation clinic) from 2005 to 2008 that fulfilled the structural characteristics of item 8-552 of the German coding system for operations and procedures (Operationen- und Prozedurenschlüssel, OPS), which codes for neurological and neurosurgical early rehabilitation. We studied the parameters age, sex, length of stay, type of discharge, diagnoses, and morbidity. 75.7% of the collective carried a diagnosis of cerebral ischemia, traumatic brain injury, or intracerebral hemorrhage. RESULTS: The mean length of stay over the entire period of the study was 44.6 days. A successive reduction of the mean length of stay from 2005 to 2008 was evident, from 46.8 days in 2005 to 37.5 in 2008 (p<0.001). The morbidity, too, declined over the period of the study. 76.4% of the cases analyzed stayed in hospital for at least the minimum of 8 weeks proposed by the BAR. 39.5% of the patients improved to such an extent in phase B that they were able to be transferred to a further rehabilitation facility, while about one patient in five was transferred from early rehabilitation to a nursing facility. The mortality was 0.9%. Although the early rehabilitation procedure was correctly coded, a total of 60 different diagnosis-related groups (DRGs) were applied. CONCLUSION: These data support the BAR's recommendation for a minimum length of stay of 8 weeks in phase B. The observed shortening of the length of stay was found to be primarily the result of a reduction in morbidity during early rehabilitation. This, in turn, may well be due to a selection effect of the early rehabilitation procedure code 8-552.

[Mentoring system--performance optimization of treatment by formative case management]. / Das Mentoring-System--Qualitätssteigerung im Rehabilitationsprozess durch gestaltendes Case-Management.

The efficiency of the German public health system and its principle of adequate treatment are not up to the standards required by accident insurance companies. These have to be interested in realising optimal treatment, because the amount of pecuniary reparation essentially depends on (the quality of) the state of health of the injured person. To accomplish these objectives, their case management departments have to find a way to use the resources of the public health system and to improve considerably the quality of process und structure of the treatment. This is why case management is becoming increasingly important for insurance companies. Against this background, this case report describes the process of rehabilitation of a 72-year-old woman who had an accident and suffered a traumatic brain injury. This process was managed by AMB Generali Schadenmanagement GmbH in cooperation with the consulting firm Haase & Johanns Consulting, to develop approaches to rehabilitation management. It describes the mutual benefit for the injured person and of the insurer, which is defined by the success of treatment and saving of costs (care home, damages for pain and suffering) amounting to about 700,000 Euros.

Care protocol for persistent vegetative states (PVS) and minimally conscious state (MSC) in Lorraine: retrospective study over an 18-year period.

OBJECTIVES: Retrospective analysis of the efficiency of a protocol for care of chronic vegetative states (CVS) and minimally conscious state (MCS) in Lorraine. MATERIAL AND METHOD: Two indicators are used: protocol activity (number of patients hospitalized between 1988 and 2006, number of admissions per year, of requests per year, origin of requests, waiting time) and the epidemiological data (age, sex ratio, etiology, length of stay, geographic origin, number of deaths, number of hospital discharges). The number of CVS and MCS and patients having progressed towards arousal is specified as well as the technical procedures (orthopedic surgery, number of tracheotomies). RESULTS: Forty-seven patients (30 males and 17 females) were hospitalized in a 12-bed unit. The number of admissions per year was 2.4, and the annual number of requests varied between five and 15. Hospitalization times ranged from six to 18 months. The average length of hospitalization was 41 months. Eighty-eight percent of the cases were residents of Lorraine. The etiology was traumatic (53%), vascular (38% including 12% anoxia), miscellaneous (9%). Fifteen percent rate of return to arousal (average time period: 28.41 months, traumatic etiology) with hospital discharge in four cases. CONCLUSION: The protocol is managed as part of a local scheme and enables an appropriate response to a specific clinical profile by providing up-to-date multidiscipline follow-up care and a rapid solution should intercurrent events occur (signs of arousal, orthopedic deterioration, change of environment). Typical limitations are geographical remoteness and difficulties with family support care.

Predictors of outcome following acquired brain injury in children.

Acquired brain injury (ABI) in children and adolescents can result from multiple causes, including trauma, central nervous system infections, noninfectious disorders (epilepsy, hypoxia/ischemia, genetic/metabolic disorders), tumors, and vascular abnormalities. Prediction of outcomes is important, to target interventions, allocate resources, provide education to family or caregivers, and begin appropriate planning for the future. Researchers have identified several factors associated with better or worse outcomes after ABI, including variables related to the injury itself, postinjury factors related to intervention or trajectory of recovery, and preinjury or demographic factors. When examining the scientific literature, it is important to identify how "outcome" is defined, as the predictors may change depending on the outcome studied. In addition, key variables may be specific to the etiology of injury. Therefore, predictors of outcome cannot be generalized across the various etiologies of ABI, and this review will discuss predictors within the context of multiple etiologies of ABI. This article reviews the current literature on predicting outcomes after pediatric ABI, and areas in need of further research are discussed.

The role of neuropsychological functioning in cancer survivors' return to work one year after diagnosis.

OBJECTIVE: The objective of this study was to investigate the relationship between neuropsychological functioning and the ability to work in cancer survivors. METHODS: The study involved a consecutive cohort of 45 patients who had received a primary diagnosis of cancer, were gainfully employed at baseline, and had been treated with curative intent. Twelve months after the first day of sick leave, they underwent a neuropsychological assessment that included executive function and verbal memory tests. Other clinical, person-related, and work-related factors were also assessed by questionnaire at this time. Ability to work was measured as perceived workability (0-10) and work status at 12 months of sick leave. RESULTS: Fifteen participants (33%) showed neuropsychological impairments covering various domains. The mean workability score of cancer survivors with neuropsychological impairment was 4.9, whereas those without impairments had a mean score of 6.0 (raw beta = -0.19: 95% CI = -2.9 to 0.7; adjusted beta = -0.15; 95% CI = -2.5 to 0.8). More cancer survivors with neuropsychological impairments (7/15, 47%) than without (9/30, 30%) had not yet returned to work (raw OR 0.5: 95% CI: 0.1-1.8; adjusted OR 0.5; 95% CI: 0.1-2.1). CONCLUSIONS: To date, this is the largest study to assess neuropsychological functioning objectively in combination with perceived workability and work status. Impaired neuropsychological functioning was found in one-third of the cancer survivors and was related to a lower vocational functioning, but the relationship was not statistically significant. More research is needed to test the relevance of neuropsychological impairments for vocational functioning.

Interventions to improve neuropsychological functioning in childhood cancer survivors.

A very brief historical review on the identification of neurocognitive deficits in patients treated for a pediatric malignancy that involved CNS disease, treatment, or a combination is provided. This review is particularly directed toward providing a foundation upon which the introduction of specific brain injury rehabilitation efforts and subsequent research were introduced into this population of patients. Three primary methods by which clinicians and researchers have attempted to improve neurocognitive functioning with survivors of pediatric cancer that have suffered a CNS insult are identified. From a pharmacological perspective, research is reviewed that documents the potential beneficial effects of stimulant medication. Results of two drug trials that used double-blind crossover methodology are reviewed, and it is highly likely that medications may be of significant benefit to pediatric cancer survivors who are experiencing attentional deficits, impairment in social functioning, and also declines in academic achievement. We next describe psychologically based brain injury rehabilitation efforts, including on-treatment schooling and reentry, within the survivor population. A phase III clinical trial of a comprehensive rehabilitation approach is discussed in detail. New directions in the area of brain injury rehabilitation for childhood cancer survivors are presented, and the need for professionals in this area to work toward a team approach is emphasized.

Developmental perspectives on optimizing educational and vocational outcomes in child and adult survivors of cancer.

Over the last few decades, long-term survival rates of children diagnosed with the two most common forms of childhood cancer, acute lymphoblastic leukemia (ALL) and brain tumors have improved substantially. Neurodevelopmental and psychosocial sequelae resulting from these diseases and their treatment have a direct impact on the developing brain and on the quality of life of these children and their families. The focus of this article is on optimizing neuropsychological and adaptive outcomes for children who have been successfully treated for these cancers and whose prospects for long-term survival are increasingly encouraging. We present a model for understanding systemic interactions among the multiple factors that influence the child's development over time and take into account contextual variables. Strategies for optimizing cognitive and psychosocial outcomes or ameliorating late effects need to consider treatment histories, specific stages of development, the contextual demands/developmental challenges associated with each, and the resources (internal and external to the child) available to meet these challenges. The challenges faced by survivors at the early childhood, middle childhood, adolescent, and emerging adulthood stages are discussed. We review different types of interventions and discuss how these can contribute to optimal functioning in survivors of childhood ALL and brain tumors.

Motor cortical stimulation promotes synaptic plasticity and behavioral improvements following sensorimotor cortex lesions.

Cortical stimulation (CS) as a means to modulate regional activity and excitability in cortex is emerging as a promising approach for facilitating rehabilitative interventions after brain damage, including stroke. In this study, we investigated whether CS-induced functional improvements are linked with synaptic plasticity in peri-infarct cortex and vary with the severity of impairments. Adult rats that were proficient in skilled reaching received subtotal unilateral ischemic sensorimotor cortex (SMC) lesions and implantation of chronic epidural electrodes over remaining motor cortex. Based on the initial magnitude of reaching deficits, rats were divided into severely and moderately impaired subgroups. Beginning two weeks post-surgery, rats received 100 Hz cathodal CS at 50% of movement thresholds or no-stimulation control procedures (NoCS) during 18 days of rehabilitative training on a reaching task. Stereological electron microscopy methods were used to quantify axodendritic synapse subtypes in motor cortical layer V underlying the electrode. In moderately, but not severely impaired rats, CS significantly enhanced recovery of reaching success. Sensitive movement analyses revealed that CS partially normalized reaching movements in both impairment subgroups compared to NoCS. Additionally, both CS subgroups had significantly greater density of axodendritic synapses and moderately impaired CS rats had increases in presumed efficacious synapse subtypes (perforated and multiple synapses) in stimulated cortex compared to NoCS. Synaptic density was positively correlated with post-rehabilitation reaching success. In addition to providing further support that CS can promote functional recovery, these findings suggest that CS-induced functional improvements may be mediated by synaptic structural plasticity in stimulated cortex.