Trends in Neurotrauma Epidemiology, Management, and Outcomes during the COVID-19 Pandemic in Kigali, Rwanda.

National regulations to curb the coronavirus disease 2019 (COVID-19) transmission and health care resource reallocation may have impacted incidence and treatment for neurotrauma, including traumatic brain injury (TBI) and spinal trauma, but these trends have not been characterized in Sub-Saharan Africa. This study analyzes differences in epidemiology, management, and outcomes preceding and during the COVID-19 pandemic for neurotrauma patients in a Rwandan tertiary hospital. The study setting was the Centre Hospitalier Universitaire de Kigali (CHUK), Rwanda's national referral hospital. Adult injury patients presenting to the CHUK Emergency Department (ED) were prospectively enrolled from January 27, 2020 to June 28, 2020. Study personnel collected data on demographics, injury characteristics, serial neurological examinations, treatment, and outcomes. Differences in patients before (January 27, 2020 to March 21, 2020) and during (June 1, 2020 to June 28, 2020) the COVID-19 pandemic were assessed using chi-squared and Mann-Whitney U tests. The study population included 216 patients with neurotrauma (83.8% TBI, 8.3% spine trauma, and 7.9% with both). Mean age was 34.1 years (standard deviation [SD] = 12.5) and 77.8% were male. Patients predominantly experienced injury following a road traffic accident (RTA; 65.7%). Weekly volume for TBI (mean = 16.5 vs. 17.1, p = 0.819) and spine trauma (mean = 2.0 vs. 3.4, p = 0.086) was similar between study periods. During the pandemic, patients had lower Glasgow Coma Scale (GCS) scores (mean = 13.8 vs. 14.3, p = 0.068) and Kampala Trauma Scores (KTS; mean = 14.0 vs. 14.3, p = 0.097) on arrival, denoting higher injury severity, but these differences only approached significance. Patients treated during the pandemic period had higher occurrence of hemorrhage, contusion, or fracture on computed tomography (CT) imaging (47.1% vs. 26.7%, p = 0.003) and neurological decline (18.6% vs. 7.5%, p = 0.016). Hospitalizations also increased significantly during COVID-19 (54.6% vs. 39.9%, p = 0.048). Craniotomy rates doubled during the pandemic period (25.7% vs. 13.7%, p = 0.003), but mortality was unchanged (5.5% vs. 5.7%, p = 0.944). Neurotrauma volume remained unchanged at CHUK during the COVID-19 pandemic, but presenting patients had higher injury acuity and craniotomy rates. These findings may inform care during pandemic conditions in Rwanda and similar settings.

Differences in State Traumatic Brain Injury-Related Deaths, by Principal Mechanism of Injury, Intent, and Percentage of Population Living in Rural Areas - United States, 2016-2018.

Traumatic brain injuries (TBIs) have contributed to approximately one million deaths in the United States over the last 2 decades (1). CDC analyzed National Vital Statistics System (NVSS) mortality data for a 3-year period (2016-2018) to examine numbers and rates of TBI-related deaths, the percentage difference between each state's rate and the overall U.S. TBI-related death rate, leading causes of TBI, and the association between TBI and a state's level of rurality. During 2016-2018, a total of 181,227 TBI-related deaths (17.3 per 100,000 population per year) occurred in the United States. The percentage difference between state TBI-related death rates and the overall U.S. rate during this period ranged from 46.2% below to 101.2% above the overall rate. By state, the lowest rate was in New Jersey (9.3 per 100,000 population per year); the states with the highest rates were Alaska (34.8), Wyoming (32.6), and Montana (29.5). States in the South and those with a higher proportion of residents living in rural areas had higher rates, whereas states in the Northeast and those with a lower proportion of residents living in rural areas had lower TBI-related death rates. In 43 states, suicide was the leading cause of TBI-related deaths; in other states, unintentional falls or unintentional motor vehicle crashes were responsible for the highest numbers and rates of TBI-related deaths. Consistent with previous studies (2), differences in TBI incidence and outcomes were observed across U.S. states; therefore, states can use these findings to develop and implement evidence-based prevention strategies, based on their leading causes of TBI-related deaths. Expanding evidence-based prevention strategies that address TBI-related deaths is warranted, especially among states with high rates due to suicide, unintentional falls, and motor vehicle crashes.

Increased mortality in very young children with traumatic brain injury due to abuse: A nationwide analysis of 10,965 patients.

BACKGROUND: Traumatic brain injury (TBI) is the leading cause of death and disability in young children; however, the impact of mechanism on outcomes has not been fully evaluated. We hypothesized that children with TBI due to abuse would have a higher mortality than children with accidental TBI due to motor vehicle collisions (MVC). METHODS: We performed a retrospective review of the National Kids' Inpatient (KID) hospitalizations database of children <2 years old with TBI due to abuse or MVC (2000-2016). The primary outcome was mortality. Secondary outcomes were length of stay (LOS) and hospital charges. We investigated predictors of mortality with multivariable regression. RESULTS: Of 10,965 children with TBI, 65.2% were due to abuse. Overall mortality was 9.8% (n = 1074). Abused children had longer LOS (5.7 vs 1.6 days, p < 0.0001) and higher hospital charges ($34,314 vs $19,360, p < 0.0001) than children with TBI due to MVC. The odds of mortality were 42% higher in children with abusive head trauma (OR 1.42, 95% CI 1.10-1.83, p = 0.007) compared to MVCs after adjusting for age, race, sex, neurosurgical intervention, injury severity, and insurance. CONCLUSION: Children with abusive traumatic brain injury have increased risk of mortality, longer LOS, and higher hospital charges compared to children with TBI due to motor vehicle collision after adjusting for relevant confounders. Resources must be directed at prevention and early identification of abuse.

Cost-effectiveness of mandatory bicycle helmet use to prevent traumatic brain injuries and death.

BACKGROUND: Traumatic brain injury (TBI) is the main cause of mortality and severe morbidity in cyclists admitted to Dutch emergency departments (EDs). Although the use of bicycle helmets is an effective way of preventing TBI, this is uncommon in the Netherlands. An option to increase its use is through a legal enforcement. However, little is known about the cost-effectiveness of such mandatory use of helmets in the Dutch context. The current study aimed to assess the cost-effectiveness of a law that enforces helmet use to reduce TBI and TBI-related mortality. METHODS: The cost-effectiveness was estimated through decision tree modelling. In this study, wearing bicycle helmets enforced by law was compared with the current situation of infrequent voluntary helmet use. The total Dutch cycling population, consisting of 13.5 million people, was included in the model. Model data and parameters were obtained from Statistics Netherlands, the National Road Traffic Database, Dutch Injury Surveillance System, and literature. Effects included were numbers of TBI, death, and disability-adjusted life years (DALY). Costs included were healthcare costs, costs of productivity losses, and helmet costs. Sensitivity analysis was performed to assess which parameter had the largest influence on the incremental cost-effectiveness ratio (ICER). RESULTS: The intervention would lead to an estimated reduction of 2942 cases of TBI and 46 deaths. Overall, the incremental costs per 1) death averted, 2) per TBI averted, and 3) per DALY averted were estimated at 1) € 2,002,766, 2) € 31,028 and 3) € 28,465, respectively. Most favorable were the incremental costs per DALY in the 65+ age group: € 17,775. CONCLUSIONS: The overall costs per DALY averted surpassed the Dutch willingness to pay threshold value of € 20,000 for cost-effectiveness of preventive interventions. However, the cost per DALY averted for the elderly was below this threshold, indicating that in this age group largest effects can be reached. If the price of a helmet would reduce by 20%, which is non-hypothetical in a situation of large-scale purchases and use of these helmets, the introduction of this regulation would result in an intervention that is almost cost-effective in all age groups.

Assault predicts time away from work after claims for work-related mild traumatic brain injury.

INTRODUCTION: Workplace violence carries a substantial economic loss burden. Up to 10% of all traumatic brain injury (TBI) admissions result from physical assault. There remains a paucity of research on assault as a mechanism of injury, taking into account sex, and its association with work re-entry. OBJECTIVES: The aim of this study was to characterise, by sex, the sample of workers who had sustained a work-related mild TBI (wr-mTBI) and to assess the independent influence of assault, as a mechanism of injury, on time away from work. METHODS: A population-based retrospective cohort of workers' compensation claimants in Australia (n=3129) who had sustained a wr-mTBI was used for this study. A multivariable logistic regression analysis assessed whether workers who had sustained wr-mTBI as a result of assault (wr-mTBI-assault) were more likely to claim time off work compared with workers who had sustained a wr-mTBI due to other mechanisms. RESULTS: Among claimants who sustained a wr-mTBI, 9% were as a result of assault. The distribution of demographic and vocational variables differed between the wr-mTBI-assault, and not due to assault, both in the full sample, and separately for men and women. After controlling for potential confounding factors, workers who sustained wr-mTBI-assault, compared with other mechanisms, were more likely to take days off work (OR 2.14, 95% CI 1.53 to 2.99) within a 3-month timeframe. CONCLUSION: The results have policy-related implications. Sex-specific and workplace-specific prevention strategies need to be considered and provisions to support return-to-work and well-being within this vulnerable cohort should be examined.

Writing Changes and Perceptions After Traumatic Brain Injury: "Oh, by the way, I can't write".

Purpose: Language and cognitive disruptions following traumatic brain injury (TBI) can negatively affect written expression and may result in increased difficulty achieving academic, vocational, social, and personal goals; however, scarce literature exists about TBI's effect on writing abilities. The purpose of this qualitative study was to describe the experiences and perceptions of people with TBI regarding their engagement in writing activities. Method: A transcendental phenomenological design structured the research. Data collection from 11 adults with TBI included gathering demographic and background information, completion of a TBI Symptom Checklist, and engagement in semistructured interviews. Results: Four major themes and 21 subthemes about postinjury writing recovery and current writing status emerged from the data analysis. Participants reported the extent to which writing difficulties interfered with daily activities and identified support strategies used to address persistent challenges. Conclusion: Understanding the writing experiences and perceptions of people with TBI can guide professionals in designing assessments and interventions to facilitate educational, vocational, social, and personal success following injury.

Emergency Department Visits Owing to Intentional and Unintentional Traumatic Brain Injury among Infants in the United States: A Population-Based Assessment.

OBJECTIVE: To examine national trends of emergency department (ED) visits owing to traumatic brain injury (TBI) among infants (age <12 months), specifically in the context of intentional and unintentional mechanisms. STUDY DESIGN: National Electronic Injury Surveillance System-All Injury Program data documenting nonfatal ED visits from 2003 to 2012 were analyzed. TBI was defined as ED visits resulting in a diagnosis of concussion, or fracture, or internal injury of the head. Intentional and unintentional injury mechanisms were compared using multivariable models. Joinpoint regression was used to identify significant time trends. RESULTS: TBI-related ED visits (estimated n = 713 124) accounted for 28% of all injury-related ED visits by infants in the US, yielding an average annual rate of 1722 TBI-related ED visits per 100 000 infants. Trend analysis showed an annual increase of 9.48% in the rate of TBI-related ED visits over 10 years (P < .05). For these visits, an estimated 701 757 (98.4%) were attributed to unintentional mechanisms and 11 367 (1.6%) to intentional mechanisms. Unintentional TBI-related ED visit rates increased by 9.52% annually (P < .05) and the rates of intentional TBI were relatively stable from 2003 to 2012. Infants with intentional TBI were more likely to be admitted (aOR, 11.44; 95% CI, 3.02-21.75) compared with those with unintentional TBI. CONCLUSIONS: The rate of TBI-related ED visits in infants increased primarily owing to unintentional mechanisms and intentional TBI-related ED visits remained stable over the decade. Improved strategies to reduce both intentional and unintentional injuries in infants are required.

Transient disruption of mouse home cage activities and assessment of orexin immunoreactivity following concussive- or blast-induced brain injury.

The employment of explosive weaponry in modern warfare exposes populations to shock wave-induced and impact-related brain injuries. Among the most common clinical complaints resulting from traumatic brain injury (TBI) are sleep-wake disturbances. The current study assessed the acute effects of mild concussive brain injury (CBI) and mild blast wave-induced brain injury (BTBI) on mouse behavior and orexin-A expression. Male C57BL/6J mice were exposed to CBI, BTBI, or sham procedures. Injured animals and their shams were further divided into the following subgroups: 24-h survival in standard group (SG) housing, 72-h survival in SG housing, and 72-h survival in Any-Maze cages (AMc). AMc enabled continuous monitoring of home cage activities. BTBI caused significant but transient decreases in wheel running and ingestive behaviors 24 h post-injury (PI), while CBI transiently decreased running and water intake. BTBI resulted in general hypoactivity in the open field (OF) at both PI time points for SG-housed animals. In contrast, CBI did not cause hypoactivity. Mice subjected to CBI traveled more in the center of the OF at both time points PI, suggesting that CBI caused reduced anxiety in mice. Increased activity in the center of the OF was also seen at 24 h PI after BTBI. CBI treatment caused increased CD11b immunostaining. However, neither injury was accompanied by an alteration in the number of orexin-A hypothalamic neurons. Taken together, shock wave exposure and concussive injury transiently reduced mouse activities, but some differences between the two injuries were seen.

Acute Assessment of Traumatic Brain Injury and Post-Traumatic Stress After Exposure to a Deployment-Related Explosive Blast.

Introduction: Traumatic brain injury (TBI) and post-traumatic stress disorder (PTSD) are two of the signature injuries in military service members who have been exposed to explosive blasts during deployments to Iraq and Afghanistan. Acute stress disorder (ASD), which occurs within 2-30 d after trauma exposure, is a more immediate psychological reaction predictive of the later development of PTSD. Most previous studies have evaluated service members after their return from deployment, which is often months or years after the initial blast exposure. The current study is the first large study to collect psychological and neuropsychological data from active duty service members within a few days after blast exposure. Materials and Methods: Recruitment for blast-injured TBI patients occurred at the Air Force Theater Hospital, 332nd Air Expeditionary Wing, Joint Base Balad, Iraq. Patients were referred from across the combat theater and evaluated as part of routine clinical assessment of psychiatric and neuropsychological symptoms after exposure to an explosive blast. Four measures of neuropsychological functioning were used: the Military Acute Concussion Evaluation (MACE); the Repeatable Battery for the Assessment of Neuropsychological Status (RBANS); the Headminder Cognitive Stability Index (CSI); and the Automated Neuropsychological Assessment Metrics, Version 4.0 (ANAM4). Three measures of combat exposure and psychological functioning were used: the Combat Experiences Scale (CES); the PTSD Checklist-Military Version (PCL-M); and the Acute Stress Disorder Scale (ASDS). Assessments were completed by a deployed clinical psychologist, clinical social worker, or mental health technician. Results: A total of 894 patients were evaluated. Data from 93 patients were removed from the data set for analysis because they experienced a head injury due to an event that was not an explosive blast (n = 84) or they were only assessed for psychiatric symptoms (n = 9). This resulted in a total of 801 blast-exposed patients for data analysis. Because data were collected in-theater for the initial purpose of clinical evaluation, sample size varied widely between measures, from 565 patients who completed the MACE to 154 who completed the CES. Bivariate correlations revealed that the majority of psychological measures were significantly correlated with each other (ps ≤ 0.01), neuropsychological measures were correlated with each other (ps ≤ 0.05), and psychological and neuropsychological measures were also correlated with each other (ps ≤ 0.05). Conclusions: This paper provides one of the first descriptions of psychological and neuropsychological functioning (and their inter-correlation) within days after blast exposure in a large sample of military personnel. Furthermore, this report describes the methodology used to gather data for the acute assessment of TBI, PTSD, and ASD after exposure to an explosive blast in the combat theater. Future analyses will examine the common and unique symptoms of TBI and PTSD, which will be instrumental in developing new assessment approaches and intervention strategies.

Epidemiology, Management, and Functional Outcomes of Traumatic Brain Injury in Sub-Saharan Africa.

BACKGROUND: Trauma accounts for 4.7 million deaths each year, with an estimated 90% of these occurring in low- and middle-income countries (LMICs). Approximately half of trauma-related deaths are caused by central nervous system injury. Because a thorough understanding of traumatic brain injury (TBI) in LMICs is essential to mitigate TBI-related mortality, we established a clinical and radiographic database to characterize TBI in our low-income setting. METHODS: This is a review of prospectively collected data from Kamuzu Central Hospital, a tertiary care center in the capital of Malawi. All patients admitted from October 2016 through May 2017 with a history of head trauma, altered consciousness, and/or radiographic evidence TBI were included. We performed descriptive statistics, a Cox regression analysis, and a survival analysis. RESULTS: There were 280 patients who met inclusion criteria; of these, 80.5% were men. The mean age was 28.8 ± 16.3 years. Median Glasgow Coma Scale (GCS) score was 12 (interquartile range, 8-15). Road traffic crashes constituted the most common injury mechanism (60.7%). There were 148 (52.3%) patients who received a computed tomography scan, with the most common findings being contusions (26.1%). Of the patients, 88 (33.0%) had severe TBI, defined as a GCS score ≤8, of whom 27.6% were intubated and 10.3% received tracheostomies. Overall mortality was 30.9%. Of patients who survived, 80.1% made a good recovery. Female sex was protective, and the only significant predictor of poor functional outcome was presence of severe TBI (hazard ratio, 2.98; 95% confidence interval, 1.79-4.95). CONCLUSIONS: TBI represents a significant part of the global neurosurgical burden of disease. Implementation of proven in-hospital interventions for these patients is critical to attenuate TBI-related morbidity and mortality.

Application of ERPs neuromarkers for assessment and treatment of a patient with chronic crossed aphasia after severe TBI and long-term coma - Case Report.

 Objective. The study aimed to evaluate the application of ERPs neuromarkers for the assessment and treatment of a patient with chronic crossed aphasia after severe TBI and a long-term coma. CASE REPORT: An ambidextrous female patient, aged 29, suffered from posttraumatic chronic crossed aphasia, severe TBI and a prolonged coma after a car accident. The patient took part in two differentiated rehabilitation programmes of neurotherapy included 20 sessions of relative beta training and 20 sessions of rTMS; both programmes were combined with behavioural training. The patient was tested 3 times: before the experiment, after completion of programme A, and after completion of programme B. RESULTS: In the 1st recording, the neuromarker of aphasia was found - an excess of the P2 wave over the left temporal area. There was a cognitive control deficit - an excess of omission errors and an increase of RT variability - all indexes of sporadic ADHD. In the 2nd recording, slight improvements in cognitive control, and language functions were found. In the 3rd recording, after the rTMS sessions most of her cognitive dysfunctions had been resolved, including language functions. It should be stressed that the activation (especially the increase in the ERP potential of the right side over the frontal lobe) was found. The neuromarker of aphasia did not change, only the location had slightly moved frontally. CONCLUSIONS: The application of ERP neuromarkers assists in the diagnosis, treatment, and academic success of an ambidextrous patient with chronic posttraumatic aphasia and sporadic ADHD. ERPs can be used to assess the functional brain changes induced by neurotherapeutical programmes.

Substance exposure and helmet use in all-terrain vehicle accidents: Nine years of experience at a level 1 trauma center.

INTRODUCTION: The surging popularity of all-terrain vehicles (ATV) in the United States has caused an "epidemic of injuries and mortality." The U.S. Consumer Product Safety Commission reported 99,600 injuries and 426 fatalities from ATV accidents in 2013. The aim of this study was to examine the relationship between helmet use and positive toxicology screenings on outcomes in ATV accident victims. METHODS: This is a retrospective study of patients admitted to a Level 1 Trauma Center in southwestern West Virginia following an ATV accident between 2005 and 2013. Data were obtained from the institution's Trauma Registry. RESULTS: A total of 1,857 patients were admitted during the study period with 39 (1.9%) reported deaths. Positive serum alcohol and/or urine drug screens were obtained in 66.4% of the patients tested (n=1,293). Those with positive screenings were 9.5% less likely to utilize a helmet (13.2% vs. 22.7%, p<0.001); and the lack of helmet use was associated with an increase in traumatic brain injury (57.1% vs. 41.7%, p<0.001). Positivity for substances or the lack of helmet use was significantly associated with higher morbidity. Lack of helmet use resulted in a 3.94-fold increase in the risk of discharge in a vegetative state or death. CONCLUSIONS: Drugs and alcohol use may predispose riders to be less likely to wear helmets and significantly increase the risk of a poor clinical outcome following an ATV accident. Rigorous efforts should be made to enhance safety measures through educational endeavors and amendment of current regulations to promote safe and responsible use of ATVs. PRACTICAL APPLICATIONS: Modification of regulatory requirements should be considered in order to mandate the wearing of helmets during ATV operation. In addition, expansion of safety programs should be considered in an effort to improve availability, affordability and awareness of safe ATV practices.

Assessment of Cognitive Function in the Water Maze Task: Maximizing Data Collection and Analysis in Animal Models of Brain Injury.

Animal models play a critical role in understanding the biomechanical, pathophysiological, and behavioral consequences of traumatic brain injury (TBI). In preclinical studies, cognitive impairment induced by TBI is often assessed using the Morris water maze (MWM). Frequently described as a hippocampally dependent spatial navigation task, the MWM is a highly integrative behavioral task that requires intact functioning in numerous brain regions and involves an interdependent set of mnemonic and non-mnemonic processes. In this chapter, we review the special considerations involved in using the MWM in animal models of TBI, with an emphasis on maximizing the degree of information extracted from performance data. We include a theoretical framework for examining deficits in discrete stages of cognitive function and offer suggestions for how to make inferences regarding the specific nature of TBI-induced cognitive impairment. The ultimate goal is more precise modeling of the animal equivalents of the cognitive deficits seen in human TBI.

Health & Economic Burden of Traumatic Brain Injury in the Emergency Department.

OBJECTIVE: To evaluate epidemiological patterns and lifetime costs of traumatic brain injury (TBI) identified in the emergency department (ED) within a publicly insured population in Ontario, Canada, in 2009. METHODS: A nationally representative, population-based database was used to identify TBI cases presenting to Ontario EDs between April 2009 and March 2010. We calculated unit costs for medical treatment and productivity loss, and multiplied these by corresponding incidence estimates to determine the lifetime costs of identified TBI cases across age group, sex, and mechanism of injury. RESULTS: In 2009, there were more than 133,000 ED visits for TBI in Ontario, resulting in a conservative estimate of $945 million in lifetime costs. Lifetime cost estimates ranged from $279 million to $1.22 billion depending on the diagnostic criteria used to define TBI. Peak rates of TBI occurred among young children (ages 0-4 year) and the elderly (ages 85+ years). Males experienced a 53% greater rate of TBI and incurred two-fold higher costs compared with females. Falls, sports/bicyclist-related injuries, and motor vehicle crashes represented 47%, 12%, and 10% of TBI presenting to ED, respectively, and accounted for a significant proportion of costs. CONCLUSIONS: This study revealed an enormous health and economic burden associated with TBI identified in the ED setting. Our findings underscore the importance of ongoing surveillance and prevention efforts targeted to vulnerable populations. More research is needed to fully appreciate the burden of TBI across a variety of health care settings.

Accidentes de tránsito como riesgo laboral ocurridos durante los años 2006 y 2007, valorados en la sección de medicina del trabajo del departamento de medicina legal / Traffic accidents and occupational risk occurred during the years 2006 and 2007, measured at the occupational health section of the department of forensic medicine

En los últimos años los accidentes de tránsito sufridos por los trabajadores mientras llevan a cabo su jornada laboral, han aumentado en número y severidad. En el presente trabajo se estudiaron los accidentes de tránsito que fueron valorados como riesgo laboral en la Sección de Medicina del Trabajo durante los años 2006-2007 (total de casos evaluados por esta causa 121). Obteniéndose del mismo una caracterización del trabajador afectado, siendo este, de sexo masculino, entre 30 y los 49 años, chofer o mensajero motorizado. Además se logró determinar que la mayoría de las lesiones presentadas por estos trabajadores correspondió con fracturas de los miembros inferiores (tibia y peroné) y con traumatismo craneoencefálicos, resultando como secuelas más destacadas el dolor residual y la limitación funcional, por lo que se les otorgó una incapacidad temporal y permanente acorde con la severidad de sus secuelas...

Heurística: juicio pronóstico en el traumatismo encefalocraneano / Heuristic: prognostic judgement in the traumatic brain injury

El pronóstico después del daño cerebral traumático no sólo es una interrogante para el médico, el paciente y su familia, sino también lo es para las organizaciones de salud, de seguridad social y seguros de vida y salud en general. También lo es en los cada vez más frecuentes procesos por praxis médica. La precisión exigible al pronóstico varía según cual sea su objetivo: sobrevida, secuelas, incapacidad laboral temporal o permanente, reconversión. Sabiendo la enorme dificultad implícita en esta tarea, en esta revisión se pretende analizar las variables de mayor significación pronostica, en una primera etapa, relativa al curso clínico del traumatismo, teniendo presente que hay además factores en el orden social y antropológico del sujeto y su entorno social que influirán en el impacto funcional sobre el sujeto, materia que preocupa a los médicos valoradores de daño corporal.