Discharge Against Medical Advice (DAMA) is associated with poor outcome, frequent readmission, higher mortality, and increased risk of psychiatric and medical complications. Research has shown that head injury is highly correlated with DAMA.

A recent review of past research has looked more specifically at the relationship with DAMA and traumatic brain injury. Researchers found that DAMA was more frequent in cases of intentional traumatic brain injury. Intentional brain injuries can occur because of a suicide attempt, as well as antisocial, aggressive and disruptive behaviors. DAMA was also associated with younger age (25-34) and drug or alcohol abuse.

Knowing the characteristics of patients at high risk for DAMA can help hospital staff implement prevention policies, limit DAMA occurrence, and help protect vulnerable patients from a potentially negative outcome.

Kim H, Colantonio A, Bayley M, & Dawson D. Discharge Against Medical Advice after traumatic brain injury: Is intentional injury a predictor? The Journal of Trauma Injury, Infection, and Critical Care. (September 2011).

Fatigue is one of the most common complaints after even the mildest of brain injuries. However, it can be difficult to assess and diagnose because it is often hidden by other common brain injury symptoms such as sleep problems, depression, or hypothyroidism.

A recent study of sport-related concussion found that complaints of fatigue not only correlated with increased errors on an attention test, it was also associated with changes in EEG activity. Increases in delta and theta rhythms on the EEG suggest decreased alertness and drowsiness. Athletes who complained of fatigue after a concussion also showed increased delta and theta rhythms on their EEG.

Fatigue is a very real and disabling problem for people a traumatic brain injury. It should be considered not only during the assessment of a concussed athlete’s return-to-sport, but also for anyone who suffers any severity of brain injury.

Barwick F, Arnett P, & Slobounov S. EEG correlates of fatigue during administration of a neuropsychological test battery. Clinical Neurophysiology. (September 2011).

Endothelin-1 is a powerful vasoconstrictor (narrows blood vessels) that can affect the brain for long periods of time after a brain injury. A recent study looked at the effects of this increase in endothelin-1 on outcome in pediatric traumatic brain injury. Additionally, the research team wanted to determine if therapeutic hypothermia affected outcome in relation to endothelin-1.

Levels of endothelin-1 were significantly higher in children with brain injuries than those without, and were associated with an unfavorable outcome. After comparing children who received hypothermia early after injury to those who did not, the study found that there was no difference in levels of endothelin-1. Therapeutic hypothermia therefore remains a controversial therapy for pediatric brain injury patients.

Salonia R, Empey PE, Poloyac SM, et al. Endothelin-1 is increased in cerebrospinal fluid and associated with unfavorable outcomes in children after severe traumatic brain injury. Journal of Neurotrauma. (October 2010).

Recovery from sports-related injury is an issue made complex by the pressure to return the patient to their game. However, we now know that injured brains have a vulnerable window of time in which they can be more susceptible to recurring injury.

Traditional tests of recovery include the subsiding of symptoms and improved performance in neurocognitive assessment. However, a recent study using qualitative electroencephalography (QEEG) has shown that signs of physiological damage may persist even after symptoms subside and cognitive impairments have improved.

The implication of this study is that patients with sport-related brain injuries may be returning to their sport too soon. Considering the window of vulnerability the brain has to recurrent damage, the QEEG—which is a portable, easy-to-use device—can be used as a more reliable marker of recovery.

McCrea M, Prichep L, Powell MR, et al. Acute effects and recovery after sports-related concussion: A neurocognitive and quantitative brain electrical activity study. Journal of Head Trauma Rehabilitation. (July 2010).

Memory is a difficult concept to define. To remember something requires the complex processing of information such as time, place, emotions, or sensory input (sight, smell, sound, touch), in order have the ability to re-create that information at a later time. Scientists have long tried to define memory by using models to describe this process, but some of the most useful memory models have been derived from studies of impaired memory with brain injury patients.

One important theory of memory that has come (at least partially) from brain injury studies, is the model for explicit versus implicit memory. Explicit memory refers to the memories that we can explicitly remember taking part in. For instance, we may have a strong memory of attending a child’s graduation. We not only know intellectually that the child has graduated, we can pull up the specific emotions, sights, smells, sounds, time, and place that color that memory.

Implicit memory refers to a much more subtle process—one that is difficult to observe outside a psychology lab. Implicit memory implies that a person has encoded some information in his brain, but without consciously knowing how. The information has gotten in under the radar, in other words. For instance, a psychology lab can flash words very quickly in front of a subject—too quickly for the subject to even perceive—and the subject will be surprised to learn that he can correctly guess the word, even when he has no memory of even seeing it.

In the traumatic brain injury patient, depending on what part of the brain was injured, explicit memory can be impaired. Amnesia—either the loss of memories from the past or the lost ability to learn new information—can occur because of an impaired explicit memory system. Without a specific recollection of memory detail such as sight, sound, smell, emotion, time, or place, the patient has no context to help anchor a memory into reality.

Strangely enough, however, implicit memories are very often intact in brain injury patients. These patients can perform just as well as healthy people at the quickly flashing words experiment described above. The implication of this is that rehabilitation professionals (and family members) can use the intact implicit memory system to help get new information through to the brain injury patient. By repeating a piece of specific information over and over (ie, “The coffee cups are in the right cupboard.”), the patient may implicitly remember the information, even if he has no conscious memory of learning it.

Baddeley A. Human Memory, Theory and Practice. Psychology Press Ltd. (2002).

Because of the tight spending climate this year, with regards to programs authorized through the TBI Act, BIAA and other TBI stakeholders have opted to advocate for a five year plan in achieving the full funding of $37 million to provide grants to all states including the District of Columbia, the American Indian Consortium and territories.

Increasing the program by $1 million this year will provide funding necessary to sustain the grants for the 15 states currently receiving funding along with the three additional states added this year and to ensure funding for four additional states. Steady increases over five years for this program will provide for each state including the District of Columbia and the American Indian Consortium and territories to sustain and expand state service delivery; and to expand the use of the grant funds to pay for such services as Information & Referral (I&R), service coordination and other necessary services and supports identified by the state.

BIAA has implemented the same strategy throughout its appropriations platform by asking for incremental increases towards a long-term funding goal, specifically for TBI Act programs:

• $10 million for the Centers for Disease Control and Prevention TBI Registries and Surveillance, Brain Injury Acute Care Guidelines, Prevention and National Public Education/Awareness (an increase of $4 million)
• $8 million for the Health Resources and Services Administration (HRSA) Federal TBI State Grant Program (an increase of $1 million)
• $4 million for the HRSA Federal TBI Protection & Advocacy (P&A) Systems Grant Program (an increase of $1 million)

With respect to the TBI Model Systems, BIAA is advocating for an additional $1.5 for a total of $11 million in FY 2011, in order to add one new Collaborative Research Project. This moderate increase would go towards the five year goal of $19 million as well as “line-item” status within the broader NIDRR budget.

On January 29, 2010, BIAA and other stakeholders presented appropriations requests to the Congressional Brain Injury Task Force, who adopted the plan and is currently garnering support through its membership. BIAA also has met with both House and Senate Appropriations Committee Staff to advocate for these program funding increases.

Look for grassroots action alerts in the coming weeks as the appropriations process moves forward.

One of the major consequences of spinal cord injury is death of neurons after the injury and the inability of surviving neurons to regenerate and repair their connections. This secondary injury can continue for even years after the incident and much research has been focused on promoting regeneration.

A recent animal study evaluated the benefit of cord blood stem cells injected into the injured spinal area. Using genetic markers, the researchers discovered that these stem cells could slow the secondary death of neurons. Cord blood stem cells seem to act as a neuroprotective agent (by slowing neuron death) so that there might be greater chance at regenerating surviving neurons.

Animal studies usually only help to define future human studies. Therefore the use of stem cells for spinal cord injury still needs a good deal of research before becoming a therapeutic treatment for patients. However, studies such this one show potential neuroprotective and neuroregenerative results, and help define the future of spinal cord therapy.

Dasan VR, Veeravalli KK, Tsung AJ, et al. Neuronal apoptosis is inhibited by cord blood stem cells after spinal cord injury. Journal of Neurotrauma. (November 2009).

BIAA and our friends at the Wounded Warrior Project are currently working towards enactment of legislation establishing a national program to provide training and critically-needed supports to family caregivers of veterans living with traumatic brain injuries and other severe wounds.

Reported in the Senate, S. 801, the Caregiver and Veterans Health Services Act of 2009, would provide comprehensive supports for caregivers of veterans who sustained severe injuries after September 11, 2001. The bill has been approved by the Senate Veterans Affairs Committee and is awaiting floor action.

To take action and support this bill, click on the link below to be directed to our legislative action center!

http://capwiz.com/bia/home

This week the Senate Health, Education, Labor and Pensions Committee has been continuing to consider its version of the health care overhaul, while the Finance Committee has yet to begin formal markups, but continues to discuss policy behind closed doors.

In the House, The chairmen of the Energy and Commerce, Education and Labor, and Ways and Means Committees are working on a final draft of a bill that could be released at any time. The House committees plan to mark up the legislation next week.

On July 2, 2009, BIAA circulated comments to the House Committees of Jurisdiction applauding their “efforts to design health care reform that will improve the accessibility, quality, effectiveness, and efficiency of patient care.”

More specifically, the comments expressed BIAA’s support of the protections and standards for qualified health plans included in the draft, such as no imposition of pre-existing condition exclusions, guaranteed access to essential benefits (including rehabilitation services), guaranteed issue and renewal, adequacy of provider networks, limits on cost sharing, no annual or lifetime limits on coverage, and consumer protections.

To see a full copy of the comments, click on the following link:

http://www.biausa.org/elements/policy/2009/biaa_house_tri_committee_health_reform_comments.pdf

BIAA will continue to follow the health care reform considerations carefully and advocate on behalf of the brain injury community.

As part of the Coalition for Regenerative Stem Cell Medicine, BIAA enthusiastically endorses two important pieces of legislation aimed at advancing the therapeutic potential of newborn stem cells, the unique stem cells that can be collected immediately following birth from umbilical cord blood and the cord itself, as well as helping to advance the use of one’s own newborn stem cells in regenerative medicine.

HR 1718 – The “Family Cord Blood Banking Act” amends Section 213(d) of the IRS Code to add cord blood banking services as a qualified medical expense. This change will allow individuals and couples to use tax advantaged dollars to pay for umbilical cord blood banking services through flexible spending accounts (FSAs), health savings accounts (HSAs) health reimbursement arrangements (HRAs) or the medical expenses tax deduction.

The “Family Cord Blood Banking Act” will make cord blood banking more affordable for American families and provides incentives to ensure that this valuable health resource is never thrown away.

HR. 2107 – The “Cord Blood Education and Awareness Act of 2009″ will provide expectant mothers with straightforward, accurate and easy to understand information about the value of their child’s umbilical cord blood stem cells. It will offer a government stamp of approval on all available cord blood banking options and will give expectant parents confidence in the information they are reviewing.