Awakening from coma: Assessment and stimulation in a Post-Critical Care Rehabilitation Units (PCCRU)

Brain injured patients who have suffered a coma require important medical supervision with a coordinated program of rehabilitation and are most likely to benefit from Post-Critical Care Rehabilitation Units (PCCRU). For these patients, an important challenge is to recognize signs of awareness beyond wakefulness. This evaluation is necessary to establish a diagnosis of the disorder of consciousness: vegetative state (VS) or unresponsive wakefulness syndrome versus minimally conscious state (MCS). Daily clinical observations of patients by trained caregivers confer to these particular environments an expertise in this field. The use of specific scales such as the Coma Recovery Scale Revised (CRS-R) allows the standardization of practices and provides quantitative data that are useful to follow patients, to assess the beneficial effect of a treatment or to compare patients. Neurophysiology and functional imagery can be used to search for markers of high-level brain activity. These tools are mostly used in research areas but can provide information complementary to the clinical evaluation, which involves a degree of subjectivity. Detecting awareness requires that patients are comfortable and because of the fluctuation of awareness, a sufficient time of observation is essential. A favorable atmosphere to promote the emergence of awareness comprises personalized stimulations such as sensory regulation programs. Music, noninvasive brain stimulations and several drugs can also boost awareness detection. A program integrating these practices is proposed to patients awakening from coma or for a specific assessment before the admission in dedicated units for patients in VS/MCS

A remote access CT colonography training system

Computed tomography colonography (CTC) is emerging as an alternative to conventional colonoscopy (CC). However CTC is not yet in widespread use due in part to the lack of suitably trained radiologists. We have developed a novel remote access system to train radiologists for colorectal cancer screening using CTC. To ensure that radiologists can gain the relevant experience without the need for any specialist equipment or software, we opted for designing a system that is accessible via the Internet using a standard browser. The interface lets the user locate and characterise polyps with the help of appropriate tools such as windowing, polyp measurement, zooming and a 3-D view. Each user has an account in order to allow monitoring of their training. They can also run an automatic evaluation of their work based on gold standard information previously gathered from specialists. This thesis also describes an initial implementation exclusively made up of Java Servlets. The evaluation of this system has been discussed in order to determine a better approach. The final system has been developed using a combination of Java Servlets and Applets. This approach offers fast response time to the user-interface. An iteration of lumen tracking using the system takes approximately 45 seconds. This research has yielded an operational system that meets the needs of remote access users

Behavioral and affective disorders after brain injury: French guidelines for prevention and community supports

AbstractObjectiveThe purpose of this study was to elaborate practice guidelines for the prevention of behavioral and affective disorders in adult outpatients after traumatic brain injury (TBI); but also to identify the support systems available for family, caregivers of patients with TBI within the community.MethodsThe elaboration of these guidelines followed the procedure validated by the French health authority for good practice recommendations, close to the Prisma statement. This involved a systematic and critical review of the literature looking for studies that investigated the impact of programs in community settings directed to behavioral and affective disorders post-TBI. Recommendations were than elaborated by a group of professionals and family representatives.ResultsOnly six articles were found comprising 4 studies with a control group. Two studies showed a beneficial effect of personalized behavior management program delivered within natural community settings for persons with brain injury and their caregivers. Two other studies showed the relevance of scheduled telephone interventions to improve depressive symptoms and one study emphasized the usefulness of physical training. One study investigated the relevance of an outreach program; this study showed an improvement of the patients’ independence but did not yield any conclusions regarding anxiety and depression.Discussion and recommendationsIn addition to the application of care pathways already established by the SOFMER, prevention of behavioral and affective disorders for brain-injured outpatients should involve pain management, as well as development of therapeutic partnerships. It is recommended to inform patients, their family and caregivers regarding the local organization and facilities involved in the management of traumatic brain injury. The relevance of therapeutic education for implementing coping strategies, educating caregivers on behavioral disorder management, follow-up telephone interventions, and holistic therapy seems established. The level of evidence is low and preliminary studies should be confirmed with larger controlled trials

Care management of the agitation or aggressiveness crisis in patients with TBI. Systematic review of the literature and practice recommendations

AbstractThe agitation crisis in the awakening phase after traumatic brain injury (TBI) is one of the most difficult behavioral disorders to alleviate. Current treatment options are heterogeneous and may involve excessive sedation. Practice guidelines are required by professionals in charge of TBI patients. Few reviews were published but those are old and based on expert opinions. The purpose of this work is to propose evidence-based guidelines to treat the agitation crisis.MethodsThe elaboration of these guidelines followed the procedure validated by the French health authority for good practice recommendations, close to the Prisma statement. Guidelines were elaborated on the basis of a systematic and critical review of the literature.ResultsTwenty-eight articles concerning 376 patients were analyzed. Recommendations are: when faced with an agitation crisis, the management strategy implies to search for an underlying factor that should be treated such as pain, acute sepsis, and drug adverse effect (expert opinion). Physical restraints should be discarded when possible (expert opinion). Neuroleptic agent with a marketing authorization can be used in order to obtain a quick sedation so as to protect the patient from himself, closed ones or the healthcare team but the duration should be as short as possible (expert opinion). The efficacy of beta-blockers and antiepileptics with mood regulation effects like carbamazepine and valproate yield the most compelling evidence and should be preferably used when a background regimen is envisioned (grade B for beta-blocker and C for antiepileptics). Neuroleptics, antidepressants, benzodiazepines, buspirone may be prescribed but are considered second-line treatments (expert opinion).ConclusionThis study provides a strategy for treating the agitation crisis based on scientific data and expert opinion. The level of evidence remains low and published data are often old. New studies are essential to validate results from previous studies and test new drugs and non-pharmaceutical therapies

Long-term change in nutritional status after severe traumatic brain injury

IntroductionIn the acute phase, patients who sustained a severe Traumatic Brain injury (TBI) (Glasgow Coma Scale under 8) frequently present malnutrition during critical care. Long-term nutritional outcome after a severe TBI has been less studied. Cognitive impairments and behavioural disorders together with hormonal disorders can lead to persisting malnutrition or over-eating and obesity. The purpose of this study was to follow the weight, the body mass index (BMI), albuminemia and hormonal dosage after a severe TBI.MethodsThis study relied on a research protocol designed to follow concurrently and prospectively endocrine disorders and cognitive disorders in a cohort of patients with severe TBI (Inspire-TC protocol). In the present work, we focused specifically on the evolution in weight, height, body mass index, albuminemia and endocrine abnormalities. These parameters were collected upon admission to the rehabilitation department, at 4 months, 12 months and 18 months when feasible for the severe TBI patients included in the Inspire-TC protocol. Albuminaemia was measured late after the TBI when patients agreed.Results10 patients were included. Initially 60% of the patients had biological malnutrition, 10% were overweight, 80% presented a normal BMI and 10% had an insufficient BMI. All patients gained weight during the monitoring with an overweight at 18 months for three patients. Along the overall monitoring, 44% of the patients had hormonal disruptions. The 3 patients with long-term overweight had frontal-temporal brain lesions. All three recovered walking. Only one had hormonal disruptions. Albuminaemia was normal for all patients who accepted to make this bioessay control.ConclusionThere is a tendency to gain weight after a severe TBI. Favorable factors include fronto-temporal injuries, and the presence of executive disorders. Endocrine perturbation and immobility can also contribute to overweight but were less frequently observed in this cohort

Studying the neural bases of prism adaptation using fMRI:a technical and design challenge

Prism adaptation induces rapid recalibration of visuomotor coordination. The neural mechanisms of prism adaptation have come under scrutiny since the observations that the technique can alleviate hemispatial neglect following stroke, and can alter spatial cognition in healthy controls. Relative to non-imaging behavioral studies, fMRI investigations of prism adaptation face several challenges arising from the confined physical environment of the scanner and the supine position of the participants. Any researcher who wishes to administer prism adaptation in an fMRI environment must adjust their procedures enough to enable the experiment to be performed, but not so much that the behavioral task departs too much from true prism adaptation. Furthermore, the specific temporal dynamics of behavioral components of prism adaptation present additional challenges for measuring their neural correlates. We developed a system for measuring the key features of prism adaptation behavior within an fMRI environment. To validate our configuration, we present behavioral (pointing) and head movement data from 11 right-hemisphere lesioned patients and 17 older controls who underwent sham and real prism adaptation in an MRI scanner. Most participants could adapt to prismatic displacement with minimal head movements, and the procedure was well tolerated. We propose recommendations for fMRI studies of prism adaptation based on the design-specific constraints and our results

Physical and rehabilitation medicine (PRM) care pathways: Adults with severe traumatic brain injury

AbstractThis document is part of a series of guidelines documents designed by the French Physical and Rehabilitation Medicine Society (SOFMER) and the French Federation of PRM (FEDMER). These reference documents focus on a particular pathology (here patients with severe TBI). They describe for each given pathology patients’ clinical and social needs, PRM care objectives and necessary human and material resources of the pathology-dedicated pathway. ‘Care pathways in PRM’ is therefore a short document designed to enable readers (physician, decision-maker, administrator, lawyer, finance manager) to have a global understanding of available therapeutic care structures, organization and economic needs for patients’ optimal care and follow-up. After a severe traumatic brain injury, patients might be divided into three categories according to impairment's severity, to early outcomes in the intensive care unit and to functional prognosis. Each category is considered in line with six identical parameters used in the International Classification of Functioning, Disability and Health (World Health Organization), focusing thereafter on personal and environmental factors liable to affect the patients’ needs