Blast-related injuries detected in the brains of US military personnel

ScienceDaily (June 2, 2011) — An advanced imaging technique has revealed that some U.S. military personnel with mild blast-related traumatic brain injuries have abnormalities in the brain that have not been seen with other types of imaging.

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The abnormalities were found in the brain's white matter, the wiring system that nerve cells in the brain use to communicate with each other.

The study is reported June 2 in The New England Journal of Medicine by scientists at Washington University School of Medicine in St. Louis and the Landstuhl Regional Medical Center in Landstuhl, Germany.

They evaluated 84 U.S. military personnel evacuated to Landstuhl from Iraq and Afghanistan after exposure to many types of explosive blasts. Abnormalities were found in 18 of 63 patients diagnosed with mild traumatic brain injury, but not among 21 injured in other ways.

Traumatic brain injuries are estimated to have affected as many as 320,000 military personnel in the wars in Iraq and Afghanistan. Most of these are classified as mild traumatic brain injuries, also known as concussions.

"We call these injuries 'mild', but in reality they sometimes can have serious consequences," says senior author David L. Brody, MD, PhD, assistant professor of neurology at Washington University School of Medicine in St. Louis.

In the new study, white matter abnormalities were detected using an advanced magnetic resonance imaging method called diffusion tensor imaging. Diffusion tensor imaging allows scientists to assess the movement of water in tissue. Changes in the patterns of water movement are often linked to injury or disease, but the significance of the abnormalities seen in the military service personnel is not yet fully understood.

Mild traumatic brain injury has been a controversial topic, and the new approach may provide an additional tool to help resolve some of the debate. Much of the controversy has revolved around whether symptoms following mild traumatic brain injuries are due to structural injury to the brain, disruptions in brain chemistry, psychological factors or a combination of these.

"There is still a lot more work to be done before we fully understand whether these abnormalities truly represent significant damage to the brain white matter," says lead author Christine L. Mac Donald, PhD, research instructor in neurology at Washington University. "And if so, how this damage affects attention, memory, emotional regulation, balance, coordination, sleep and other functions. Likewise, the relationship between mild traumatic brain injury and post-traumatic stress disorder is especially important. Our ongoing studies will hopefully start to answer some of these questions."

Researchers have used diffusion tensor imaging to study mild civilian brain injuries previously and did not see abnormalities in the areas highlighted by the new study. These regions included the orbitofrontal cortex, an area involved in emotional regulation and reward-based behaviors, and the cerebellum, an area linked to coordination, movement, organization and planning.

These regions were predicted to be especially vulnerable to blasts based on previously published computer simulations. The results suggest that there may be fundamental differences between blast-related traumatic brain injuries and the sorts of mild traumatic brain injuries sustained by civilians, such as those caused by car accidents, falls, blows to the head and sports injuries.

In addition, advanced imaging also showed abnormalities in parts of the brain known to be harmed in civilian trauma.

Military personnel in the study all had blast-related injuries plus other injuries such as falls, motor vehicle crashes or being struck by blunt objects. The exact contribution of blast effects versus other injuries could not be fully determined in the study.

Up to a year after injury, the white matter abnormalities were still detectible, though their appearance on the scans had changed over time.

The results come from a collaborative team that included Mac Donald, who lived at Landstuhl for five and a half months to work on the study; Col. Stephen F. Flaherty, MD (now retired); and Lt. Col. Raymond Fang, MD, of the military medical staff at Landstuhl Regional Medical Center. The Landstuhl Regional Medical Center has been the central triage point for the wars in Iraq and Afghanistan for many years and is the closest hospital with a reliable MRI scanner.

Brody emphasizes that mild traumatic brain injury is still a diagnosis based on a history of an injury to the head that causes loss of consciousness, memory loss, confusion or other disruption in the function of the brain.

"A negative MRI scan, even with these advanced methods, does not rule out mild traumatic brain injury," he says. "These MRI-based methods show great promise, but are not yet ready to be used in routine clinical practice."

Brody said he believes the approach used in the study may prove helpful in military and civilian contexts and in children and adults.

"Our hope is that these advanced MRI-based methods will one day help make more accurate diagnoses, assist with triage and allow treatment interventions to start early for people with traumatic brain injuries," he says.

Mac Donald CL, Johnson AM, Cooper D, Nelson EC, Werner NJ, Shimony JS, Snyder AZ, Raichle ME, Witherow JR, Fang R, Flaherty SF, Brody DL. Detection of blast-related traumatic brain injury in U.S. military personnel. The New England Journal of Medicine, June 2, 2011.

Funding from the Congressionally Directed Medical Research Program and the National Institutes of Health (NIH) supported this research.

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People who have had head injuries report more violent behavior

ScienceDaily (June 2, 2011) — Young people who have sustained a head injury during their lifetime are more likely to engage in violent behavior, according to an eight-year study from the University of Michigan School of Public Health.

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Further, the research found that young people who suffered a recent head injury (within a year of being questioned for the study) were even more likely to report violent behavior.

The report, which appears in the current issue of the journal Pediatrics, is one of the few studies to examine long-term effects of head injuries in a general population of young adults. Most other similar studies were conducted in prison populations.

There's been a recent blitz of media and research attention regarding youth, college and professional athletes who suffer head injuries and concussions while playing. This study is broader, but confirms previous findings about the connection between violence and head injuries, says lead author Sarah Stoddard, a research assistant professor at the School of Public Health.

"These are not necessarily sports-playing injuries," said Stoddard, who also is a research fellow at the U-M School of Nursing. "They could be from a car accident or from previous violent behavior, but it does support some of the sports research that's been going on with concussions."

Stoddard used data from the School of Public Health's Flint Adolescent Study, which looks at many issues regarding urban youth. Marc Zimmerman, professor of public health and chair of the U-M Department of Health Behavior and Health Education, is the principal investigator on that study.

The researchers followed a group of ninth-graders from four schools in Flint, Mich., into young adulthood. They conducted annual interviews over eight years. In years five and six, participants were asked if they had ever sustained a head injury. Those who said yes -- about 23 percent -- reported more violent behavior in year eight of the study.

Moreover, Stoddard and Zimmerman examined the proximal relationship between a head injury and violent behavior and found that an injury reported in year seven of the study predicted violent behavior in year eight.

"We found that the link between a head injury and later violence was stronger when a head injury was more recent, even after controlling for other factors including previous violent behavior," Stoddard said.

The results also suggest that adolescents and young adults who have suffered a head injury that did not interfere with their ability to participate in an hour-long interview may still experience significant adverse developmental or behavioral effects.

The researchers defined a head injury as having been knocked unconscious or sustaining a concussion or a fractured skull.

Traumatic brain injury is a serious public health issue, they say. An estimated 1.7 million people annually sustain a TBI, and that only includes people who get medical care, so the number is likely much higher. Roughly 75 percent of head injuries are mild and many do not receive medical attention, but any TBI disrupts the function of the brain. Long-term impact can include changes in cognition, language and emotion, including irritability, impulsiveness and violence.

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New U.S. national study finds boxing injuries on the rise; Youth head injury rates also concerning

ScienceDaily (Mar. 2, 2011) — The risk and nature of injury in the sport of boxing has generated a great deal of controversy in the medical community, especially in relation to youth boxing. A new study, conducted by researchers in the Center for Injury Research and Policy of The Research Institute at Nationwide Children's Hospital, examined boxing injuries among participants 6 years of age and older from 1990 to 2008.

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During the 19-year study period, an average of 8,700 boxing injuries were treated in United States emergency departments each year, and approximately 2,500 of those injuries were to children and adolescents 6 to 17 years of age. The number of boxing injuries each year increased 211 percent during the study, climbing from 5,361 injuries in 1990 to nearly 17,000 injuries in 2008.

According to the study, released online February 28, 2011 by the American Journal of Preventive Medicine, the most common injury diagnosis was a fracture (28 percent). The hand was the most frequently injured body region (33 percent), followed by the head and neck (23 percent). While the majority of injuries occurred at a sports or recreation facility (54 percent), one-third of the injuries (34 percent) occurred at home.

The most concerning discovery from the study was the similar proportion of concussions/closed head injuries (CHIs) among the age groups (9 percent among 12-17 year olds, 8 percent among 18-24 year olds and 9 percent among 25-34 year olds).

"We expected a smaller proportion of concussions/CHIs among younger boxers, since they generate a lower punch force," said Gary Smith, MD, DrPH, senior author of the study and director of the Center for Injury Research and Policy at Nationwide Children's Hospital. "The fact that young boxers are experiencing a similar proportion of concussions and CHI's as older boxers is extremely concerning given the potential risk of developing chronic traumatic encephalopathy (CTE) with repetitive brain trauma. These repetitive blows to the head may be placing boxers under 18 years of age at risk for neurological impairment and psychological problems due to CTE."

The findings from this study support the position of medical societies that oppose boxing, especially among youth.

"Although there is risk of injury with most sports, boxing is unique because participants are rewarded for intentionally striking their opponent in the face and head with the intent of harming or incapacitating them," said Dr. Smith, also a professor of Pediatrics at The Ohio State University College of Medicine. "The increasing number of boxing injuries, coupled with the potential long-term consequences of these injuries, suggests that increased injury prevention efforts are needed."

This is the first nationally representative study to examine boxing injuries treated in emergency departments. Data for this study were obtained from the National Electronic Injury Surveillance System (NEISS), which is operated by the U.S. Consumer Product Safety Commission. The NEISS dataset provides information on consumer product-related and sports and recreation-related injuries treated in hospital emergency departments across the country. Boxing participation data were obtained from the Superstudy of Sports Participation.

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Brain injuries rise sharply in minor hockey after bodychecking rules relaxed, Canadian study shows

ScienceDaily (Mar. 16, 2011) — Minor league hockey players in the Atom division are more than 10 times likely to suffer a brain injury since bodychecking was first allowed among the 9 and 10-year-olds, says a study led by St. Michael's Hospital neurosurgeon Dr. Michael Cusimano.

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The findings, published online in the journal Open Medicine, add to the growing evidence that bodychecking holds greater risk than benefit for youth and support widespread calls to ban the practice.

According to the researchers, led by Cusimano, director of the Injury Prevention Research Centre at St. Michael's Hospital in Toronto, the odds of visiting an emergency department due to a brain injury from bodychecking increased significantly among all minor hockey players after Hockey Canada relaxed bodychecking rules in the 1998/1999 season. At that time, the organization allowed, for the first time, body contact among 9 and 10 year-olds in the Atom division.

The team examined the records of 8,552 male youth 6-17 years-old who attended one of five emergency departments in Ontario for hockey related injuries that occurred before and after the rule change. Researchers found more than half of hockey-related injuries were a result of bodychecking. What's more, the risk of a head or neck injury, including concussions, increased across all minor hockey divisions.

"Our work confirmed the fact that body checking is the most common cause of injury in hockey. While proponents argue lowering the age for bodychecking helps players learn how to properly bodycheck and reduces injuries at older ages, our study clearly showed the opposite ― the risk of all injuries and especially, brain injuries, increases with exposure to bodychecking," Cusimano said. "While all age groups showed increases in injuries, the youngest were the most vulnerable and that bodychecking puts youth unnecessarily at the risk of the long-term effects of brain injuries, such as cognitive and social-behavioural problems."

For some time, researchers like Dr. Cusimano have called on organizations like the NHL to take more leadership in reducing the incidence of brain injuries. In recent weeks, pressure has mounted on the NHL after Pittsburgh Penquins captain Sidney Crosby and Montreal Canadiens' Max Pacioretty suffered serious concussions that sidelined both players.

"Ice hockey is a sport with great potential to increase the health of individuals but practices that increase the risk for the vast majority of players must be minimized," Cusimano adds. "It is now very clear that there is no benefit to any one or any group to continue to allow bodychecking. Hockey organizers, sponsors, the media, coaches, trainers, and players and parents must come together to advocate for multifaceted approaches that include changes to the rules to reduce the risk of injury."

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Regenerating nerve cells: Research offers hope in new treatment for spinal cord injuries

ScienceDaily (May 3, 2011) — Rutgers researchers have developed an innovative new treatment that could help minimize nerve damage in spinal cord injuries, promote tissue healing and minimize pain.

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After a spinal cord injury there is an increased production of a protein (RhoA) that blocks regeneration of nerve cells that carry signals along the spinal cord and prevents the injured tissue from healing.

Scientists at the W.M. Keck Center for Collaborative Neuroscience and Quark Pharmaceuticals Inc. have developed a chemically synthesized siRNA molecule that decreases the production of the RhoA protein when administered to the spine and allows regeneration of the nerve cells.

"It is exciting because this minimally-invasive treatment can selectively target the injured tissue and thereby promote healing and reduce pain," says Martin Grumet, associate director of the Keck Center and senior author of a recent study published in the Journal of Neurotrauma.

The neuropathic pain, also known as phantom pain that occurs as a result of a spinal cord injury is often associated with an increased production of RhoA. When researchers injected the chemically synthesized molecular substance into the spinal cords of laboratory rats with spinal cord injury using a procedure similar to a spinal tap, there was an overall improvement in tissue healing and recovery.

More than 250,000 people in the United States are living with a spinal cord injury and currently there is no way to reverse the damage. No drugs for early treatment of spinal cord injury have been approved in over a decade. Based on this joint research, Quark Pharmaceuticals, Inc now has a drug development program for the treatment of spinal cord injury and neuropathic pain. This new research is supported by grants from the New Jersey Commission for Spinal Cord Research and Quark.

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