Protein and calories can help lessen effects of severe traumatic brain injury, report says

ScienceDaily (Apr. 21, 2011) — To help alleviate the effects of severe traumatic brain injury (TBI), the U.S. Department of Defense should ensure that all military personnel with this type of injury receive adequate protein and calories immediately after the trauma and through the first two weeks of treatment, says a new report from the Institute of Medicine. Evidence from several studies of severely brain-injured patients shows that providing energy and protein to patients early reduces inflammation and improves their outcomes, said the committee of experts who wrote the report.

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This is the only nutrition-related approach to treating TBI that the committee recommended DOD implement at this time based on its review of the possible benefits of nutrients, dietary supplements, and specific diets to improve outcomes for TBI ranging from mild to severe. Several other nutritional approaches show potential for reducing the symptoms of brain injury, but there is not yet enough evidence about their effectiveness to recommend their adoption.

The committee identified the B vitamin choline, the amino acid-like compound creatine, n-3 fatty acids commonly known as EPA and DHA, and zinc as the most promising areas of investigation and recommended that DOD scientists and other researchers give them priority attention. These approaches are ones for which human clinical trials have been undertaken or are ongoing.

Other approaches, including antioxidants, flavonoids, ketogenic diets, and vitamin D, have less supporting evidence that has come solely from animal studies or from studies in people with different conditions. Although researchers must prioritize resources, DOD should continue to monitor the clinical literature for any new findings about the potential of these nutrients and diets in lessening brain injury effects, the report says.

The research priorities outlined in the report could generate information that provides health professionals with a fuller picture of which nutrients and dietary approaches work safely and most effectively. This information could also lead to new evidence-based clinical guidelines. There are few well-supported guidelines to inform health professionals' use of foods and dietary supplements to treat brain-injured patients, so clinicians employ a wide range of practices.

The IOM study focused on the potential role of nutrition in protecting against or treating the immediate and near-term effects of TBI. It did not evaluate the role of nutritional therapies in the rehabilitation phase or address long-term health effects associated with brain trauma, such as post-traumatic stress disorder, Alzheimer's disease, pain, and depression. A review of nutrition approaches to lessen long-term effects of TBI would be useful, the committee noted.

TBI is a significant cause of death and disability among personnel serving in the wars in Iraq and Afghanistan. It also contributes to nearly one-third of all injury-related deaths in the United States, making it a major health concern for the civilian population as well. According to recent estimates, between 1.6 million and 3.8 million sports-related TBIs occur annually, including those not treated by a health care provider.

The study was sponsored by the U.S. Army Medical Research and Materiel Command of the U.S. Department of Defense. Established in 1970 under the charter of the National Academy of Sciences, the Institute of Medicine provides independent, objective, evidence-based advice to policymakers, health professionals, the private sector, and the public. The National Academy of Sciences, National Academy of Engineering, Institute of Medicine, and National Research Council make up the National Academies.

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Radar shows promise for detecting concussions in athletes and soldiers

ScienceDaily (Apr. 26, 2011) — Walking and thinking at the same time can be especially difficult for persons who've suffered concussions, and scientists hope to use that multitasking challenge -- measured by a simple radar system -- to quickly screen individuals who may have suffered brain injuries.

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By asking an individual to walk a short distance while saying the months of the year in reverse order, researchers at the Georgia Tech Research Institute (GTRI) can determine if that person is impaired and possibly suffering from a concussion. This simple test, which could be performed on the sideline of a sporting event or on a battlefield, has the potential to help coaches and commanders decide if athletes and soldiers are ready to engage in activity again.

"When a person with a concussion performs cognitive and motor skill tasks simultaneously, they have a different gait pattern than a healthy individual, and we can identify those anomalies in a person's walk with radar," said GTRI research engineer Jennifer Palmer.

More than 1 million concussions and other mild traumatic brain injuries are reported each year in the United States and catching them right after they happen can improve treatment and prevent further injury or other long-term health issues. Diagnosing concussions can be difficult, though, because the symptoms of concussions are not always easily visible or detectable, even though they last for weeks or months following the incident. Methods exist for detecting concussions, but most focus purely on cognitive impairment and do not assess accompanying motor skill deterioration.

Details of GTRI's technique, which simultaneously examines a person's cognitive and motor skills, will be presented on April 26 at the SPIE Defense, Security and Sensing conference in Orlando. GTRI research engineers Kristin Bing and Amy Sharma, principal research scientist (ret) Eugene Greneker, and research scientist Teresa Selee also worked on this project, which is supported by the GTRI Independent Research and Development (IRAD) program.

Several studies have shown that measuring changes in gait could be used to diagnose concussions, but measuring a person's gait typically requires wearing special clothing with reflective markers or sensors so that movements can be captured with motion analysis cameras. Using radar for gait analysis would be faster and less intrusive than these existing techniques. The assessment would be done with radar systems similar to those used by police for measuring the speed of vehicles.

For their study, the GTRI research team compared how 10 healthy individuals walked normally and when impaired. For the impairment scenario, individuals wore goggles that simulated alcohol impairment. Past research has shown that concussion impairment is equivalent to having a blood alcohol level of 0.05 percent.

During the trials, each individual performed four 30-second walking tasks: a normal walk, walk while saying the months of the year in reverse order, walk while wearing the goggles, and walk while wearing the goggles and performing the cognitive task. For each task, the subjects walked away from the radar system, turned around and walked back toward the radar system.

"We're using a 10.5 gigahertz continuous wave radar, which is similar to a police officer's radar gun that measures the speed of a car," explained Bing. "The data we collect tells us the velocity of everything that's in the field of view of the radar at that time, including a person's foot kicks, and head and torso movements."

The researchers analyzed the radar data using information-theoretic techniques, which detected similarities and differences in the information without having to identify and align specific body parts. In addition, these techniques could recognize a gait anomaly without requiring that an individual's normal gait be measured before the person became impaired.

"By looking for differences in the gait patterns of normal and impaired individuals, we found that healthy individuals could be distinguished from impaired individuals wearing the goggles," explained Palmer. "Healthy individuals demonstrated a more periodic gait with regular and higher velocity foot kicks and faster torso and head movement than impaired individuals when completing a cognitive task."

The results also indicated that if no cognitive task was performed, a healthy individual's gait pattern was not statistically different when wearing and not wearing the goggles.

"We found that we needed to examine a person's physical and mental capabilities at the same time to see a change in gait and detect impairment," said Bing. "It's easy for a person to concentrate on one task, but when that person has to multitask we can begin to discriminate between someone who is impaired and someone who is not."

In the future, the researchers plan to collect additional data from healthy individuals of different heights and weights, and from individuals exhibiting concussion symptoms according to neuropsychological screening tests performed at a hospital. They also plan to reduce the size of the system so that it becomes more practical to use.

"For the military, we envision the system could fit into a tough box so that commanders can have it in the field," added Bing. "They could simply press a button, connect the radar system to a laptop, and an easy-to-use interface would display the results and tell them whether their soldier is exhibiting signs of a concussion."

Approval from the Food and Drug Administration will be required before this system can be used to diagnose concussions.

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Neurorobotics reveals brain mechanisms of self-consciousness

ScienceDaily (Apr. 27, 2011) — A new study uses creative engineering to unravel brain mechanisms associated with one of the most fundamental subjective human feelings: self-consciousness. The research, published in the April 28 issue of the journal Neuron, identifies a brain region called the temporo-parietal junction (TPJ) as being critical for the feeling of being an entity localized at a particular position in space and for perceiving the world from this position and perspective.

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Recent theories of self-consciousness highlight the importance of integrating many different sensory and motor signals, but it is not clear how this type of integration induces subjective states such as self-location ("Where am I in space?") and the first-person perspective ("From where do I perceive the world?"). Studies of neurological patients reporting out-of-body experiences have provided some evidence that brain damage interfering with the integration of multisensory body information may lead to pathological changes of the first-person perspective and self-location. However, it is still not known how to examine brain mechanisms associated with self-consciousness.

"Recent behavioral and physiological work, using video-projection and various visuo-tactile conflicts showed that self-location can be manipulated in healthy participants," explains senior study author, Dr. Olaf Blanke, from the Ecole Polytechnique Fédérale de Lausanne in Switzerland. "However, so far these experimental findings and techniques do not allow for the induction of changes in the first-person perspective and have not been integrated with neuroimaging, probably because the experimental set-ups require participants to sit, stand, or move. This makes it very difficult to apply and film the visuo-tactile conflicts on the participant's body during standard brain imaging techniques."

Making use of inventive neuroimaging-compatible robotic technology that was developed by Dr. Gassert's group at the Swiss Federal Institute of Technology in Zurich, Dr. Blanke and colleagues studied healthy subjects and employed specific bodily conflicts that induced changes in self-location and first-person perspective while simultaneously monitoring brain activity with functional magnetic resonance imaging. They observed that TPJ activity reflected experimental changes in self-location and first-person perspective. The researchers also completed a large study of neurological patients with out-of-body experiences and found that brain damage was localized to the TPJ.

"Our results illustrate the power of merging technologies from engineering with those of neuroimaging and cognitive science for the understanding of the nature of one of the greatest mysteries of the human mind: self-consciousness and its neural mechanisms," concludes Dr. Blanke. "Our findings on experimentally and pathologically induced altered states of self-consciousness present a powerful new research technology and reveal that TPJ activity reflects one of the most fundamental subjective feelings of humans: the feeling that 'I' am an entity that is localized at a position in space and that 'I' perceive the world from here."

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Device measures brain temperature non-invasively: Monitoring could be critical in life-saving cooling therapy

ScienceDaily (May 3, 2011) — Doctors have long sought a way to directly measure the brain's temperature without inserting a probe through the skull. Now researchers have developed a way to get the brain's precise temperature with a device the diameter of a poker-chip that rests on a patient's head, according to findings presented May 1 at the annual meeting of the Pediatric Academic Societies in Denver.

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"This is the first time that anyone has presented data on the brain temperature of a human obtained non-invasively," said principal researcher Dr, Thomas Bass, a neonatologist at Children's Hospital of The King's Daughters in Norfolk, Va., and a professor of pediatrics at the hospital's academic partner, Eastern Virginia Medical School.

The research also suggests that an injured brain can be significantly warmer than the body, a finding critical to cooling therapies that reduce brain damage in everyone from elderly heart attack victims to hypoxic newborns.

"Knowing the actual brain temperature may allow us to improve outcomes by keeping the brain at an optimum temperature," said Dr. Bass.

With the help of a $750,000 National Institutes of Health grant, a research team led by Dr. Bass adapted an instrument that calculates temperatures by detecting microwave emissions produced by all human tissue.

Those microwaves pass unimpeded through the skull, like light passing through a sheet of glass. As tissue temperatures increase, the emissions grow more intense. Engineers calibrated the device to measure the temperature of brain tissue 1.5 centimeters beneath the skull.

In the trial whose results were presented, the device was placed on the heads of infants undergoing cooling therapy at CHKD. The device's brain temperature readings were correlated with rectal and esophageal temperatures. The difference in temperature between the brain and the body recorded by other means was as high as 5.4% Fahrenheit.

"That's difference is larger than we expected," Dr. Bass said.

Dr. Bass, who pioneered research on cooling therapy for hypoxic newborns, and set about this research because he believed the therapy could be improved if doctors knew precise temperature of the damaged organ, the brain.

Hypoxic brain damage in infants occurs most often in full-term births when the child suffers oxygen loss either immediately before or during delivery. Because of a quirk in the brain, a child can be revived but brain cells continue to die over several days, resulting in brain damage or death. Doctors could do little to stop this progression; parents often watched helplessly as their sons and daughters literally died before their eyes.

Based on the observation that children rescued from freezing ponds after extended periods of time suffered little or no brain damage, cooling therapy involves chilling an infant's body to 92 degrees for 72 hours after brain injury.

A clinical trial on the therapy showed that cooling the child stops or reduces the progression of brain cell death, drastically reducing brain damage and death. The results were so positive that the therapy is now standard in advanced neonatal intensive-care units worldwide.

Cooling therapy is now used with other patients as well, including heart attack victims whose brains have suffered oxygen deprivation.

Because cooling therapy's success relies on the temperature of the brain, precise readings of the brain's temperature is likely to improve a therapy that's already proven remarkably effective.

Children's Hospital of The King's Daughters is the only freestanding pediatric hospital in Virginia.

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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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CT scans are frequently unnecessary after head injury in children, large study finds

ScienceDaily (May 9, 2011) — Overall, roughly half of U.S. children taken to hospital emergency departments (EDs) for a head injury receive a head CT scan, often to ease worried parents' concerns. Yet true traumatic brain injury is uncommon. A multi-center study of more than 40,000 children with minor blunt head trauma, led by Children's Hospital Boston and UC Davis, shows that allowing a period of observation can reduce the use of head CT by as much as half without compromising care -- and without exposing children to ionizing radiation.

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Results appear in the June 2011 issue of Pediatrics (published online May 9).

"Only a small percentage of children with blunt head trauma really have something serious going on," says Lise Nigrovic, MD, MPH, of Children's Hospital Boston, who co-led the study with Nathan Kuppermann, MD, MPH, chair of the Department of Emergency Medicine at UC Davis. "If you can be watched in the ED for a few hours, you may not need a CT."

This change in practice would not only be cost-saving, but is better medicine, the researchers say.

Nigrovic, Kuppermann and colleagues analyzed the outcomes of children presenting at 25 different emergency departments, as part of a large prospective study conducted by the Pediatric Emergency Care Applied Research Network (PECARN). Of 40,113 children whose records could be analyzed, 5,433 (14 percent) were observed before making a decision about CT use. Observation times varied, as did the severity of head trauma.

Overall, the children who were observed had a lower rate of CT than those not observed (31 vs. 35 percent). When the researchers matched the observed and non-observed groups for severity of head injury and the practice style of different hospitals, this difference was more pronounced: The likelihood of a CT scan in the observed group was about half that of similar non-observed patients (odds ratio, 0.53). In particular, children whose symptoms improved during observation were less likely to eventually have CT.

Allowing for an observation period did not compromise safety, the study found: Clinically important traumatic brain injury -- resulting in death, neurosurgical intervention, intubation for more than 24 hours or hospital admission for two nights or more -- was equally uncommon in the observed and non-observed groups (0.75 vs. 0.87 percent).

Nigrovic and Kuppermann note that cranial CT itself presents additional risks for children. Children's growing brain tissue is more sensitive to ionizing radiation than adults', and because of their longer life expectancy, their lifetime risk of developing a radiation-induced malignancy is greater.

"CT isn't bad if you really need, but you don't want to use it in children who are at low risk for having a significant injury," says Nigrovic. "For parents, this means spending a couple of extra hours in the ED in exchange for not getting a CT. It's the children in the middle risk groups -- those who don't appear totally normal, but whose injury isn't obviously severe -- for whom observation can really help."

The researchers were unable to determine the actual length of time the children were observed in the ED, a question they would like to investigate in the future. Practice guidelines from the American Academy of Pediatrics recommend a child be carefully observed for 4 to 6 hours after injury.

"There is a clear need to develop appropriate and safe guidelines for decreasing the number of inappropriate head CT scans that we do on children," says Kuppermann. "The results of this analysis demonstrate that a period of observation before deciding to use head CT scans on many injured children can spare children from inappropriate radiation when it is not called for, while not increasing the risk of missing important brain injuries."

Nigrovic offers the following general guidelines for parents whose child has a head injury:

Check with your primary care clinician before taking the child to the ED. If your child has headache, vomiting and/or confusion, or symptoms that worsen over time, an ED visit is appropriate. The ED clinician may reasonably choose to observe your child for several hours once you arrive before deciding about a head CT. The change of symptoms over time is an important factor in deciding whether to obtain a cranial CT.

The study was funded by the Health Resources and Services Administration/Maternal and Child Health Bureau, Division of Research, Training, and Education, and the Emergency Medical Services of Children Program.

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Brain region necessary for making decisions about economic value identified

ScienceDaily (May 19, 2011) — Neuroeconomic research at the University of Pennsylvania has conclusively identified a part of the brain that is necessary for making everyday decisions about value. Previous functional magnetic imaging studies, during which researchers use a powerful magnet to determine which parts of a subjects brain are most active while doing a task, have suggested that the ventromedial frontal cortex, or VMF, plays an evaluative role during decision making.

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Now, Joseph Kable, an assistant professor of psychology in Penn's School of Arts and Sciences, has demonstrated the causal relationship between the VMF and such decisions.

"When you're doing functional imaging and looking at the relationship between brain activity and a decision," Kable said, "you don't know that the brain activity is causally important in that decision. They could be correlated for different reasons."

Kable and his colleagues, which included Penn undergraduate Khoi Vo and researchers from McGill University, addressed the limitations of imaging studies by recruiting experimental subjects who had suffered damage to that part of their brains, often from strokes, aneurysms or brain tumors.

"People with damage to their ventromedial frontal cortex should be less able to choose things that are most valuable and they should be less consistent in their choices," Kable said.

"That's exactly what we found." Their research was published in The Journal of Neuroscience.

Kable's experiment involved a simple questionnaire, where people with and without VMF damage were asked to pick between groupings of juice boxes and chocolate bars, based on which they liked more.

The subjects were sequentially given 11 sheets of paper, which listed two or more groups they could choose. As an incentive for them to pick the one they truly wanted more, the researchers promised to give each subject one of the 11 groups he or she selected at the end of the experiment. The subjects were also able to pick what kind of juice and chocolate they preferred before the experiment began.

While there were no price tags on any of the items, the grouped items on each sheet had a fixed value relative to one another and the total amount that could be spent. A subject could pick between a group with six juice boxes and two chocolate bars, a group with three juice boxes and three chocolate bars and a group with no juice boxes and four chocolate bars, implying that the chocolate was three times as expensive as the juice.

Crucially, the relative values and amount that could be spent changed between each of the 11 sheets. By choosing in the different contexts and being given an opportunity to review and change their previous selections, the subjects revealed how much they preferred one item to another.

"We wanted to give people the best chance possible to be consistent," Kable said. "But on the flip side we didn't want to make it obvious how you would be consistent."

Consistency was key. If subjects made selections that contradicted their previously revealed preference, it indicated they couldn't properly assign a value to the items they were presented with. For example, a subject who chose no juices and two chocolates rather than six juices and no chocolates should not then choose two juices and no chocolates over no juices and six chocolates.

"Most of the control group didn't make any inconsistent choices, and all but one of the people who have VMF damage made at least one," Kable said. Many of the subjects with VMF damage made multiple inconsistent choices.

The strength of the findings of this kind of neuroeconomic experiment opens the door to more complex experiments dealing with real monetary value and to investigations into other parts of the brain that are associated with economic decision making.

In addition to Kable and Vo, the research was conducted by Nathalie Camille, Cathryn A. Griffiths and Lesley K. Fellows of the Department of Neurology and Neurosurgery at McGill.

The research was supported by the Canadian Institutes of Health Research and the National Institutes of Health.

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