Brain Injury Blog

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Douglas native Raymond Gould, 27, and his mother, Carol Gould, of Fitchburg, interact in Raymond’s room at St. Mary Health Care Center in Worcester. Mr. Gould is recovering from brain surgery. These should be the prime years of Raymond Gould’s life. Until last November, the 27-year old waiter’s life was full of friends, good times, dancing and music. g

, dancing and.

His life changed forever when a sinus infection traveled to his brain. With his brain swelling dangerously, he lapsed into a coma for six weeks and had three surgeries to reduce the swelling. He has since navigated a slow, painful recovery. Last week, the young man who had coached the color guard at Douglas High School and dreamed of competing on the television show “So You Think You Can Dance?” moved into a nursing home, St. Mary Health Care Center in Worcester.

“He’s a little frustrated, realizing where he is,” said his mother, Carol Gould of Fitchburg. “I didn’t want him in a nursing home, but there are so few options out there for someone with a brain injury like Ray’s.”But those options may improve in the next year or two as the state implements a settlement agreement reached in a federal class action lawsuit brought on behalf of Massachusetts residents with both traumatic and acquired brain injuries. The settlement may help Mr. Gould and others like him to leave institutions and live in the community.

On his third day at St. Mary last week, Mr. Gould, who needs a wheelchair because he has trouble standing, seemed a bit down. He answered every question in the negative, with a shake of his head. He refused to speak more than his name, although his mother said he can chat on his cell phone. He clenched his hands. When he got upset, he tapped his fists against his thighs.

His dark mood lifted, however, when his sister April and his 4-month-old nephew, Logan, arrived for a visit. He broke into a smile. Holding Logan in his arms, he said, “Hi buddy.” He kissed the baby on the forehead. Despite his frustrations at his body’s betrayal, Mr. Gould has managed to keep his sense of humor, his mother said. One night they were praying, as is their habit when Ms. Gould takes her leave of her son every night. “God, hear our prayers,” she ended. “God, don’t listen to my mother,” he said.

Ms. Gould said she is eternally thankful that St. Mary accepted her son, and said the staff has been incredibly supportive. Still, Mr. Gould hasn’t exactly rushed out of his room to play bingo with his elderly hall mates. He pretty much keeps to himself. Following his stay at Spaulding Rehabilitation Hospital in Boston, going home or moving into his own apartment proved impossible. There was nothing available.

“The options are limited. There really aren’t that many facilities that specialize in treating brain injuries,” said Arlene Korab, executive director of the Westboro-based Brain Injury Association of Massachusetts. “Recovering from brain injuries is a very long, prolonged rehabilitation. You need continuous therapies to retrain the brain to do what it used to.”

There are services for the very young, the very old and those who suffer from traumatic brain injury, which is caused by a blow to the head. Besides institutions, there are group homes and some limited at-home support services.

But for young people with an acquired brain injury such as Mr. Gould’s, the only current option is a nursing home or rehabilitative facility. “You get a young person sitting there with senior citizens; it’s a whole different way of living,” Ms. Korab said. “A lot of them get depressed.”

Mr. Gould’s friends have been holding numerous fundraisers on his behalf, but the costs of his rehabilitation are staggering. He did not have health insurance before he fell ill and is now covered by MassHealth, the state’s Medicaid health insurance program. Ms. Gould said her son’s health care coverage has limited his care options and suspects that St. Mary will lose money by treating him. She lost her job as a sales representative as she stayed by his side and navigated the health care system on his behalf.

The recent settlement of the federal class action lawsuit may someday offer Mr. Gould and his mother hope. The first-in-the-nation lawsuit, Hutchinson v. Patrick, was filed in 2007 by the Brain Injury Association of Massachusetts and five patients with brain injuries. The lawsuit accused the state of violating the federal Americans with Disabilities Act by keeping brain injury patients in institutions — even after their doctors say they no longer need to be in a nursing facility — because no services exist to help them live with family or on their own.

The lawsuit demanded that the state and federal government pay for community services for nearly 2,000 Massachusetts residents with brain injuries who currently live in nursing homes and rehabilitative facilities. “I think about the residents (with brain injuries)… and I know what their empty lives are like,” wrote Cathy Hutchinson, 55, of Attleboro, one of the plaintiffs in the lawsuit. After a brainstem stroke in 1996 left her a mute quadriplegic, she spent 11 years in a nursing home.

“Sometimes,” she wrote in an e-mail, “I feel like I am in prison for a crime I didn’t commit. I need to start living my life, instead of just existing in a wheelchair.” For many years, treatment and therapy for brain injury patients was largely nonexistent because it was believed patients did not recover, said Dr. Jean McGuire, assistant secretary for disability policy and programs with the Executive Office of Health and Human Services. That idea has changed, especially because so many more people now survive serious brain injuries.

“This is not the first time that the state’s response was dictated by a settlement,” Dr. McGuire said. “We’re proceeding to build the services for people who want to come out of institutions and live in the community. We’re going into uncharted territory, and there’s going to be a lot to learn about what is the right mix of services.”

The settlement of the Hutchinson case will help Medicaid-eligible residents of nursing homes and rehab facilities who acquired their brain injury through a traumatic event such as an accident or through a stroke, poisoning or, like Mr. Gould, a disease.

Under the settlement agreement, which is still subject to court approval, the state will create two waiver programs designed to transition individuals with brain injuries out of nursing facilities and other institutions into community residences. The programs must be approved by the federal government, which will pay half the cost.

The program will be implemented over several years, but should result in approximately 200 to 250 persons a year leaving nursing facilities. Dr. McGuire said it will likely be a year before the first brain injury patients begin to move from institutions to community settings.

Before then, Mr. Gould will most likely need another placement. His MassHealth plan has agreed to pay for his stay at St. Mary through September. What happens then? “I guess we’ll see,” Ms. Gould said.

Source: TELEGRAM & GAZETTE STAFF - Aaron Nicodemus 06.06.2010

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About four years ago, John Donoghue’s son, Jacob, then 18, took his father aside and declared, “Dad, I now understand what you do — you’re ‘The Matrix’!” Dr. Donoghue, 61, is a professor of engineering and neuroscience at Brown University, studying how human brain signals could combine with modern electronics to help paralyzed people gain greater control over their environments. He’s designed a machine, the BrainGate, that uses thought to move objects. We spoke for two hours in his Brown University offices in Providence, R.I., and then again by telephone. An edited version of the two conversations follows:

Q. WHAT EXACTLY IS BRAINGATE?

A. It’s a way for people who’ve been paralyzed by strokes, spinal cord injuries or A.L.S. to connect their brains to the outside world. The system uses a tiny sensor that’s been implanted into the part of a person’s brain that generates movement commands. This sensor picks up brain signals, transmits them to a plug attached to the person’s scalp. The signals then go to a computer which is programmed to translate them into simple actions.

Q. WHY MOVE THE SIGNALS OUT OF THE BODY?

A. Because for many paralyzed people, there’s been a break between their brain and the rest of their nervous system. Their brains may be fully functional, but their thoughts don’t go anywhere. What BrainGate does is bypass the broken connection. Free of the body, the signal is directed to machines that will turn thoughts into action.

Q. HAVE YOU CREATED A BIONIC NERVOUS SYSTEM?

A. Well, a piece of it. We’ve done it with physical components — wires, computers, electronics, as opposed to stem cells. That would be a biological repair. It’s what Christopher Reeve was pushing so hard for. Reeve hoped you could put some stem cells into the damaged area and they could reconstruct everything. That hasn’t happened yet, though people are working on it.

In the meanwhile, we’re making progress on the mechanical repair. Thus far, five people — “participants” — have received the implant. We have permission to study 14 more. I can’t say that we’ve given them back their ability to control their world. Still, we definitely are at the beginning of getting people to do meaningful things like get themselves a drink of water when they want one. Or move a computer’s cursor, which makes communication possible.

To read the balance of this article, click on the link below:

http://www.nytimes.com/2010/08/03/science/03conv.html?_r=1

Source: The New York Times – Claudia Dreifus - Aug. 2, 2010

Consuming dark chocolate may prevent stroke-related brain injuries, according to a study published in the Journal of Cerebral Blood Flow and Metabolism.

Using mice, a team of researchers fed one group a small amount of epicatechin, a natural compound found in dark chocolate. After 90 minutes had passed since consumption, the investigators induced strokes in the animals.

The study showed that the mice who ate the compound suffered less brain damage compared to a group that experienced strokes and weren’t given the nutrient. The researcher discovered that the epicatechin was stimulating two levels of nerve cells that protect the brain against injury.

The researchers concluded that this study could lead to preventing brain damage in stroke patients and the development of cognitive-related disorders. However, they feel that further research will be needed to discover the amount of dark chocolate one would need to consume.

“Epicatechin itself may not be shielding brain cells from free radical damage directly, but instead, epicatechin, and its metabolites, may be prompting the cells to defend themselves,” said Sylvain Dore, an associate professor at the Johns Hopkins University School of Medicine. He added that the protein is “needed to jump-start the protective pathway that is already present within the cells, even a small amount may be sufficient.”

Approximately 6.4 million patients in the U.S. who suffered strokes in 2006 are still alive today, according to the American Heart Association.

Source: Betterhealthresearch.com by Donna Parker June 2, 2010

Most comprehensive study of its kind shows impact of brain injury on women

Most comprehensive study of its kind shows impact of brain injury on women’s reproductive health 

June 30, 2010 – After a brain injury, women often ask how the injury will affect their fertility, pregnancy and postpartum health. Now a new study provides some much-needed answers.

Published in the June issue of the Journal of Women’s Health, the study is the most comprehensive investigation to date of women’s health issues after traumatic brain injury.

“Traumatic brain injury is a major public health problem, yet little is known about its long-term effect on women’s reproductive health,” says Dr. Angela Colantonio, a senior scientist at Toronto Rehab and principal author of the study.

“Our findings provide important information for women who have experienced a traumatic brain injury, and for health professionals working with these women.”

The study, which examined the health outcomes of 104 premenopausal women 5-12 years after moderate to severe brain injury, found that:

* women with traumatic brain injury (TBI) were more likely to experience menstrual disturbances, including irregular cycles and amenorrhea (not having a period)

* women with TBI did not appear to have significantly more problems with getting pregnant when compared to women without brain injury

* women with TBI had fewer children

* significantly more women with TBI experienced postpartum difficulties, compared to women without brain injuries

* women with TBI reported lower levels of perceived health, including mental health, physical function, perceived support, and income

 “These findings inform prognosis after TBI for women and provide evidence for long-term monitoring of health outcomes and increased support after childbirth,” the authors write.

To read the balance of this article, follow the link provided:

https://docs.google.com/viewer?a=v&pid=gmail&attid=0.1&thid=129b1e1ea1472249&mt=application/msword&url=https://mail.google.com/mail/?ui%3D2%26ik%3D3f98c3fdfb%26view%3Datt%26th%3D129b1e1ea1472249%26attid%3D0.1%26disp%3Dattd%26zw&sig=AHIEtbStw2jivclOb8VaPLjJQA4gRdG8Ww&pli=1

Source: Toronto Rehab Media Release

June 30, 2010

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A recent CDC report found that an estimated 1.7 million people sustain a traumatic brain injury (TBI) in the U.S. each year.

This would be approximate 4,700 TBI’s per day.

Fifty-two thousand people die each year in America from traumatic brain injuries, representing nearly one-third of all injury deaths.

The majority of TBI’s that occur each year are concussions or other forms of mild TBI.

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WASHINGTON(REUTERS) Shutting off a single gene can help stop the cascade of damage that can paralyze people with spinal cord injuries, U.S. researchers reported on Wednesday. They propose using a common, generic diabetes drug in combination with a gene-silencing technique to stop spine injuries from getting any worse, and believe the approach may also work in people with stroke and traumatic brain injuries.

Their experiment, published in the journal Science Translational Medicine, shows it is possible to stop the bleeding that can cause the damage from an injured spinal cord to spread and worsen. “What we’re doing is preventing bleeding from occurring,” said Marc Simard of the University of Maryland, which has licensed the technology to a company Simard works with called Remedy Pharmaceuticals.

When the spinal cord or brain is injured, the capillaries can burst, bringing in an overwhelming wave of chemicals called inflammatory factors that are meant to heal but that often worsen the damage. This is why stroke patients do not always show immediate symptoms but can worsen in the hours afterwards.

Simard’s team demonstrated that a gene called ABCC8 starts this process. It controls a molecule called the sulfonylurea receptor 1 or SUR1.

Drug could stop spinal injuries, researchers say

“It gets activated after an injury like ischemia (when blood vessels are blocked) or trauma,” Simard said.

Simard’s team blocked this gene in mice and rats using gene-blocking therapy called antisense and showed that after a spinal cord injury, the damage and effects were much less without ABCC8. They also tested the spinal cords of seven patients who died within five days of a spinal cord injury and showed the same gene was active. The next step is to try this approach in people, said Simard. “I think we are pretty darn close to a clinical trial,” he said in a telephone interview.

EASY TO MAKE

The antisense drugs are easy to make, he said. And the common diabetes drug glyburide blocks the destructive SUR1 protein made by the gene. Remedy Pharmaceuticals is working to make an infused version of both drugs that could work together to block the gene and block the protein that the gene makes.

Glyburide is already in Phase I safety trials for treating traumatic brain injury and stroke, Simard said. “My hope is eventually you could get it into the ambulance,” Simard added. He hopes there will be no side-effects from giving the drug, even to lightly injured people, so that ambulance workers could give an immediate infusion to anyone with apparent brain or spinal cord damage to stop the deadly cascade of damage.

The potential market is large. “Worldwide, the incidence of spinal cord injury ranges from 10 to 83 per million people per year,” Simard’s team wrote. Many teams are looking for ways to prevent the early damage that makes brain and spinal cord injuries so devastating.

A team has engineered an enzyme that can gobble up scar tissue formed after spinal cord injuries, and is working with Acorda Therapeutics to develop it. Another team found last year that injecting tiny polymer spheres into rats right after spine injuries helped the animals recover movement and prevented secondary nerve damage.

Yet another group found last year that a common and safe blue food dye might block inflammation.

Source: REUTERS News

By Maggie Fox, Health & Science Editor

April 21, 2010

Australia is a place that can actually change the world in mental health, provided we get the right government support to do so - Patrick McGorry

A Public Service Announcement on Australian TV features Australian of the Year Psychiatrist Patrick McGorry claiming that nearly half the population will experience mental ill-health during their lifetime.  Considering that after World War II, psychiatrists claimed that one in 20 people had a mental disorder, and now it’s every second one of us, that’s a damning 1000 percent failure rate for psychiatrists in reducing “mental illness.”   Let’s get real;  the reason psychiatrists claim more people are mentally ill is because they can keep  inventing new ways to label them mentally ill— but the press and governments are  starting to catch on, evidenced by all the controversy surrounding psychiatry’s upcoming edition of their Diagnostic and Statistical Manual of Mental Disorders (DSM)—better known as psychiatry’s billing bible.   Yet of all the proposed “mental disorders” ranging from overeating to kids throwing tantrums, no proposed model of mental disorder is more insidious and dangerous than that of Patrick McGorry, who promotes diagnosing people before they develop a so-called mental disorder—drugging them before they become “mentally ill.”  Yet the Australian government has bought into it hook, line and sinker—despite the fact McGorry’s plan is so outrageous, even his peers, such as psychiatrist Allen Frances, former Chair of the DSM task force, have called it ”the most ill-conceived and potentially harmful.”

Make no mistake, the pre-drugging agenda is Patrick McGorry’s baby—his dream for a new paradigm in mental health, one that has the power to diagnose and drug people before they become mentally ill —  welcome to the Brave New World of Patrick McGorry.   And he isn’t stopping with Australia; his plan is to go global.  As he recently stated, “Australia is a place that can actually change the world in mental health, provided we get the right government support to do so.”

The fact that McGorry’s agenda is so controversial it even has other psychiatrists protesting it—has not deterred the Australian government from funding this “ill-conceived” plan.  A recent letter to Citizens Commission on Human Rights states, “The Australian Government is providing $25.5 million over four years from 2010-2011 to expand Early Psychosis Prevention and Intervention Centre (EPPIC) model,” developed by McGorry who founded EPPIC and the Orygen Youth Health in Victoria, Australia.

The Australian Government has already been criticized for massive expenditure on psychotropic drugs increasing more than 660 percent during the last decade—with a whopping 3,100 percent increase on antipsychotic drugs (with at least 15 Australian deaths in the under 19 year olds as a tragic consequence of this).  This can only get worse when under McGorry’s plan with an enormous client base that can be prescribed drugs despite the fact they are not yet “mentally ill”.   It’s called prodrome (prodromos meaning the forerunner of an event)—referring to “a period of prepsychotic disturbance” that may or may not develop into psychosis or “schizophrenia” in other words, the crystal ball theory.

Australia Meets the US in Pre-Drug Scam

McGorry’s plan for Australia to “lead the change” in world mental health is happening—to the detriment of those who may be forced to undergo drug treatment based on a psychiatrist’s hunch that they might, one day, become  ill.   In the U.S., on May 13, 2009, the Department of Health and Human Services convened a Technical Expert Panel (TEP) discussed “emerging evidence around psychopharmacological interventions for first episode schizophrenia” citing the research efforts of McGorry and others.

The push for pre-diagnosing and pre-drugging has even those within the psychiatric profession calling foul; Dr. Richard Warner, professor of psychiatry at the University of Colorado, counters the idea that science drives McGorry’s pre-disorder assessment, stating, “Given the expected number of false positives, the potential for harm is significant.”

However, as Anthony Pelosi, honorary professor, Department of Psychiatry, Hairmyres Hospital, wrote in a counter to McGorry in the British Medical Journal last year, “this has not stopped their skillful lobbying of politicians, journalists, patients, and carers with upbeat messages about the prevention.” “Skilful lobbying” is right.

Source: CCHR International

Citizens Commission on Human Rights International

June 16, 2010

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Alaska has one of the highest incidences of brain injuries in the nation – more than 10,000 Alaskans live with a life-long disability resulting from a brain injury.

Dr. Harvey Jacobs, a national expert on brain injuries.  He’s in Anchorage this week to share information at the Alaska Brain Injury Conference.  Dr. Jacobs says the consequences of a brain injury can be devastating. He says anyone can be susceptible to such an injury. Falls, vehicle accidents and physical assaults are the most common causes, and all age groups are vulnerable.   Dr. Jacobs says prevention is the key.

He says wearing bicycle and motorcycle helmets is essential to protect the brain.  A good investment, he says, considering the jello-like brain can be injured even by a mild blow.   According to Center for Disease Control data, the financial losses due to brain injuries in our society could be $100 billion a year in costs of care and lost economic opportunities.  There are 1.7 million brain injured people in the US, and 80,000 to 100,000 of them have permanent disabilities.

Jill Hodges, executive director of the Alaska Brain Injury Network, says the Bethel area has the highest incidence of brain injuries in the state. 800 Alaskans are hospitalized each year with moderate to severe brain injuries, 650 of those survive.

Males aged 16 – 24 are at the highest risk, but infants are at risk, too, because of shaken baby syndrome.  She says a lot of work has to be done to convince bush snow-machiners and four wheelers to wear head protection.  She says the state and the Alaska Native Health Consortium have made some efforts in this direction.  Hodges says in rural Alaska, CT scans are rare, so most injured rural residents are medevaced to Anchorage or Seattle for acute care, but on return to the village, the state and the regional behavioral health service become the primary caregivers.  Hodges says there is no single rehabilitative care center in Alaska, but progress is being made in that direction.

Source: Alaska News Ellen Lockyer – July 29, 2010

Douglas native Raymond Gould, 27, and his mother, Carol Gould, of Fitchburg, interact in Raymond’s room at St. Mary Health Care Center in Worcester. Mr. Gould is recovering from brain surgery. These should be the prime years of Raymond Gould’s life. Until last November, the 27-year old waiter’s life was full of friends, good times, dancing and music. g

, dancing and.

His life changed forever when a sinus infection traveled to his brain. With his brain swelling dangerously, he lapsed into a coma for six weeks and had three surgeries to reduce the swelling. He has since navigated a slow, painful recovery. Last week, the young man who had coached the color guard at Douglas High School and dreamed of competing on the television show “So You Think You Can Dance?” moved into a nursing home, St. Mary Health Care Center in Worcester.

“He’s a little frustrated, realizing where he is,” said his mother, Carol Gould of Fitchburg. “I didn’t want him in a nursing home, but there are so few options out there for someone with a brain injury like Ray’s.”But those options may improve in the next year or two as the state implements a settlement agreement reached in a federal class action lawsuit brought on behalf of Massachusetts residents with both traumatic and acquired brain injuries. The settlement may help Mr. Gould and others like him to leave institutions and live in the community.

On his third day at St. Mary last week, Mr. Gould, who needs a wheelchair because he has trouble standing, seemed a bit down. He answered every question in the negative, with a shake of his head. He refused to speak more than his name, although his mother said he can chat on his cell phone. He clenched his hands. When he got upset, he tapped his fists against his thighs.

His dark mood lifted, however, when his sister April and his 4-month-old nephew, Logan, arrived for a visit. He broke into a smile. Holding Logan in his arms, he said, “Hi buddy.” He kissed the baby on the forehead. Despite his frustrations at his body’s betrayal, Mr. Gould has managed to keep his sense of humor, his mother said. One night they were praying, as is their habit when Ms. Gould takes her leave of her son every night. “God, hear our prayers,” she ended. “God, don’t listen to my mother,” he said.

Ms. Gould said she is eternally thankful that St. Mary accepted her son, and said the staff has been incredibly supportive. Still, Mr. Gould hasn’t exactly rushed out of his room to play bingo with his elderly hall mates. He pretty much keeps to himself. Following his stay at Spaulding Rehabilitation Hospital in Boston, going home or moving into his own apartment proved impossible. There was nothing available.

“The options are limited. There really aren’t that many facilities that specialize in treating brain injuries,” said Arlene Korab, executive director of the Westboro-based Brain Injury Association of Massachusetts. “Recovering from brain injuries is a very long, prolonged rehabilitation. You need continuous therapies to retrain the brain to do what it used to.”

There are services for the very young, the very old and those who suffer from traumatic brain injury, which is caused by a blow to the head. Besides institutions, there are group homes and some limited at-home support services.

But for young people with an acquired brain injury such as Mr. Gould’s, the only current option is a nursing home or rehabilitative facility. “You get a young person sitting there with senior citizens; it’s a whole different way of living,” Ms. Korab said. “A lot of them get depressed.”

Mr. Gould’s friends have been holding numerous fundraisers on his behalf, but the costs of his rehabilitation are staggering. He did not have health insurance before he fell ill and is now covered by MassHealth, the state’s Medicaid health insurance program. Ms. Gould said her son’s health care coverage has limited his care options and suspects that St. Mary will lose money by treating him. She lost her job as a sales representative as she stayed by his side and navigated the health care system on his behalf.

The recent settlement of the federal class action lawsuit may someday offer Mr. Gould and his mother hope. The first-in-the-nation lawsuit, Hutchinson v. Patrick, was filed in 2007 by the Brain Injury Association of Massachusetts and five patients with brain injuries. The lawsuit accused the state of violating the federal Americans with Disabilities Act by keeping brain injury patients in institutions — even after their doctors say they no longer need to be in a nursing facility — because no services exist to help them live with family or on their own.

The lawsuit demanded that the state and federal government pay for community services for nearly 2,000 Massachusetts residents with brain injuries who currently live in nursing homes and rehabilitative facilities. “I think about the residents (with brain injuries)… and I know what their empty lives are like,” wrote Cathy Hutchinson, 55, of Attleboro, one of the plaintiffs in the lawsuit. After a brainstem stroke in 1996 left her a mute quadriplegic, she spent 11 years in a nursing home.

“Sometimes,” she wrote in an e-mail, “I feel like I am in prison for a crime I didn’t commit. I need to start living my life, instead of just existing in a wheelchair.” For many years, treatment and therapy for brain injury patients was largely nonexistent because it was believed patients did not recover, said Dr. Jean McGuire, assistant secretary for disability policy and programs with the Executive Office of Health and Human Services. That idea has changed, especially because so many more people now survive serious brain injuries.

“This is not the first time that the state’s response was dictated by a settlement,” Dr. McGuire said. “We’re proceeding to build the services for people who want to come out of institutions and live in the community. We’re going into uncharted territory, and there’s going to be a lot to learn about what is the right mix of services.”

The settlement of the Hutchinson case will help Medicaid-eligible residents of nursing homes and rehab facilities who acquired their brain injury through a traumatic event such as an accident or through a stroke, poisoning or, like Mr. Gould, a disease.

Under the settlement agreement, which is still subject to court approval, the state will create two waiver programs designed to transition individuals with brain injuries out of nursing facilities and other institutions into community residences. The programs must be approved by the federal government, which will pay half the cost.

The program will be implemented over several years, but should result in approximately 200 to 250 persons a year leaving nursing facilities. Dr. McGuire said it will likely be a year before the first brain injury patients begin to move from institutions to community settings.

Before then, Mr. Gould will most likely need another placement. His MassHealth plan has agreed to pay for his stay at St. Mary through September. What happens then? “I guess we’ll see,” Ms. Gould said.

Source: TELEGRAM & GAZETTE STAFF - Aaron Nicodemus 06.06.2010

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Children younger than 5 who suffer head trauma or an unexplained life-threatening event should have an ophthalmologic evaluation, particularly if there is suspicion of abuse, according to a clinical report from the American Academy of Pediatrics.

The same holds true when children die unexpectedly, according to Alex V. Levin, MD, of the Wills Eye Institute in Philadelphia and Cindy W. Christian, MD, of Children’s Hospital of Philadelphia, authors of the report.

Retinal hemorrhages have been recognized as an important clue to abusive head trauma for three decades, especially when the injury results from repetitive acceleration-deceleration forces with or without blunt head impact, explained Levin and Christian.

However, “unsuspecting physicians misdiagnose the condition of up to one-third of symptomatic victims, depending on their age, severity of symptoms, and family composition,” they wrote online in Pediatrics.

Unilateral retinal hemorrhage typically is not associated with visual compromise, so ocular signs and symptoms alone cannot be the basis of determining whether an ophthalmologic consultation is needed.

And although health professionals other than ophthalmologists may be skilled at recognizing retinal hemorrhages, a full view of the retina and characterization of the number, types, and patterns of hemorrhages are needed to fully appreciate the cause of the damage. This ophthalmologic exam should be done, whenever possible, with indirect ophthalmoscopy and pupil dilation, preferably within the first 24 hours of injury, because the ocular findings may be transient.

“Information gained in such an evaluation might lead to identifying an etiology and, in the case of a surviving child, prevent death by preventing further abuse or recognizing other disease,” wrote the authors, who are from the AAP’s committee on child abuse and neglect.

If pharmacologic pupil dilation is considered inadvisable, such as in children with severe, unstable central nervous system injury, direct ophthalmoscopy or dilation with fast-acting mydriatics can be tried.

The range of retinal abnormalities associated with head trauma is wide and can include small, intraretinal hemorrhages confined to the posterior pole to numerous, multilayered hemorrhages extending to the edge of the retina. The ophthalmologic examination cannot be relied on to assess for brain injury, however. Brain imaging is needed for this purpose, even if the child is neurologically asymptomatic.

An ocular fundus examination also can determine if a systemic disease is the cause of retinal abnormalities, as can occur in leukemia and bacterial endocarditis. If the injury in a child younger than 5 is fatal, the eyes and orbital tissue should be removed at autopsy and examined by an ocular pathologist. “One obstacle to postmortem examination of the eyes and orbits has been a societal distaste or resistance that, in some cases, has led to fear among pathologists of legal repercussion,” the authors observed.

But families’ concerns can be allayed; because the eyes can be removed without disfigurement should funeral viewing be desired. Postmortem removal may not be needed, in all cases, however, for instance if the death resulted from witnessed accidental head trauma.

In conclusion, Levin and Christian wrote, “ophthalmologic examination and/or postmortem eye and orbital tissue removal should be performed in all cases in which a child is alleged to have suffered significant morbidity secondary to a short fall or other minor trauma disproportionate to the clinical injury and consistent with child abuse.”

Source: MedPage Nancy Walsh 26 July 2010