The prevalence of traumatic brain injury among young offenders in custody: a systematic review.

OBJECTIVES: To examine the prevalence of traumatic brain injury (TBI) among young people in custody and to compare this with estimates within the general youth population. DESIGN: Systematic review of research from various national contexts. Included studies were assessed for the relevance of the definition of TBI and the research population, and the quality of the study design. RESULTS: Ten studies were identified for inclusion in the review. Four of these studies included control groups. No studies examining comorbidity of TBI and other neurodevelopmental disorders among incarcerated young people were identified. CONCLUSION: Reported prevalence rates of brain injury among incarcerated youth range from 16.5% to 72.1%, with a rate of 100% reported among a sample of young people sentenced to death. This suggests considerable levels of need among incarcerated young people. Where control groups or directly comparable studies within the general population exist, there is strong and consistent evidence of a prevalence of TBI among incarcerated youth that is substantially greater than that in the general population. This disparity is seemingly more pronounced as the severity of the injury increases.

Self-reported traumatic brain injury and postconcussion symptoms in incarcerated youth.

OBJECTIVES: To determine the prevalence rate of traumatic brain injury (TBI) in incarcerated youth and whether frequency and severity of TBI are associated with postconcussion symptoms (PCS), violent offending behaviors, age of first conviction, and substance abuse. PARTICIPANTS: Sixty-one incarcerated male juvenile offenders with an average age of 16 years. MAIN MEASURES: Self-rated measures of head injury, TBI, PCS (Rivermead Post-concussion Symptoms Questionnaire), history of alcohol and drug use, and criminal history. RESULTS: More than 70% reported at least 1 head injury at some point in their lives, and 41% reported experiencing a head injury with loss of consciousness. Postconcussion symptoms reliably increased with the frequency and severity of TBI. The relation between frequency and symptoms was mostly accounted for by severity of TBI. Alcohol use reliably increased with the severity of TBI and was associated with PCS. Alcohol use did not account for the dose-response relation between TBI and PCS. CONCLUSIONS: Findings indicate a need to account for TBI in offender populations in managing care needs, which may contribute to reduction in offending behaviors.

Healthcare professionals' attitudes towards traumatic brain injury (TBI): the influence of profession, experience, aetiology and blame on prejudice towards survivors of brain injury.

PRIMARY OBJECTIVE: To investigate the attitudes of healthcare professionals towards individuals with traumatic brain injury (TBI) and their relationship to intended healthcare behaviour. RESEARCH DESIGN: An independent groups design utilized four independent variables; aetiology, group, blame and gender to explore attitudes towards survivors of brain injury. The dependent variables were measured using the Prejudicial Evaluation and Social Interaction Scale (PESIS) and Helping Behaviour Scale (HBS). METHODS AND PROCEDURES: A hypothetical vignette based methodology was used. Four hundred and sixty participants (131 trainee nurses, 94 qualified nurses, 174 trainee doctors, 61 qualified doctors) were randomly allocated to one of six possible conditions. MAIN OUTCOMES AND RESULTS: Regardless of aetiology, if an individual is to blame for their injury, qualified healthcare professionals have more prejudicial attitudes than those entering the profession. There is a significant negative relationship between prejudice and helping behaviour for qualified healthcare professionals. CONCLUSIONS: Increased prejudicial attitudes of qualified staff are related to a decrease in intended helping behaviour, which has the potential to impact negatively on an individual's recovery post-injury.

Shock ignition: a new approach to high gain inertial confinement fusion on the national ignition facility.

Shock ignition, an alternative concept for igniting thermonuclear fuel, is explored as a new approach to high gain, inertial confinement fusion targets for the National Ignition Facility (NIF). Results indicate thermonuclear yields of approximately 120-250 MJ may be possible with laser drive energies of 1-1.6 MJ, while gains of approximately 50 may still be achievable at only approximately 0.2 MJ drive energy. The scaling of NIF energy gain with laser energy is found to be G approximately 126E (MJ);{0.510}. This offers the potential for high-gain targets that may lead to smaller, more economic fusion power reactors and a cheaper fusion energy development path.

Demonstration of high-energy 2 omega (526.5 nm) operation on the National Ignition Facility Laser System.

A single beamline of the National Ignition Facility (NIF) has been operated at a wavelength of 526.5 nm (2 omega) by frequency converting the fundamental 1053 nm (1 omega) wavelength with an 18.2 mm thick type-I potassium dihydrogen phosphate (KDP) second-harmonic generator (SHG) crystal. Second-harmonic energies of up to 17.9 kJ were measured at the final optics focal plane with a conversion efficiency of 82%. For a similarly configured 192-beam NIF, this scales to a total 2 omega energy of 3.4 MJ full NIF equivalent (FNE).

Depressive rumination reduces specificity of autobiographical memory recall in acquired brain injury.

Individuals with acquired brain injuries (ABI) often experience depression following injury, with estimated rates between 20 and 40% within the first year and up to 50% thereafter (Fleminger et al., 2003). Previous studies with non-brain-injured individuals have identified that rumination is prevalent in both the development and maintenance of depression. The study aimed to explore how depressive rumination may contribute to overgeneral memory recall in ABI patients, by assessing the effects of manipulating ruminative self-focus on autobiographical memory performance across levels of brain injury. Fifty-eight ABI individuals with mild (28) to moderate/severe (30) cognitive impairments were assessed on measures of mood, rumination and autobiographical memory. They were then randomly assigned into matched groups for an intervention (a distraction) or a rumination task. Following intervention, they were re-assessed for autobiographical recall and rumination. Findings indicate that ruminative self-focus reduced specificity of autobiographical memory in individuals with ABI, suggesting that depressive rumination plays a role in the reduced access to autobiographical memories. Higher baseline levels of depression and rumination were also associated with less specificity in recall. These findings indicate the value of identifying and treating depression among this population.

National Ignition Facility laser performance status.

The National Ignition Facility (NIF) is the world's largest laser system. It contains a 192 beam neodymium glass laser that is designed to deliver 1.8 MJ at 500 TW at 351 nm in order to achieve energy gain (ignition) in a deuterium-tritium nuclear fusion target. To meet this goal, laser design criteria include the ability to generate pulses of up to 1.8 MJ total energy, with peak power of 500 TW and temporal pulse shapes spanning 2 orders of magnitude at the third harmonic (351 nm or 3omega) of the laser wavelength. The focal-spot fluence distribution of these pulses is carefully controlled, through a combination of special optics in the 1omega (1053 nm) portion of the laser (continuous phase plates), smoothing by spectral dispersion, and the overlapping of multiple beams with orthogonal polarization (polarization smoothing). We report performance qualification tests of the first eight beams of the NIF laser. Measurements are reported at both 1omega and 3omega, both with and without focal-spot conditioning. When scaled to full 192 beam operation, these results demonstrate, to the best of our knowledge for the first time, that the NIF will meet its laser performance design criteria, and that the NIF can simultaneously meet the temporal pulse shaping, focal-spot conditioning, and peak power requirements for two candidate indirect drive ignition designs.

Neuropsychological dysfunction following repeat concussions in jockeys.

BACKGROUND: Single and repeat concussions have a high prevalence in sport. However, there is limited research into longterm risks associated with single and repeat concussions. OBJECTIVES: To determine the effects of single and repeat historical concussions on the neuropsychological functioning and neurological reports of licensed jockeys. METHODS: Six hundred and ninety eight licensed jockeys in the UK were assessed for neurological and neuropsychological symptoms of concussion at least three months after potential episodes. RESULTS: Jockeys reporting multiple historical injuries versus a single injury showed reliable decrements on a measure of response inhibition and, to a less robust degree, on divided attention. Younger adults showed greater vulnerability. CONCLUSIONS: Repeated concussion is associated with reliable decrements in cognitive performance--even after a three month window for recent recovery.

An epidemiological study of head injuries in a UK population attending an emergency department.

We aimed to identify the attendance rate for all head injuries, and for moderate to severe head injury (MSHI), in an emergency department (ED), and related risk factors for MSHI, including age, sex, area of residence, and socioeconomic status (SES). This was a retrospective descriptive epidemiological study of an ED database of head injury attendances over 6 years, carried out in an ED that serves both urban and mixed rural and urban areas, with a wide socioeconomic range, and a total population of 344,600. The main outcome measure was rates of attendance for head injury. Head injury presentations accounted for 3.4% of all attendances per year. An overall rate of 453 per 100,000 was found for all head injuries, of which 40 per 100,000 were moderate to severe (10.9%). Urban residents had significantly greater risk of presenting with MSHI compared with residents of mixed/rural areas. Males were more at risk than females, and children and adolescents had higher risk of MSHI. A high attendance rate of MSHI was found in the <5 year old age group in urban areas for both sexes. A gradient, with higher attendance in groups with lower SES, was observed for children in urban areas, while the gradient was reversed in mixed/rural areas. Head injuries are a relatively common cause of attendance at ED. There is significant variation in attendance with MSHI with regard to sex, age, socioeconomic factors, and type of area of residence. The planning and delivery of preventative and management services may be improved by such analyses.

Off-pump coronary artery bypass grafting provides complete revascularization with reduced myocardial injury, transfusion requirements, and length of stay: a prospective randomized comparison of two hundred unselected patients undergoing off-pump versus conventional coronary artery bypass grafting.

OBJECTIVE: Retrospective comparisons of selected patients undergoing off-pump versus conventional on-pump coronary artery bypass grafting have yielded inconsistent results and raised concerns about completeness of revascularization in off-pump coronary artery bypass grafting. METHODS: Two hundred unselected patients referred for elective primary coronary artery bypass grafting were randomly assigned to undergo off-pump coronary artery bypass grafting with an Octopus tissue stabilizer (Medtronic, Inc, Minneapolis, Minn) or conventional coronary artery bypass grafting with cardiopulmonary bypass by a single surgeon. Revascularization intent determined before random assignment was compared with the revascularization performed. All management followed strict, unbiased, criteria-driven protocols. Patients and nonoperative care providers were blinded to surgical group. RESULTS: Baseline characteristics were similar. The number of grafts performed per patient (mean +/- SD 3.39 +/- 1.04 for off-pump coronary artery bypass grafting, 3.40 +/- 1.08 for conventional coronary artery bypass grafting) and the index of completeness of revascularization (number of grafts performed/number of grafts intended, 1.00 +/- 0.18 for off-pump coronary artery bypass grafting, 1.01 +/- 0.09 for conventional coronary artery bypass grafting) were similar. Likewise, the index of completeness of revascularization was similar between groups for the lateral wall. Combined hospital and 30-day mortalities and stroke rates were similar. Postoperative myocardial serum enzyme measures were significantly lower after off-pump coronary artery bypass grafting, suggesting less myocardial injury. Adjusted postoperative thromboelastogram indices, fibrinogen, international normalized ratio, and platelet levels all showed significantly less coagulopathy after off-pump coronary artery bypass grafting. Patients undergoing off-pump coronary artery bypass grafting received fewer units of blood, were more likely to avoid transfusion altogether, and had a higher hematocrit at discharge. Cardiopulmonary bypass was an independent predictor of transfusion (odds ratio 2.42, P =.0073) by multivariate analysis. More patients undergoing off-pump coronary artery bypass grafting were extubated in the operating room and within 4 hours. Postoperative length of stay (in days) was shorter for off-pump coronary artery bypass grafting (5.1 +/- 6.5 for off-pump coronary artery bypass grafting, 6.1 +/- 8.2 for conventional coronary artery bypass grafting, P =.005 by Wilcoxon test). One patient (in the conventional coronary artery bypass grafting group) required angioplasty for graft closure within 30 days. CONCLUSIONS: When compared with conventional coronary artery bypass grafting with cardiopulmonary bypass, off-pump coronary artery bypass grafting achieved similar completeness of revascularization, similar in-hospital and 30-day outcomes, shorter length of stay, reduced transfusion requirement, and less myocardial injury.

Neurorehabilitation for two cases of post-traumatic stress disorder following traumatic brain injury.

INTRODUCTION: We present two cases to illustrate the assessment and management of post-traumatic stress disorder (PtSD) in the context of traumatic brain injury (TBI). Case KE suffered a TBI in a road traffic accident (RTA) in which his girlfriend was killed. Case CM survived a penetrating neurological injury from a severe knife attack. Both suffered cognitive difficulties, primarily in attention and memory, and selective visual impairments, and had endured significant losses of social role. METHOD: Within a neurorehabilitation programme, goals were set regarding management of their cognitive difficulties for regaining social roles and for the management of their PtSD symptoms. Cognitive behavioural therapy (CBT) was provided for managing PtSD symptoms, which included use of a stress inoculation and graduated exposure to avoided situations and trauma re-experiences. RESULTS: Both survivors reported significant improvements in managing mood state, and in redeveloping social roles. Objective measures confirmed significant gains from intervention. CONCLUSIONS: CBT, set within a neurorehabilitation programme, can lead to improvement in PtSD symptoms and psychosocial outcome in TBI survivors.

Neurorehabilitation and cognitive-behaviour therapy of anxiety disorders after brain injury: An overview and a case illustration of obsessive-compulsive disorder.

Survivors of acquired and traumatic brain injuries may often experience anxiety states. Psychological reactions to neurological trauma may be caused by a complex interaction of a host of factors. We explore how anxiety states may be understood in terms of a biopsychosocial formulation of such factors. We also review the current evidence for the presence of specific anxiety disorders after brain injury. We then describe how cognitive-behaviour therapy (CBT), a treatment of choice for many anxiety disorders, may be integrated with cognitive rehabilitation (CR), for the management of anxiety disorders in brain injury. We illustrate how CBT and CR may be delivered with a case of a survivor of traumatic brain injury (TBI) who had developed obsessive compulsive disorder and health anxiety. We show how CBT plus CR allows a biopsychosocial formulation to be developed of the survivor's concerns for guiding a goal-based intervention. The survivor made significant gains from intervention in terms of goals achieved and changes on clinical measures. We argue that large-scale research is needed for developing an evidence base for managing emotional disorders in brain injury.

Brief report: prevalence of post-traumatic stress disorder symptoms after severe traumatic brain injury in a representative community sample.

PRIMARY OBJECTIVE: In this study, the authors investigated the prevalence of symptoms of post-traumatic stress disorder (PTSD) in a community sample of 66 survivors of severe traumatic brain injury (TBI). RESEARCH DESIGN, METHODS AND PROCEDURES: A representative sample of survivors of TBI were selected on the basis of having suffered significant disturbance in consciousness following their trauma event in the form of coma and/or post-traumatic amnesia. Neuropsychological testing confirmed that participants had suffered cognitive deficits consistent with severe brain injury. Participants were administered the Impact of Events inventory for symptoms of PTSD. MAIN OUTCOMES AND RESULTS: The authors found a prevalence rate of 18% for moderate-to-severe PTSD symptoms. CONCLUSIONS: PTSD symptoms are common following severe TBI. Further research is needed to establish protective and predictive factors for PTSD in TBI groups.

The Konno aortoventriculoplasty for repeat aortic valve replacement.

OBJECTIVE: To evaluate the outcome of aortic root augmentation by the Konno-aortoventriculoplasty technique as part of reoperative aortic valve replacement. METHODS: Since 1983, 15 patients, 12 males and three females, had repeat aortic valve replacement (AVR) with concomitant Konno aortoventriculoplasty. Age ranged from 1.2 to 18 years (mean 12.5 years). The underlying anatomic diagnoses were valve and subvalvar aortic stenosis in 11, truncal valve insufficiency in one, endocarditis in one, Shone's complex in one and severe aortic insufficiency associated with a ventricular septal defect in one patient. All patients had had previous AVR. The causes for reoperation were prosthetic valve stenosis due to growth in ten and paravalvular leak in one, homograft failure in two, xenograft failure in one, and left ventricular outflow tract obstruction (LVOTO) after mitral valve replacement in one patient. The mean size of explanted prostheses was 19.2 mm (13-23 mm) while the mean size of the implanted prostheses was 24.3 mm (19-27 mm) (P<0.01). Previous aortic root enlargement had been performed in 11 patients in conjunction with AVR. The Manougian technique was used previously in two, Konno aortoventriculoplasty in eight, and both techniques in one patient. The newly implanted aortic valves were a homograft in one patient and mechanical prostheses in 14 patients. RESULTS: There was one operative death (1 of 15 or 6.6%) in a 17.5 year old patient with previous AVR and posterior root enlargement, due to low cardiac output state. Follow-up ranged from 6 months to 17 years (mean 7.2 years). The only late death occurred in an 11.6-year-old patient due to prosthetic valve endocarditis. Two patients had complete heart block and had permanent pacemaker insertion (2 of 15 or 13.3%). One patient had pulmonary valve replacement because of combined stenosis and insufficiency 5 years after operation. All 13-surviving patients are asymptomatic at latest follow up. CONCLUSION: Konno aortoventriculoplasty with repeat AVR may be safely performed. Excellent results may be achieved despite previous aortic root enlargement. It is a good surgical option for complex LVOTO and may even reduce reoperation in children by allowing placement of a larger prosthesis.

Advances in imaging of lymph flow disorders.

Conventional oil-contrast lymphography has long been the mainstay for lymphatic imaging. However, the emergence of computed tomography (CT) and magnetic resonance (MR) imaging has severely curtailed its use. Because of recent improvements and refinements, lymphangioscintigraphy now permits high-resolution imaging of peripheral lymphatic vessels and provides insight into lymph flow dynamics. It is indispensable for patients with known or suspected lymphatic circulatory disorders in confirming the diagnosis and delineating the pathogenesis and evolution of lymphedema. In addition, lymphangioscintigraphy helps evaluate lymphatic truncal anatomy and radiotracer transport. It can also be used to evaluate the efficacy of various treatment options designed to facilitate lymph flow or reduce lymph formation. The procedure is essentially noninvasive, can easily be repeated, and does not adversely affect the lymphatic vascular endothelium. MR imaging complements lymphangioscintigraphy in the monitoring and treatment of more complex lymphatic circulatory disorders, whereas CT facilitates catheter-guided percutaneous sclerosis or obliteration of specific lymphangiectasia or lymphangioma syndromes. Ultrasonography has proved useful in the setting of filariasis. Patients with a provisional diagnosis of peripheral lymphatic dysfunction or idiopathic edema should undergo diagnostic lymphangioscintigraphy and, in some cases, MR imaging to verify diagnostic accuracy, pinpoint the specific abnormality, and help guide subsequent therapy.

Extra-anatomic aortic bypass via sternotomy for complex aortic arch stenosis in children.

OBJECTIVE: Recurrent aortic narrowing after repair of aortic coarctation or interrupted aortic arch, as well as diffuse, long-segment aortic hypoplasia, can be difficult to manage. Extra-anatomic ascending aorta-descending aorta bypass grafting through a sternotomy is an alternative approach for this problem. METHODS: Since 1985, 19 patients aged 2 months to 18 years (mean 10.7 years) underwent extra-anatomic bypass with 10- to 30-mm Dacron grafts. The initial diagnosis was coarctation with hypoplastic arch in 15, interrupted aortic arch in 3, and diffuse long-segment aortic hypoplasia in 1. Seventeen of the children had a total of 22 previous operations: transthoracic interposition or bypass graft (n = 7), end-to-end anastomosis (n = 7), subclavian arterioplasty (n = 6), and synthetic patch (n = 2). The mean time from initial repair was 8.0 years (range 0.6-18 years). Three children had previous sternotomies. Cardiopulmonary bypass was avoided in all but 6 patients (5 with simultaneous intracardiac repairs). RESULTS: No hospital or late deaths occurred. On follow-up from 4 months to 14.7 years (mean 7.9 years), no reoperations for recurrent stenosis were performed. Two patients have arm-to-leg pressure gradients: 20 mm Hg at rest in 1 patient and a 60-mm Hg systolic exercise gradient with no resting gradient in the other. One patient required exclusion of an aortic aneurysm at the old coarctation repair site 13 years after extra-anatomic bypass. Three children had subsequent successful cardiac operations. CONCLUSIONS: Extra-anatomic bypass is an effective and relatively easy approach for selected cases of complex or reoperative aortic arch obstruction. It should be considered as an alternative operative technique for complex aortic arch reconstruction.

Simultaneous irradiation for prostate cancer: intermediate results with modern techniques.

PURPOSE: In this study of men with early stage prostate cancer we evaluated treatment outcome after modern simultaneous irradiation, comprising transperineal implantation followed by external beam radiation. Disease-free survival rates were calculated according to an undetectable prostate specific antigen (PSA) nadir. MATERIALS AND METHODS: From 1992 to 1996, 689 men with clinical stage T1-T2, N0, Nx prostate cancer were treated with ultrasound guided transperineal 125iodine seed implantation followed 3 weeks later by external beam radiation. Disease-free status was defined as the achievement and maintenance of a PSA nadir of 0.2 ng./ml. or less. Median followup was 4 years (range 3 to 7). None of these men received neoadjuvant or adjuvant hormonal therapy. RESULTS: Overall 5-year disease-free survival was 88%. The 5-year rate according to PSA 4.0 ng./ml. or less, 4.1 to 10.0, 10.1 to 20.0 and greater than 20.0 was 94%, 93%, 75% and 69%, respectively. Multivariate analysis revealed that pretreatment PSA was the strongest indicator of subsequent disease-free status in regard to Gleason score or clinical stage. CONCLUSIONS: Intermediate treatment outcome analysis of modern simultaneous radiation supports the principles of radiation dose intensification for intracapsular disease plus the treatment of potential microscopic capsular penetration.

Radionuclide lymphangioscintigraphy in the evaluation of peripheral lymphedema.

PURPOSE: The primary difficulty in evaluating and treating peripheral lymphedema is visualization of the lymphatics. Functional lymphatic studies have been performed on patients with peripheral edema to diagnose lymphedema, to determine its severity, and to understand the varied drainage patterns. METHODS: After intradermal injection in the hands or feet, initial flow and whole-body images were taken using Tc-99m human serum albumin in more than 700 patients with possible lymphedema. RESULTS: Clear images of truncal lymph transport and draining lymph nodes were obtained, and pattern differences between primary and secondary lymphedema were seen. Follow-up studies showed any functional change in lymphatic dynamics. CONCLUSION: Peripheral lymphatics can now be easily visualized. Because lymphangioscintigraphy can be performed before and after medical treatment, follow-up evaluation of patients with lymphedema is possible. The procedure is noninvasive, repeatable, easy to perform, and harmless to the lymphatic endothelium.

Prostate specific antigen bounce after radioactive seed implantation followed by external beam radiation for prostate cancer.

PURPOSE: Prostate specific antigen (PSA) may temporarily increase following radiotherapy for prostate cancer without signaling cancer recurrence. We describe this phenomenon which is called PSA bounce. MATERIALS AND METHODS: From 1984 to 1995, 779 stage T1T2N0 cancer cases were treated with simultaneous radiotherapy with a 125iodine prostate implant followed by external beam radiation. Median pretreatment PSA was 7.7 ng./ml. (range 0.3 to 188). PSA bounce was defined as an increase of 0.1 ng./ml. or greater above the preceding PSA level after simultaneous radiation followed by a subsequent decrease below that level. Disease-free status was defined as the ability to achieve and maintain posttreatment PSA 0.2 ng./ml. or less. RESULTS: PSA bounce was observed in 35% of men (273 of 779). Median time to PSA bounce was 18 months from the time of implant and 92% of bounces were observed within 36 months. Median pre-bounce PSA was 0.7 ng/ml. (range 0.1 to 8.9) and median bounce height (increase above the pre-bounce level) was 0.4 ng./ml. (range 0.1 to 15.8). No distinguishing characteristics were observed between men with PSA bounce and those with cancer recurrence, and bounce had no prognostic significance relative to recurrence. CONCLUSIONS: PSA bounce is common following seed implantation for prostate cancer. It produces anxiety in men previously treated for prostate cancer and confounds the diagnosis of recurrence.

Nutritional therapies for ulcerative colitis: literature review, chart review study, and future research.

Few clinical studies suggest a significant influence of diet or nutritional supplementation on ulcerative colitis. One reason is that ulcerative colitis, like many chronic diseases, is multifactorial. This article will describe and review the relevant literature on ulcerative colitis, including studies of (1) diet and intravenous therapy, (2) nutritional status and nutritional supplementation, and (3) bowel flora and immune function and their influences. Also, results of a retrospective chart review study that was done at a complementary medicine office will be presented. Finally, suggestions for future research will be discussed based on a nutritional model of ulcerative colitis. Taken together, it is hoped that these areas will clarify the current status of ulcerative colitis research and promote the types of investigations that are necessary to establish the validity of nutritional influences on ulcerative colitis as well as the mechanisms that are involved.