Publications by authors named "Olli Tenovuo"

86 Publications

Editorial: Biomarkers of Brain Damage - A Complex Challenge With Great Potential.

Front Neurol 2021 18;12:664445. Epub 2021 Mar 18.

Department of Anesthesiology and Intensive Care, Hallands Hospital Halmstad, Lund University, Lund, Sweden.

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http://dx.doi.org/10.3389/fneur.2021.664445DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8012542PMC
March 2021

Unmet Rehabilitation Needs after Traumatic Brain Injury across Europe: Results from the CENTER-TBI Study.

J Clin Med 2021 Mar 3;10(5). Epub 2021 Mar 3.

Institute of Medical Psychology and Medical Sociology, University Medical Center Göttingen, 37073 Göttingen, Germany.

This study aims to assess rehabilitation needs and provision of rehabilitation services for individuals with moderate-to-severe disability and investigate factors influencing the probability of receiving rehabilitation within six months after traumatic brain injury (TBI). Overall, the analyses included 1206 individuals enrolled in the CENTER-TBI study with severe-to-moderate disability. Impairments in five outcome domains (daily life activities, physical, cognition, speech/language, and psychological) and the use of respective rehabilitation services (occupational therapy, physiotherapy, cognitive and speech therapies, and psychological counselling) were recorded. Sociodemographic and injury-related factors were used to investigate the probability of receiving rehabilitation. Physiotherapy was the most frequently provided rehabilitation service, followed by speech and occupational therapy. Psychological counselling was the least frequently accessed service. The probability of receiving a rehabilitative intervention increased for individuals with greater brain injury severity (odds ratio (OR) 1.75, CI 95%: 1.27-2.42), physical (OR 1.92, CI 95%: 1.21-3.05) and cognitive problems (OR 4.00, CI 95%: 2.34-6.83) but decreased for individuals reporting psychological problems (OR 0.57, CI 95%: 1.21-3.05). The study results emphasize the need for more extensive prescription of rehabilitation services for individuals with disability. Moreover, targeted rehabilitation programs, which aim to improve outcomes, should specifically involve psychological services to meet the needs of individuals recovering from TBI.
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http://dx.doi.org/10.3390/jcm10051035DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7959119PMC
March 2021

Assessing the Severity of Traumatic Brain Injury-Time for a Change?

J Clin Med 2021 Jan 4;10(1). Epub 2021 Jan 4.

Concussion Care Centre of Virginia and Tree of Life, Richmond, VA 23233, USA.

Traumatic brain injury (TBI) has been described to be man's most complex disease, in man's most complex organ. Despite this vast complexity, variability, and individuality, we still classify the severity of TBI based on non-specific, often unreliable, and pathophysiologically poorly understood measures. Current classifications are primarily based on clinical evaluations, which are non-specific and poorly predictive of long-term disability. Brain imaging results have also been used, yet there are multiple ways of doing brain imaging, at different timepoints in this very dynamic injury. Severity itself is a vague concept. All prediction models based on combining variables that can be assessed during the acute phase have reached only modest predictive values for later outcome. Yet, these early labels of severity often determine how the patient is treated by the healthcare system at large. This opinion paper examines the problems and provides caveats regarding the use of current severity labels and the many practical and scientific issues that arise from doing so. The objective of this paper is to show the causes and consequences of current practice and propose a new approach based on risk classification. A new approach based on multimodal quantifiable data (including imaging and biomarkers) and risk-labels would be of benefit both for the patients and for TBI clinical research and should be a priority for international efforts in the field.
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http://dx.doi.org/10.3390/jcm10010148DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7795933PMC
January 2021

Care transitions in the first 6 months following traumatic brain injury: Lessons from the CENTER-TBI study.

Ann Phys Rehabil Med 2020 Nov 24. Epub 2020 Nov 24.

Department of Physical Medicine and Rehabilitation, Oslo University Hospital, Oslo, Norway; Faculty of Medicine, Institute of Health and Society, Research Centre for Habilitation and Rehabilitation Models and Services (CHARM), University of Oslo, Oslo, Norway.

Background: No large international studies have investigated care transitions during or after acute hospitalisations for traumatic brain injury (TBI).

Objectives: To characterise various TBI-care pathways and the number of associated transitions during the first 6 months after TBI and to assess the impact of these on functional TBI outcome controlled for demographic and injury-related factors.

Methods: This was a cohort study of patients with TBI admitted to various trauma centres enrolled in the Collaborative European NeuroTrauma Effectiveness Research in TBI (CENTER-TBI) study. Number of transitions and specific care pathways were identified. Multiple logistic regression analyses were used to assess the impact of number of transitions and care pathways on functional outcome at 6 months post-injury as assessed by the Glasgow Outcome Scale-Extended (GOSE).

Results: In total, 3133 patients survived the acute TBI-care pathway and had at least one documented in-hospital transition at 6-month follow-up. The median number of transitions was 3 (interquartile range 2-3). The number of transitions did not predict functional outcome at 6 months (odds ratio 1.08, 95% confidence interval 1.09-1.18; p = 0.063). A total of 378 different care pathways were identified; 8 were identical for at least 100 patients and characterized as "common pathways". Five of these common care pathways predicted better functional outcomes at 6 months, and the remaining 3 pathways were unrelated to outcome. In both models, increased age, violence as the cause of injury, pre-injury presence of systemic disease, both intracranial and overall injury severity, and regions of Southern/Eastern Europe were associated with unfavourable functional outcomes at 6 months.

Conclusions: A high number of different and complex care pathways was found for patients with TBI, particularly those with severe injuries. This high number and variety of care pathway possibilities indicates a need for standardisation and development of "common data elements for TBI care pathways" for future studies.

Study Registration: ClinicalTrials.gov NCT02210221.
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http://dx.doi.org/10.1016/j.rehab.2020.10.009DOI Listing
November 2020

Admission Levels of Interleukin 10 and Amyloid β 1-40 Improve the Outcome Prediction Performance of the Helsinki Computed Tomography Score in Traumatic Brain Injury.

Front Neurol 2020 30;11:549527. Epub 2020 Oct 30.

Department of Specialities of Internal Medicine, Faculty of Medicine, University of Geneva, Geneva, Switzerland.

Blood biomarkers may enhance outcome prediction performance of head computed tomography scores in traumatic brain injury (TBI). To investigate whether admission levels of eight different protein biomarkers can improve the outcome prediction performance of the Helsinki computed tomography score (HCTS) without clinical covariates in TBI. Eighty-two patients with computed tomography positive TBIs were included in this study. Plasma levels of β-amyloid isoforms 1-40 (Aβ40) and 1-42 (Aβ42), glial fibrillary acidic protein, heart fatty acid-binding protein, interleukin 10 (IL-10), neurofilament light, S100 calcium-binding protein B, and total tau were measured within 24 h from admission. The patients were divided into favorable (Glasgow Outcome Scale-Extended 5-8, = 49) and unfavorable (Glasgow Outcome Scale-Extended 1-4, = 33) groups. The outcome was assessed 6-12 months after injury. An optimal predictive panel was investigated with the sensitivity set at 90-100%. The HCTS alone yielded a sensitivity of 97.0% (95% CI: 90.9-100) and specificity of 22.4% (95% CI: 10.2-32.7) and partial area under the curve of the receiver operating characteristic of 2.5% (95% CI: 1.1-4.7), in discriminating patients with favorable and unfavorable outcomes. The threshold to detect a patient with unfavorable outcome was an HCTS > 1. The three best individually performing biomarkers in outcome prediction were Aβ40, Aβ42, and neurofilament light. The optimal panel included IL-10, Aβ40, and the HCTS reaching a partial area under the curve of the receiver operating characteristic of 3.4% (95% CI: 1.7-6.2) with a sensitivity of 90.9% (95% CI: 81.8-100) and specificity of 59.2% (95% CI: 40.8-69.4). Admission plasma levels of IL-10 and Aβ40 significantly improve the prognostication ability of the HCTS after TBI.
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http://dx.doi.org/10.3389/fneur.2020.549527DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7661930PMC
October 2020

Volume Change in Frontal Cholinergic Structures After Traumatic Brain Injury and Cognitive Outcome.

Front Neurol 2020 13;11:832. Epub 2020 Aug 13.

Division of Clinical Neurosciences, Turku Brain Injury Centre, Turku University Hospital, Turku, Finland.

The cholinergic nuclei in the basal forebrain innervate frontal cortical structures regulating attention. Our aim was to investigate if cognitive test results measuring attention relate to the longitudinal volume change of cholinergically innervated structures following traumatic brain injury (TBI). During the prospective, observational TBIcare project patients with all severities of TBI ( = 114) and controls with acute orthopedic injuries ( = 17) were recruited. Head MRI was obtained in both acute (mean 2 weeks post-injury) and late (mean 8 months) time points. T1-weighted 3D MR images were analyzed with an automatic segmentation method to evaluate longitudinal, structural brain volume change. The cognitive outcome was assessed with the Cambridge Neuropsychological Test Automated Battery (CANTAB). Analyses included 16 frontal cortical structures, of which four showed a significant correlation between post-traumatic volume change and the CANTAB test results. The strongest correlation was found between the volume loss of the supplementary motor cortex and motor screening task results (R-sq 0.16, < 0.0001), where poorer test results correlated with greater atrophy. Of the measured sum structures, greater cortical gray matter atrophy rate showed a significant correlation with the poorer CANTAB test results. TBI caused volume loss of frontal cortical structures that are heavily innervated by cholinergic neurons is associated with neuropsychological test results measuring attention.
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http://dx.doi.org/10.3389/fneur.2020.00832DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7438550PMC
August 2020

Predictors of Access to Rehabilitation in the Year Following Traumatic Brain Injury: A European Prospective and Multicenter Study.

Neurorehabil Neural Repair 2020 09 7;34(9):814-830. Epub 2020 Aug 7.

Raymond Poincaré Hospital, AP-HP, Garches, France.

Background: Although rehabilitation is beneficial for individuals with traumatic brain injury (TBI), a significant proportion of them do not receive adequate rehabilitation after acute care.

Objective: Therefore, the goal of this prospective and multicenter study was to investigate predictors of access to rehabilitation in the year following injury in patients with TBI.

Methods: Data from a large European study (CENTER-TBI), including TBIs of all severities between December 2014 and December 2017 were used (N = 4498 patients). Participants were dichotomized into those who had and those who did not have access to rehabilitation in the year following TBI. Potential predictors included sociodemographic factors, psychoactive substance use, preinjury medical history, injury-related factors, and factors related to medical care, complications, and discharge.

Results: In the year following traumatic injury, 31.4% of patients received rehabilitation services. Access to rehabilitation was positively and significantly predicted by female sex (odds ratio [OR] = 1.50), increased number of years of education completed (OR = 1.05), living in Northern (OR = 1.62; reference: Western Europe) or Southern Europe (OR = 1.74), lower prehospital Glasgow Coma Scale score (OR = 1.03), higher Injury Severity Score (OR = 1.01), intracranial (OR = 1.33) and extracranial (OR = 1.99) surgery, and extracranial complication (OR = 1.75). On contrast, significant negative predictors were lack of preinjury employment (OR = 0.80), living in Central and Eastern Europe (OR = 0.42), and admission to hospital ward (OR = 0.47; reference: admission to intensive care unit) or direct discharge from emergency room (OR = 0.24).

Conclusions: Based on these findings, there is an urgent need to implement national and international guidelines and strategies for access to rehabilitation after TBI.
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http://dx.doi.org/10.1177/1545968320946038DOI Listing
September 2020

Alterations in Microstructure and Local Fiber Orientation of White Matter Are Associated with Outcome after Mild Traumatic Brain Injury.

J Neurotrauma 2020 12 17;37(24):2616-2623. Epub 2020 Aug 17.

Department of Clinical Neurosciences, Intensive Care, Emergency Care and Pain Medicine, University of Turku, Turku, Finland.

Mild traumatic brain injury (mTBI) can have long-lasting consequences. We investigated white matter (WM) alterations at 6-12 months following mTBI using diffusion tensor imaging (DTI) and assessed if the alterations associate with outcome. Eighty-five patients with mTBI underwent diffusion-weighted magnetic resonance imaging (MRI) on average 8 months post-injury and patients' outcome was assessed at the time of imaging using the Glasgow Outcome Scale-Extended (GOS-E). Additionally, 30 age-matched patients with extracranial orthopedic injuries were used as control subjects. Voxel-wise analysis of the data was performed using a tract-based spatial statistics (TBSS) approach and differences in microstructural metrics between groups were investigated. Further, the susceptibility of the abnormalities to specific fiber orientations was investigated by analyzing the first eigenvector of the diffusion tensor in the voxels with significant differences. We found significantly lower fractional anisotropy (FA) and higher mean diffusivity (MD) and radial diffusivity (RD) in patients with mTBI compared with control subjects, whereas no significant differences were observed in axial diffusivity (AD) between the groups. The differences were present bilaterally in several WM regions and correlated with outcome. Moreover, multiple clusters were found in the principal fiber orientations of the significant voxels in anisotropy, and similar orientation patterns were found for the diffusivity metrics. These directional clusters correlated with patients' functional outcome. Our study showed that mTBI is associated with WM changes at the chronic stage and these alterations occur in several WM regions. In addition, several significant clusters of WM alterations in specific fiber orientations were found and these clusters were associated with outcome.
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http://dx.doi.org/10.1089/neu.2020.7081DOI Listing
December 2020

Interleukin 10 and Heart Fatty Acid-Binding Protein as Early Outcome Predictors in Patients With Traumatic Brain Injury.

Front Neurol 2020 2;11:376. Epub 2020 Jun 2.

Department of Specialities of Internal Medicine, Faculty of Medicine, University of Geneva, Geneva, Switzerland.

Patients with traumatic brain injury (TBI) exhibit a variable and unpredictable outcome. The proteins interleukin 10 (IL-10) and heart fatty acid-binding protein (H-FABP) have shown predictive values for the presence of intracranial lesions. To evaluate the individual and combined outcome prediction ability of IL-10 and H-FABP, and to compare them to the more studied proteins S100β, glial fibrillary acidic protein (GFAP), and neurofilament light (NF-L), both with and without clinical predictors. Blood samples from patients with acute TBI (all severities) were collected <24 h post trauma. The outcome was measured >6 months post injury using the Glasgow Outcome Scale Extended (GOSE) score, dichotomizing patients into: (i) those with favorable (GOSE≥5)/unfavorable outcome (GOSE ≤ 4) and complete (GOSE = 8)/incomplete (GOSE ≤ 7) recovery, and (ii) patients with mild TBI (mTBI) and patients with TBIs of all severities. When sensitivity was set at 95-100%, the proteins' individual specificities remained low. H-FABP showed the best specificity (%) and sensitivity (100%) in predicting complete recovery in patients with mTBI. IL-10 had the best specificity (50%) and sensitivity (96%) in identifying patients with favorable outcome in patients with TBIs of all severities. When individual proteins were combined with clinical parameters, a model including H-FABP, NF-L, and ISS yielded a specificity of 56% and a sensitivity of 96% in predicting complete recovery in patients with mTBI. In predicting favorable outcome, a model consisting IL-10, age, and TBI severity reached a specificity of 80% and a sensitivity of 96% in patients with TBIs of all severities. Combining novel TBI biomarkers H-FABP and IL-10 with GFAP, NF-L and S100β and clinical parameters improves outcome prediction models in TBI.
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http://dx.doi.org/10.3389/fneur.2020.00376DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7280446PMC
June 2020

Mild traumatic brain injury recovery: a growth curve modelling analysis over 2 years.

J Neurol 2020 Nov 13;267(11):3223-3234. Epub 2020 Jun 13.

Division of Anaesthesia, Department of Medicine, University of Cambridge, Cambridge, UK.

Background: An improved understanding of the trajectory of recovery after mild traumatic brain injury is important to be able to understand individual patient outcomes, for longitudinal patient care and to aid the design of clinical trials.

Objective: To explore changes in health, well-being and cognition over the 2 years following mTBI using latent growth curve (LGC) modelling.

Methods: Sixty-one adults with mTBI presenting to a UK Major Trauma Centre completed comprehensive longitudinal assessment at up to five time points after injury: 2 weeks, 3 months, 6 months, 1 year and 2 years.

Results: Persisting problems were seen with neurological symptoms, cognitive issues and poor quality of life measures including 28% reporting incomplete recovery on the Glasgow Outcome Score Extended at 2 years. Harmful drinking, depression, psychological distress, disability, episodic memory and working memory did not improve significantly over the 2 years following injury. For other measures, including the Rivermead Post-Concussion Symptoms and Quality of Life after Brain Injury (QOLIBRI), LGC analysis revealed significant improvement over time with recovery tending to plateau at 3-6 months.

Interpretation: Significant impairment may persist as late as 2 years after mTBI despite some recovery over time. Longitudinal analyses which make use of all available data indicate that recovery from mTBI occurs over a longer timescale than is commonly believed. These findings point to the need for long-term management of mTBI targeting individuals with persisting impairment.
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http://dx.doi.org/10.1007/s00415-020-09979-xDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7578150PMC
November 2020

Admission Levels of Total Tau and β-Amyloid Isoforms 1-40 and 1-42 in Predicting the Outcome of Mild Traumatic Brain Injury.

Front Neurol 2020 13;11:325. Epub 2020 May 13.

Division of Clinical Neurosciences, Department of Neurosurgery, Turku University Hospital, Turku, Finland.

The purpose of this study was to investigate if admission levels of total tau (T-tau) and β-amyloid isoforms 1-40 (Aβ40) and 1-42 (Aβ42) could predict clinical outcome in patients with mild traumatic brain injury (mTBI). A total of 105 patients with mTBI [Glasgow Coma Scale (GCS) ≥ 13] recruited in Turku University Hospital, Turku, Finland were included in this study. Blood samples were drawn within 24 h of admission for analysis of plasma T-tau, Aβ40, and Aβ42. Patients were divided into computed tomography (CT)-positive and CT-negative groups. The outcome was assessed 6-12 months after the injury using the Extended Glasgow Outcome Scale (GOSE). Outcomes were defined as complete (GOSE 8) or incomplete (GOSE < 8) recovery. The Rivermead Post Concussion Symptoms Questionnaire (RPCSQ) was also used to assess mTBI-related symptoms. Predictive values of the biomarkers were analyzed independently, in panels and together with clinical parameters. The admission levels of plasma T-tau, Aβ40, and Aβ42 were not significantly different between patients with complete and incomplete recovery. The levels of T-tau, Aβ40, and Aβ42 could poorly predict complete recovery, with areas under the receiver operating characteristic curve 0.56, 0.52, and 0.54, respectively. For the whole cohort, there was a significant negative correlation between the levels of T-tau and ordinal GOSE score (Spearman ρ = -0.231, = 0.018). In a multivariate logistic regression model including age, GCS, duration of posttraumatic amnesia, Injury Severity Score (ISS), time from injury to sampling, and CT findings, none of the biomarkers could predict complete recovery independently or together with the other two biomarkers. Plasma levels of T-tau, Aβ40, and Aβ42 did not significantly differ between the outcome groups either within the CT-positive or CT-negative subgroups. Levels of Aβ40 and Aβ42 did not significantly correlate with outcome, but in the CT-positive subgroup, the levels of T-tau significantly correlated with ordinal GOSE score (Spearman ρ = -0.288, = 0.035). The levels of T-tau, Aβ40, and Aβ42 were not correlated with the RPCSQ scores. The early levels of T-tau are correlated with the outcome in patients with mTBI, but none of the biomarkers either alone or in any combinations could predict complete recovery in patients with mTBI.
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http://dx.doi.org/10.3389/fneur.2020.00325DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7237639PMC
May 2020

Influence of Concomitant Extracranial Injury on Functional and Cognitive Recovery From Mild Versus Moderateto Severe Traumatic Brain Injury.

J Head Trauma Rehabil 2020 Nov/Dec;35(6):E513-E523

University Division of Anaesthesia, Department of Medicine (Drs Carroll, Menon, and Newcombe and Mss Manktelow, Outtrim, Chatfield, and Forsyth), Academic Department of Neurosurgery, Department of Clinical Neurosciences (Dr Hutchinson), Wolfson Brain Imaging Centre, Department of Clinical Neurosciences (Drs Sahakian, Menon, and Newcombe), Department of Psychiatry (Dr Sahakian), and Behavioural & Clinical Neuroscience Institute (Dr Sahakian), University of Cambridge, Cambridge, United Kingdom; Turku Brain Injury Center, University of Turku, Turku, Finland (Drs Tenovuo and Posti); Turku University Hospital, Turku, Finland (Drs Tenovuo and Posti); Department of Neurosurgery, Turku University Hospital, Turku, Finland (Dr Posti); and Division of Psychology, University of Stirling, Stirling, United Kingdom (Dr Wilson).

Objective: To determine the effect of extracranial injury (ECI) on 6-month outcome in patients with mild traumatic brain injury (TBI) versus moderate-to-severe TBI.

Participants/setting: Patients with TBI (n = 135) or isolated orthopedic injury (n = 25) admitted to a UK major trauma center and healthy volunteers (n = 99).

Design: Case-control observational study.

Main Measures: Primary outcomes: (a) Glasgow Outcome Scale Extended (GOSE), (b) depression, (c) quality of life (QOL), and (d) cognitive impairment including verbal fluency, episodic memory, short-term recognition memory, working memory, sustained attention, and attentional flexibility.

Results: Outcome was influenced by both TBI severity and concomitant ECI. The influence of ECI was restricted to mild TBI; GOSE, QOL, and depression outcomes were significantly poorer following moderate-to-severe TBI than after isolated mild TBI (but not relative to mild TBI plus ECI). Cognitive impairment was driven solely by TBI severity. General health, bodily pain, semantic verbal fluency, spatial recognition memory, working memory span, and attentional flexibility were unaffected by TBI severity and additional ECI.

Conclusion: The presence of concomitant ECI ought to be considered alongside brain injury severity when characterizing the functional and neurocognitive effects of TBI, with each presenting challenges to recovery.
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http://dx.doi.org/10.1097/HTR.0000000000000575DOI Listing
May 2020

Integrative Analysis of Circulating Metabolite Profiles and Magnetic Resonance Imaging Metrics in Patients with Traumatic Brain Injury.

Int J Mol Sci 2020 Feb 19;21(4). Epub 2020 Feb 19.

School of Medical Sciences, Örebro University, 702 81 Örebro, Sweden.

Recent evidence suggests that patients with traumatic brain injuries (TBIs) have a distinct circulating metabolic profile. However, it is unclear if this metabolomic profile corresponds to changes in brain morphology as observed by magnetic resonance imaging (MRI). The aim of this study was to explore how circulating serum metabolites, following TBI, relate to structural MRI (sMRI) findings. Serum samples were collected upon admission to the emergency department from patients suffering from acute TBI and metabolites were measured using mass spectrometry-based metabolomics. Most of these patients sustained a mild TBI. In the same patients, sMRIs were taken and volumetric data were extracted (138 metrics). From a pool of 203 eligible screened patients, 96 met the inclusion criteria for this study. Metabolites were summarized as eight clusters and sMRI data were reduced to 15 independent components (ICs). Partial correlation analysis showed that four metabolite clusters had significant associations with specific ICs, reflecting both the grey and white matter brain injury. Multiple machine learning approaches were then applied in order to investigate if circulating metabolites could distinguish between positive and negative sMRI findings. A logistic regression model was developed, comprised of two metabolic predictors (erythronic acid and -inositol), which, together with neurofilament light polypeptide (NF-L), discriminated positive and negative sMRI findings with an area under the curve of the receiver-operating characteristic of 0.85 (specificity = 0.89, sensitivity = 0.65). The results of this study show that metabolomic analysis of blood samples upon admission, either alone or in combination with protein biomarkers, can provide valuable information about the impact of TBI on brain structural changes.
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http://dx.doi.org/10.3390/ijms21041395DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7073036PMC
February 2020

Randomized Controlled Trials of Rehabilitation Services in the Post-acute Phase of Moderate and Severe Traumatic Brain Injury - A Systematic Review.

Front Neurol 2019 6;10:557. Epub 2019 Jun 6.

Department of Physical Medicine and Rehabilitation, Oslo University Hospital Ulleval, Oslo, Norway.

There is a gap in knowledge regarding effective rehabilitation service delivery in the post-acute phase after traumatic brain injury (TBI). Recently, Gutenbrunner et al. proposed a classification system for health-related rehabilitation services (International Classification System for Service Organization in Health-related Rehabilitation, ICSO-R) that could be useful for contrasting and comparing rehabilitation services. The ICSO-R describes the dimensions of Provision (i.e., context of delivered services), Funding (i.e., sources of income and refunding), and Delivery (i.e., mode, structure and intensity) at the meso-level of services. We aim to: -Provide an overview of randomized, controlled trials (RCTs) with rehabilitation service relevance provided to patients with moderate and severe TBI in the post-acute phase using the ICSO-R as a framework; and -Evaluate the extent to which the provision, funding and delivery dimensions of rehabilitation services were addressed and differed between the intervention arms in these studies. A systematic literature search was performed in OVID MEDLINE, EMBASE, CINHAL, PsychINFO, and CENTRAL, including multidisciplinary rehabilitation interventions with RCT designs and service relevance targeting moderate and severe TBI in the post-acute phase. 23 studies with 4,644 TBI patients were included. More than two-thirds of the studies were conducted in a hospital-based rehabilitation setting. The contrast in Context between the intervention arms often co-varied with Resources. The funding of the services was explicitly described in only one study. Aspects of the Delivery dimension were described in all of the studies, and the Mode of Production, Intensity, Aspects of Time and Peer Support were contrasted in the intervention arms in several of the studies. A wide variety of outcome measures were applied often covering Body function, as well as the Activities and Participation domains of the International Classification of Functioning, Disability, and Health (ICF). Aspects of service organization and resources as well as delivery may clearly influence outcome of rehabilitation. Presently, lack of uniformity of data and collection methods, the heterogeneity of structures and processes of rehabilitation services, and a lack of common outcome measurements make comparisons between the studies difficult. Standardized descriptions of services by ICSO-R, offer the possibility to improve comparability in the future and thus enhance the relevance of rehabilitation studies.
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http://dx.doi.org/10.3389/fneur.2019.00557DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6563754PMC
June 2019

Serum Neurofilament Light Is Elevated Differentially in Older Adults with Uncomplicated Mild Traumatic Brain Injuries.

J Neurotrauma 2019 08 23;36(16):2400-2406. Epub 2019 Apr 23.

6Department of Neurosurgery, Tampere University Hospital and University of Tampere, Tampere, Finland.

Neurofilament light (NF-L) might have diagnostic and prognostic potential as a blood biomarker for mild traumatic brain injury (mTBI). However, elevated NF-L is associated with several neurological disorders associated with older age, which could confound its usefulness as a traumatic brain injury biomarker. We examined whether NF-L is elevated differentially following uncomplicated mTBI in older adults with pre-injury neurological disorders. In a case-control study, a sample of 118 adults (mean age = 62.3 years, standard deviation [SD] = 22.5, range = 18-100; 52.5% women) presenting to the emergency department (ED) with an uncomplicated mTBI were enrolled. All participants underwent head computed tomography in the ED and showed no macroscopic evidence of injury. The mean time between injury and blood sampling was 8.3 h (median [Md] = 3.5; SD = 13.5; interquartile range [IQR] = 1.9-6.0, range = 0.8-67.4, and 90% collected within 19 h). A sample of 40 orthopedically-injured trauma control subjects recruited from a second ED also were examined. Serum NF-L levels were measured and analyzed using Human Neurology 4-Plex A assay on a HD-1 Single Molecule Array (Simoa) instrument. A high correlation was found between age and NF-L levels in the total mTBI sample (r = 0.80), within the subgroups without pre-injury neurological diseases (r = 0.76) and with pre-injury neurological diseases (r = 0.68), and in the trauma control subjects (r = 0.76). Those with mTBIs and pre-injury neurological conditions had higher NF-L levels than those with no pre-injury neurological conditions ( < 0.001, Cohen's d = 1.01). Older age and pre-injury neurological diseases are associated with elevated serum NF-L levels in patients with head trauma and in orthopedically-injured control subjects.
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http://dx.doi.org/10.1089/neu.2018.6341DOI Listing
August 2019

Correlation of Blood Biomarkers and Biomarker Panels with Traumatic Findings on Computed Tomography after Traumatic Brain Injury.

J Neurotrauma 2019 07 5;36(14):2178-2189. Epub 2019 Apr 5.

13 Department of Psychiatry and Neurochemistry, Sahlgrenska Academy at the University of Gothenburg, Mölndal, Sweden.

The aim of the study was to examine the ability of eight protein biomarkers and their combinations in discriminating computed tomography (CT)-negative and CT-positive patients with traumatic brain injury (TBI), utilizing highly sensitive immunoassays in a well-characterized cohort. Blood samples were obtained from 160 patients with acute TBI within 24 h of admission. Levels of β-amyloid isoforms 1-40 (Aβ40) and 1-42 (Aβ42), glial fibrillary acidic protein (GFAP), heart fatty-acid binding protein (H-FABP), interleukin 10 (IL-10), neurofilament light (NF-L), S100 calcium-binding protein B (S100B), and tau were measured. Patients were divided into CT-negative ( = 65) and CT-positive ( = 95), and analyses were conducted separately for TBIs of all severities (Glasgow Coma Scale [GCS] score 3-15) and mild TBIs (mTBIs; GCS 13-15). NF-L, GFAP, and tau were the best in discriminating CT-negative and CT-positive patients, both in patients with mTBI and with all severities. In patients with all severities, area under the curve of the receiver operating characteristic (AUC) was 0.822, 0.817, and 0.781 for GFAP, NF-L, and tau, respectively. In patients with mTBI, AUC was 0.720, 0.689, and 0.676, for GFAP, tau, and NF-L, respectively. The best panel of three biomarkers for discriminating CT-negative and CT-positive patients in the group of all severities was a combination of GFAP+H-FABP+IL-10, with a sensitivity of 100% and specificity of 38.5%. In patients with mTBI, the best panel of three biomarkers was H-FABP+S100B+tau, with a sensitivity of 100% and specificity of 46.4%. Panels of biomarkers outperform individual biomarkers in separating CT-negative and CT-positive patients. Panels consisted mainly of different biomarkers than those that performed best as an individual biomarker.
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http://dx.doi.org/10.1089/neu.2018.6254DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6909751PMC
July 2019

Risk Factors for Recurrent Hematoma After Surgery for Acute Traumatic Subdural Hematoma.

World Neurosurg 2019 Jan 10. Epub 2019 Jan 10.

Division of Clinical Neurosciences, Department of Neurosurgery, Turku University Hospital and University of Turku, Turku, Finland; Neurovascular Surgery Program, Section of Neurosurgery, University of Chicago Medicine and Biological Sciences, Chicago, Illinois, USA. Electronic address:

Objective: The development of postcraniotomy hematoma (PCH) after surgery for acute traumatic subdural hematoma (aSDH) has been associated with an increased risk of a poor outcome. The risk factors contributing to PCH remain poorly understood. Our aim was to study the potential risk factors for PCH in a consecutive series of surgically evacuated patients with aSDH.

Methods: A total of 132 patients with aSDH treated at Turku University Hospital (Turku, Finland) from 2008 to 2012 were enrolled in the present retrospective cohort study. The demographic, clinical, laboratory, and imaging data were collected from the medical records. A comprehensive analysis of the data using 6 different univariate methods, including machine learning and multivariate analyses, was conducted to identify the factors related to PCH.

Results: The incidence of PCH after primary surgery for traumatic aSDH was 10.6%. The patients experiencing PCH were younger (P = 0.04). No difference was found in the use of anticoagulant or antiplatelet medication for the patients with and without PCH. Multivariate analyses identified alcohol inebriation at the time of injury (odds ratio [OR], 12.67; P = 0.041) and hypocapnia (OR, 26.09; P = 0.003) as independent risk factors for PCH. The patients with PCH had had hyponatremia (OR, 0.08; P = 0.018) less often, and their maximal systolic blood pressure was lower (OR, 0.94; P = 0.009). The area under the curve for the multivariate model was 0.96 (P = 0.049), with a Youden index of 0.88.

Conclusions: The results suggest that alcohol inebriation at the time of injury and hypocapnia during hospitalization are risk factors for the development of PCH.
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http://dx.doi.org/10.1016/j.wneu.2018.12.155DOI Listing
January 2019

TBIcare Investigators' Response to Papa and Wang (doi: 10:1089/neu.2017.5030): Raising the Bar for Traumatic Brain Injury Biomarker Research: Methods Make a Difference.

J Neurotrauma 2019 05 25;36(10):1680-1681. Epub 2019 Feb 25.

2 Turku Brain Injury Centre, Turku University Hospital, Turku, Finland.

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http://dx.doi.org/10.1089/neu.2017.5209DOI Listing
May 2019

Early Levels of Glial Fibrillary Acidic Protein and Neurofilament Light Protein in Predicting the Outcome of Mild Traumatic Brain Injury.

J Neurotrauma 2019 05 8;36(10):1551-1560. Epub 2019 Jan 8.

1 Department of Neurosurgery, Turku University Hospital, Turku, Finland.

The purpose of this study was to correlate the early levels of glial fibrillary acidic protein (GFAP) and neurofilament light protein (NF-L) with outcome in patients with mild traumatic brain injury (mTBI). A total of 107 patients with mTBI (Glasgow Coma Scale ≥13) who had blood samples for GFAP and NF-L available within 24 h of arrival were included. Patients with mTBI were divided into computed tomography (CT)-positive and CT-negative groups. Glasgow Outcome Scale-Extended (GOSE) was used to assess the outcome. Outcomes were defined as complete (GOSE 8) versus incomplete (GOSE <8), and favorable (GOSE 5-8) versus unfavorable (GOSE 1-4). GFAP and NF-L concentrations in blood were measured using ultrasensitive single molecule array technology. Patients with incomplete recovery had significantly higher levels of NF-L compared with those with complete recovery ( = 0.005). The levels of GFAP and NF-L were significantly higher in patients with unfavorable outcome than in patients with favorable outcome ( = 0.002 for GFAP and  < 0.001 for NF-L). For predicting favorable outcome, the area under the receiver operating characteristic curve for GFAP and NF-L was 0.755 and 0.826, respectively. In a multi-variate logistic regression model, the level of NF-L was still a significant predictor for complete recovery (odds ratio [OR] = 1.008; 95% confidence interval [CI], 1.000-1.016). Moreover, the level of NF-L was a significant predictor for complete recovery in CT-positive patients (OR = 1.009; 95% CI, 1.001-1.016). The early levels of GFAP and NF-L are significantly correlated with the outcome in patients with mTBI. The level of NF-L within 24 h from arrival has a significant predictive value in mTBI also in a multi-variate model.
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http://dx.doi.org/10.1089/neu.2018.5952DOI Listing
May 2019

Practitioners' opinions on traumatic brain injury care pathways in Finland and France: different organizations, common issues.

Brain Inj 2019 18;33(2):205-211. Epub 2018 Nov 18.

e Department of Rehabilitation and Brain Trauma, Division of Clinical Neurosciences , Turku University Hospital and University of Turku , Turku , Finland.

Objective: In traumatic brain injury (TBI), differences in health-care contexts have profound effects on care pathways. Objectives were to compare TBI pathways of care and practitioners' views on quality of care issues in two large European areas: Varsinais-Suomi, Finland and Ile-de-France, France.

Methods: Thematic analysis of semi-structured interviews was conducted with TBI practitioners (n = 10) from all stages of TBI care. Interviews addressed organization and financing of care, decision-making on care transitions, and perceived issues. The structure-process-outcome model of Donabedian was used to classify findings related to quality of care issues.

Results: Main differences in organization of care pathways for people with TBI were related to financing modalities, number of pathway alternatives, inpatient versus outpatient rehabilitation, and indirect versus direct referrals to rehabilitation. Similar categories of issues were raised in the two settings. Issues in structures involved availability of services, financial access, and heterogeneity of expertise. Issues in processes involved diagnosis and follow-up, training regarding cognitive impairments, decision-making for referrals, transition delays, and care pathways of very severely affected patients.

Conclusions: These findings provide clues to address care pathways in further comparative studies. Determinants of care pathway quality could be classified as direct or indirect, binding or adaptive organizational factors.
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http://dx.doi.org/10.1080/02699052.2018.1539869DOI Listing
January 2020

Mortality after traumatic brain injury and the effect of posttraumatic epilepsy.

Neurology 2018 08 1;91(9):e878-e883. Epub 2018 Aug 1.

From the University of Turku (J.U., S.L., S.T., E.L., O.T.); and Turku University Hospital (S.L., O.T.), Finland.

Objective: To assess the effect of posttraumatic epilepsy (PTE) on mortality and causes of death after traumatic brain injury (TBI).

Methods: Medical reports were collected retrospectively of patients who sustained TBI between 1996 and 2013. After defining patients with PTE and picking up 2 non-PTE matched TBI controls for every patient with PTE, the database included 714 patients. Demographic data, cause and mechanism of injury, nature of injury (focal injury, intracranial bleeding), time from accident to first seizure, remission rates, neurosurgical operations undertaken, and mortality data were collected.

Results: Of the 714 patients, 555 (77.7%) were men and 159 (22.3%) were women. There was an obvious increase in long-term mortality in patients with PTE compared to control TBI patients. This increase became evident after about 1 year from the injury, when approximately 95% of both non-PTE and PTE patients were alive; after that, the difference in mortality increased. The difference remained significant at least up to 15 years from the injury, when around 65% of non-PTE patients with TBI were alive compared to only 45% of patients with PTE. In patients with PTE, the mortality was 1.75 times higher ( = 0.0001). There was no significant difference in causes of death.

Conclusion: This study shows that long-term mortality is higher in patients with PTE than other patients with TBI, although the reasons for this difference remain unclear.
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http://dx.doi.org/10.1212/WNL.0000000000006077DOI Listing
August 2018

A Decision Support System for Diagnostics and Treatment Planning in Traumatic Brain Injury.

IEEE J Biomed Health Inform 2019 05 1;23(3):1261-1268. Epub 2018 Jun 1.

Traumatic brain injury (TBI) occurs when an external force causes functional or structural alterations in the brain. Clinical characteristics of TBI vary greatly from patient to patient, and a large amount of data is gathered during various phases of clinical care in these patients. It is hard for clinicians to efficiently integrate and interpret all of these data and plan interventions in a timely manner. This paper describes the technical architecture and functionality of a web-based decision support system (DSS), which not only provides advanced support for visualizing complex TBI data but also predicts a possible outcome by using a state-of-the-art Disease State Index machine-learning algorithm. The DSS is developed by using a three-layered architecture and by employing modern programming principles, software design patterns, and using robust technologies (C#, ASP.NET MVC, HTML5, JavaScript, Entity Framework, etc.). The DSS is comprised of a patient overview module, a disease-state prediction module, and an imaging module. After deploying it on a web-server, the DSS was made available to two hospitals in U.K. and Finland. Afterwards, we conducted a validation study to evaluate its usability in clinical settings. Initial results of the study indicate that especially less experience clinicians may benefit from this type of decision support software tool.
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http://dx.doi.org/10.1109/JBHI.2018.2842717DOI Listing
May 2019

Comparing disability between traumatic brain injury and spinal cord injury using the 12-item WHODAS 2.0 and the WHO minimal generic data set covering functioning and health.

Clin Rehabil 2018 Dec 2;32(12):1676-1683. Epub 2018 Jul 2.

3 Department of Physical and Rehabilitation Medicine, Turku University Hospital and University of Turku, Turku, Finland.

Objective:: To compare disability between two patient groups using short validated tools based on International Classification of Functioning, Disability and Health (ICF).

Design:: Cross-sectional study.

Setting:: University hospital specialist outpatient clinic.

Subjects:: A total of 94 patients with traumatic brain injury and 59 with spinal cord injury.

Main Measures:: Disability evaluated using self-reported and proxy 12-item WHODAS 2.0 (World Health Organization Disability Assessment Schedule), and physician-rated WHO minimal generic data set covering functioning and health.

Results:: The two measures used showed severe but very different disabilities in these patient groups. Disability was assessed worse by physicians in the spinal cord injury population (sum 15.8 vs. 12.7, P = 0.0001), whereas disability assessed by the patients did not differ significantly between the two groups (sum 18.4 vs. 21.2). Further analysis revealed that in patients with "high disability" (the minimal generic data set score ⩾15), self-reported functioning was more severely impaired in the traumatic brain injury group compared to the spinal cord injury group (29.7 vs. 21.4, P < 0.0001), with no difference between these two diagnostic groups in patients with "low disability" (the minimal generic data set below 15). Patients with traumatic brain injury perceived more difficulties in cognition, getting along and participation, patients with spinal cord injury in mobility and self-care.

Conclusion:: Both generic measures were able to detect severe disability but also to detect differences between two patient populations with different underlying diagnoses.
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http://dx.doi.org/10.1177/0269215518785945DOI Listing
December 2018

Serum Metabolites Associated with Computed Tomography Findings after Traumatic Brain Injury.

J Neurotrauma 2018 11 21;35(22):2673-2683. Epub 2018 Aug 21.

1 Turku Centre for Biotechnology, University of Turku , Turku, Finland .

There is a need to rapidly detect patients with traumatic brain injury (TBI) who require head computed tomography (CT). Given the energy crisis in the brain following TBI, we hypothesized that serum metabolomics would be a useful tool for developing a set of biomarkers to determine the need for CT and to distinguish among different types of injuries observed. Logistical regression models using metabolite data from the discovery cohort (n = 144, Turku, Finland) were used to distinguish between patients with traumatic intracranial findings and those with negative findings on head CT. The resultant models were then tested in the validation cohort (n = 66, Cambridge, United Kingdom). The levels of glial fibrillary acidic protein and ubiquitin C-terminal hydrolase-L1 were also quantified in the serum from the same patients. Despite there being significant differences in the protein biomarkers in patients with TBI, the model that determined the need for a CT scan validated poorly (area under the curve [AUC] = 0.64: Cambridge patients). However, using a combination of six metabolites (two amino acids, three sugar derivatives, and one ketoacid) it was possible to discriminate patients with intracranial abnormalities on CT and patients with a normal CT (AUC = 0.77 in Turku patients and AUC = 0.73 in Cambridge patients). Further, a combination of three metabolites could distinguish between diffuse brain injuries and mass lesions (AUC = 0.87 in Turku patients and AUC = 0.68 in Cambridge patients). This study identifies a set of validated serum polar metabolites, which associate with the need for a CT scan. Additionally, serum metabolites can also predict the nature of the brain injury. These metabolite markers may prevent unnecessary CT scans, thus reducing the cost of diagnostics and radiation load.
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http://dx.doi.org/10.1089/neu.2017.5272DOI Listing
November 2018

Difficult diagnosis of facial pain: A case report and mini-review.

Scand J Pain 2010 Oct 1;1(4):179-183. Epub 2010 Oct 1.

Department of Radiology, Turku University Hospital, Turku, Finland.

This case report elucidates pitfalls of clinical and radiologic investigations of neuropathic pain due to trigeminal pathology, and utility of neurophysiologic examination when diagnosing facial pain. Our patient was a 63-year-old woman who developed acute, severe facial pain, first located behind the left eye. Neuralgic exacerbations, paresthesia within lower face on the left and restricted mouth opening occurred during the course of the disease with gradual progression. Brain MRI and CT scans were interpreted as normal at 4 and 10 months after symptom onset. At 9 months, detailed neurophysiologic examination showed severe chronic mandibular neuropathy at the left oval foramen with more prominent disturbance of the thick myelinated nerve fibers than the small fibers suggesting compressive etiology. Guided by the neurophysiologic findings, 11 months after the onset of the symptoms, a new brain MRI with contrast enhancement revealed metastatic adenocarcinoma of the left temporal bone along the mandibular nerve, exactly matching the site indicated by the neurophysiologic examination. Neurophysiologic tests offer cost-effective, sensitive tools for screening and accurate level diagnostics of neuropathy and neuropathic pain, which can be utilized also in the diagnosis of facial pain. In addition, whenever there are progressing neurologic deficits or neurophysiologic signs indicating expansive lesion, despite initially normal findings in the brain imaging studies, repeated MRI examinations are warranted, preferably focusing to the 'neurophysiologic region of interest' to avoid radiologic sampling errors. As no isolated technique achieves 100% diagnostic accuracy, only rational combinations of different methods will result in correct diagnosis of facial pain without unnecessary delays. Treatment of neuropathic pain is often delayed because of difficulties in reaching the correct diagnosis. During the work-up, many differential diagnostic alternatives have to be considered, also in patients with chronic orofacial pain. Table 1 shows the most important differential diagnoses of orofacial pain.
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http://dx.doi.org/10.1016/j.sjpain.2010.08.004DOI Listing
October 2010

Psychiatric (axis I) and personality (axis II) disorders in patients with burning mouth syndrome or atypical facial pain.

Scand J Pain 2011 Oct 1;2(4):155-160. Epub 2011 Oct 1.

Department of Clinical Neurophysiology, Turku University Hospital, Turku, Finland.

Background and aims Burning mouth syndrome (BMS) and atypical facial pain (AFP) are often persistent idiopathic pain conditions that mainly affect middle-aged and elderly women. They have both been associated with various psychiatric disorders. This study examined current and lifetime prevalence of psychiatric axis I (symptom-based) and II (personality) disorders in patients with chronic idiopathic orofacial pain, and investigated the temporal relationship of psychiatric disorders and the onset of orofacial pain. Method Forty patients with BMS and 23 patients with AFP were recruited from Turku university hospital clinics. Mean age of the patients was 62.3 years (range 35-84) and 90% were female. BMS and AFP diagnoses were based on thorough clinical evaluation, and all patients had undergone clinical neurophysiological investigations including blink reflex and thermal quantitative tests. Current and lifetime DSM-IV diagnoses of axis I and II disorders were made on clinical basis with the aid of SCID-I and II-interviews. The detected prevalence rates and their 95% confidence intervals based on binomial distribution were compared to three previous large population-based studies. Results Of the 63 patients, 26 (41.3%) had had an axis I disorder that preceded the onset of orofacial pain, and 33 (52.4%) had had a lifetime axis I disorder. Rate of current axis I disorders was 36.5%, indicating that only about 16% of lifetime disorders had remitted, and they tended to run chronic course. The most common lifetime axis I disorders were major depression (30.2%), social phobia (15.9%), specific phobia (11.1%), and panic disorder (7.9%). Twelve patients (19.0%) had at least one cluster C personality disorder already before the emergence of orofacial pain. Patients with cluster C personality disorders are characterized as fearful and neurotic. None of the patients had cluster A (characterized as odd and eccentric) or B (characterized as dramatic, emotional or erratic) personality disorders. The most common personality disorders were obsessive-compulsive personality (14.3%), dependent personality (4.8%), and avoidant personality (3.2%). The majority of the patients (54%) had also one or more chronic pain conditions other than orofacial pain. In almost all patients (94%) they were already present at the onset of orofacial pain. Conclusions Our results suggest that major depression, persistent social phobia, and neurotic, fearful, and obsessive-compulsive personality characteristics are common in patients with chronic idiopathic orofacial pain. Most psychiatric disorders precede the onset of orofacial pain and they tend to run a chronic course. Implications We propose that the high psychiatric morbidity, and comorbidity to other chronic pain conditions, in chronic idiopathic orofacial pain can be best understood in terms of shared vulnerability to both chronic pain and specific psychiatric disorders, most likely mediated by dysfunctional brain dopamine activity.
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http://dx.doi.org/10.1016/j.sjpain.2011.06.004DOI Listing
October 2011

Usability of World Health Organization Disability Assessment Schedule in chronic traumatic brain injury.

J Rehabil Med 2018 Jun;50(6):514-518

Department of Rehabilitation and Brain Trauma, Turku University Hospital, PO Box 52, FI-20521 Turku, Finland.

Objectives: To investigate functioning measured with the 12-item World Health Organization Disability Assessment Schedule (WHODAS 2.0) in patients with mild, moderate and severe traumatic brain injury, and to compare patients' experiences with assessments made by their significant others and by consultant neurologists.

Methods: A total of 112 consecutive patients with traumatic brain injury (29 mild, 43 moderate, 40 severe) and their significant others completed a 12-item WHODAS 2.0 survey. A neurologist assessed functioning with the International Classification of Functioning, Disability and Health minimal generic set.

Results: The total patient and proxy WHODAS 2.0 sum score was rated as severe, and impairments in household tasks, learning, community life, emotional functions, concentrating, dealing with strangers, maintaining friendships, and working ability as around moderate in all 3 severity groups. In standing, walking, washing, and dressing oneself the reported impairments increased from mild in mild traumatic brain injury to moderate in severe traumatic brain injury. A neurologist rated the overall functioning, working ability, and motor activities most impaired in severe traumatic brain injury, while there were no between-group differences in energy and drive functions and emotional functions.

Conclusion: Patients with chronic traumatic brain injury perceive a diversity of significant difficulties in activities and participation irrespective of the severity of the injury. We recommend assessing disability in traumatic brain injury with the short and understandable WHODAS 2.0 scale, when planning client-oriented services.
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http://dx.doi.org/10.2340/16501977-2345DOI Listing
June 2018

Cranioplasty After Severe Traumatic Brain Injury: Effects of Trauma and Patient Recovery on Cranioplasty Outcome.

Front Neurol 2018 9;9:223. Epub 2018 Apr 9.

Department of Biomaterials Science and Turku Clinical Biomaterials Centre--TCBC, Institute of Dentistry, University of Turku, Turku, Finland.

Background: In patients with severe traumatic brain injury (sTBI) treated with decompressive craniectomy (DC), factors affecting the success of later cranioplasty are poorly known.

Objective: We sought to investigate if injury- and treatment-related factors, and state of recovery could predict the risk of major complications in cranioplasty requiring implant removal, and how these complications affect the outcome.

Methods: A retrospective cohort of 40 patients with DC following sTBI and subsequent cranioplasty was studied. Non-injury-related factors were compared with a reference population of 115 patients with DC due to other conditions.

Results: Outcome assessed 1 day before cranioplasty did not predict major complications leading to implant removal. Successful cranioplasty was associated with better outcome, whereas a major complication attenuates patient recovery: in patients with favorable outcome assessed 1 year after cranioplasty, major complication rate was 7%, while in patients with unfavorable outcome the rate was 42% ( = 0.003). Of patients with traumatic subarachnoid hemorrhage (tSAH) on admission imaging 30% developed a major complication, while none of patients without tSAH had a major complication ( = 0.014). Other imaging findings, age, admission Glasgow Coma Scale, extracranial injuries, length of stay at intensive care unit, cranioplasty materials, and timing of cranioplasty were not associated with major complications.

Conclusion: A successful cranioplasty after sTBI and DC predicts favorable outcome 1 year after cranioplasty, while stage of recovery before cranioplasty does not predict cranioplasty success or failure. tSAH on admission imaging is a major risk factor for a major complication leading to implant removal.
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http://dx.doi.org/10.3389/fneur.2018.00223DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5904383PMC
April 2018

Traumatic brain injury: Patient experience and satisfaction with discharge from trauma hospital.

J Rehabil Med 2018 Jun;50(6):505-513

Department of Physical Medicine and Rehabilitation, Department of Neurosurgery, Oslo University Hospital, 0424 Oslo, Norway.

Objectives: To describe the discharge process for patients with traumatic brain injury from a trauma hospital, and patient experience and satisfaction with care transition. Furthermore, to evaluate associations between discharge process and patient satisfaction and quality of care transition.

Design: Prospective-retrospective observational study.

Subjects/patients: Seventy-four patients admitted to ward or intensive care unit at a trauma referral hospital within 24 h of traumatic brain injury.

Methods: Baseline characteristics and discharge process variables were extracted from medical records. Patients were interviewed 6-months post-injury about their experience and satisfaction with care transition, using a visual analogue scale (VAS) and the Care Transition Measurement (CTM-3®) as outcome measures. Regression analyses were performed to investigate associations between discharge process and outcome.

Results: One-third of patients were not involved in the discharge process, and information in discharge summaries was often inadequate. Patients' involvement in care transition and co-ordination of care were significantly associated with overall satisfaction (VAS, p = 0.002 and p = 0.001, respectively) and quality of care transition (CTM-3®, p = 0.003 and p = 0.007, respectively). Patients with more severe injuries reported lower satisfaction and quality of care transition.

Conclusion: Patient's involvement in healthcare decision-making and co-ordination of care is important for self-reported satisfaction with transition and quality of care transition.
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http://dx.doi.org/10.2340/16501977-2332DOI Listing
June 2018

Digital Gaming for Improving the Functioning of People With Traumatic Brain Injury: Randomized Clinical Feasibility Study.

J Med Internet Res 2018 03 19;20(3):e77. Epub 2018 Mar 19.

Turku School of Economics, Centre for Collaborative Research, University of Turku, Turku, Finland.

Background: Traumatic brain injury (TBI) is a major health problem that often requires intensive and long-term rehabilitation.

Objective: The aim of this study was to determine whether rehabilitative digital gaming facilitates cognitive functioning and general well-being in people with TBI.

Methods: A total of 90 Finnish-speaking adults with TBI (18-65 years) were recruited from an outpatient neuroscience clinic. The participants were randomly allocated to one of the three groups: a rehabilitation gaming group (n=29, intervention), an entertainment gaming group (n=29, active control), or a passive control group (n=32). The gaming groups were instructed to engage in gaming for a minimum of 30 min per day for 8 weeks. Primary and secondary outcomes were measured at three time points: before the intervention, after the intervention, and 3 months following the intervention. The primary outcome was cognitive status measured by processing speed and visuomotor tasks (The Trail Making Test; Wechsler Adult Intelligence Scale-Fourth Edition, WAIS-IV, symbol search, coding, and cancellation tasks). Secondary outcomes were attention and executive functions (Simon task), working memory (WAIS-IV digit span and Paced Auditory Serial Addition Test, PASAT), depression (Patient Health Questionnaire-9), self-efficacy (General Self-efficacy Scale), and executive functions (Behavior Rating Inventory of Executive Function-Adult Version). Feasibility information was assessed (acceptability, measurement instruments filled, dropouts, adherence, usability, satisfaction, and possible future use). Cognitive measurements were conducted in face-to-face interviews by trained psychologists, and questionnaires were self-administered.

Results: The effects of rehabilitation gaming did not significantly differ from the effects of entertainment gaming or being in a passive control group. For primary outcomes and PASAT tests, the participants in all three groups showed overall improvement in test scores across the three measurement points. However, depression scores increased significantly between baseline and after 8 weeks and between baseline and after 3 months in the rehabilitative gaming group. No differences were found in patients' self-efficacy between the three measuring points in any of the groups. Participants did use the games (rehabilitation group: 93%, 27/29; entertainment group 100%, 29/29). Games were seen as a usable intervention (rehabilitation group: 70%, 14/29; entertainment group: 83%, 20/29). The rehabilitation group was less satisfied with the gaming intervention (68%, 13/29 vs 83%, 20/29), but they were more willing to use the game after the intervention period (76%, 16/29 vs 63%, 15/29). Total time spent on gaming during the intervention period was low (15.22 hour rehabilitation gaming group, 19.22 hour entertainment gaming group).

Conclusions: We did not find differences between the groups in improvement in the outcome measures. The improvements in test performance by all three groups may reflect rehearsal effects. Entertainment gaming had elements that could be considered when rehabilitative games are designed for, implemented in, and assessed in larger clinical trials for persons with TBI.

Trial Registration: ClinicalTrials.gov NCT02425527; https://clinicaltrials.gov/ct2/show/NCT02425527 (Archived by WebCite at http://www.webcitation.org/6esKI1uDH).
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http://dx.doi.org/10.2196/jmir.7618DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5881042PMC
March 2018