This article advances, for the first time, a framework for situating public health law interventions as occurring in a predictable four-stage process. Whether the intervention is related to mandatory seat-belt laws, HIV prevention through needle-exchanges, or distracted-driving laws, these public health law interventions have generally been characterized by the following four stages. First, a series of publicized incidents, observances, or outcomes generate significant media attention, and are framed as public health harms. Then, a few select states evaluate such harms and (...) proactively seek testimony or evidence designed to support a law-based intervention. After this initial public engagement, states enact legal frameworks designed to minimize or reduce the harm, often in the absence of full information about the scope of harm or potential effectiveness of the intervention. In contrast, scholars have proposed that at these early stages, lawmaking should be evidence-based and “developed through a continuous process that uses the best available quantitative and qualitative evidence.”5 Our experience evaluating youth sports traumatic brain injury lawmaking suggests that, like other public health issues with sudden and intense media attention, an evidence-based approach was lacking during these early stages. (shrink)

Background The European Union aims to optimize patient protection and efficiency of health-care research by harmonizing procedures across Member States. Nonetheless, further improvements are required to increase multicenter research efficiency. We investigated IRB procedures in a large prospective European multicenter study on traumatic brain injury, aiming to inform and stimulate initiatives to improve efficiency. Methods We reviewed relevant documents regarding IRB submission and IRB approval from European neurotrauma centers participating in the Collaborative European NeuroTrauma Effectiveness Research in Traumatic Brain Injury. (...) Documents included detailed information on IRB procedures and the duration from IRB submission until approval. They were translated and analyzed to determine the level of harmonization of IRB procedures within Europe. Results From 18 countries, 66 centers provided the requested documents. The primary IRB review was conducted centrally or locally and primary IRB approval was obtained after one, two or three review rounds with a median duration of respectively 50 and 98 days until primary IRB approval. Additional IRB approval was required in 55% of countries and could increase duration to 535 days. Total duration from submission until required IRB approval was obtained was 114 days and appeared to be shorter after submission to local IRBs compared to central IRBs. Conclusion We found variation in IRB procedures between and within European countries. There were differences in submission and approval requirements, number of review rounds and total duration. Research collaborations could benefit from the implementation of more uniform legislation and regulation while acknowledging local cultural habits and moral values between countries. (shrink)

This essay addresses the question: What is the probative value of including neuroscience data in court cases where the defendant might have had a traumatic brain injury? That is, this essay attempts to articulate how well we can connect scientific data and clinical test results to the demands of the Daubert standard in the United States’ court system, and, given the fact that neuroimaging is already being used in our courts, what, if anything, we should do about this fact. Ultimately, (...) I am not sure that there are completely satisfactory answers to this query at this particular time in our legal history. I briefly rehearse the recent use of brain research in our legal system, summarize how neuroscience data regarding TBI and its relation to poor behavioral outcomes are currently used in the courtroom, review challenges with using these data, and highlight fundamental tensions between how the legal system views the causes of behavior and how medicine, neuroscience, and psychology do. Until these tensions are resolved, it is unclear the place neuroscience data should have in courts. (shrink)

Using a longitudinal case study design, we have tracked the recovery of motor function following severe traumatic brain injury (TBI) through a multimodal neuroimaging approach. In 2006, Canadian Soldier Captain (retired) Trevor Greene (TG) was attacked with an axe to the head while on tour in Afghanistan. TG continues intensive daily rehabilitation, which recently included the integration of physical therapy (PT) with neuromodulation using translingual neurostimulation (TLNS) to facilitate neuroplasticity. Recent findings with PT+TLNS demonstrated that recovery of motor function occurred (...) beyond conventional time limits, currently extending past 14-years post-injury. To investigate whether PT+TLNS similarly resulted in associated cognitive function improvements, we examined event-related potentials (ERPs) with the brain vital signs framework. In parallel with motor function improvements, brain vital signs detected significant increases in basic attention (as measured by P300 response amplitude) and cognitive processing (as measured by contextual N400 response amplitude). These objective cognitive improvements corresponded with TG’s self-reported improvements, including a noteworthy and consistent reduction in ongoing symptoms of post-traumatic stress disorder (PTSD). The findings provide valuable insight into the potential importance of non-invasive neuromodulation in cognitive rehabilitation, in addition to initial indications for physical rehabilitation. (shrink)

Tbis inquiry may be thought of as a sequel to The Concepts of Value and as an extension of the brief core-vocabulary of aesthetic concepts found in one of the appendices to it. In terms of sheer numbers, most of the value concepts of our language are to be found in the area of human relations and of the aesthetic. There are also other value vocabularies, shorter but equally important, for example, the cognitive and logical. These and other objects of (...) pbilosopbical study (for example, the question of "other minds") deserve the kind of empirical survey that has been made of moral and aesthetic notions, if only to test a priori approaches to them. In the present studyan even more determined empirical approach than that adopted for the first has been found necessary. Once the moral or human value vocabulary has been identified, sentential contexts for the use of the terms readily come to mind. In a study of the language of criticism, however, the vocabulary has first to be sought in the utterances of critics themselves and quoted in sufficient context to make their critical intentions clear. The outcome is that the present study is of great length, about half of it being quotations from critics. The rule adopted for arriving at tbis length go on collecting quotations as long as new types of appraisal came was to to light. (shrink)

Traumatic brain injury (TBI) is a major cause of death and disability in Western society, and often results in functional and neuropsychological abnormalities. Memory impairment is one of the most significant cognitive implications after TBI. In the current study we investigated procedural memory acquisition by observational training in TBI patients. It was previously found that while practicing a new motor skill, patients engage in all three phases of skill learning–fast acquisition, between-session consolidation, and long-term retention, though their pattern of learning (...) is atypical compared to healthy participants. A different set of studies showed that training by observing a motor task, generally prompted effective acquisition and consolidation of procedural knowledge in healthy participants. The aim of our study was to (i) evaluate the potential benefit of action observation in TBI patients. (ii) Examine the possibility of general improvement in performance between the first (24 h post-training) and second (2 weeks post-training) stage of the study. (iii) Investigate the link between patients’ ability to benefit from observational learning (viaperformance gains–speed and accuracy) and common measures of injury (such as severity of injury, functional and cognitive measures).Materials and methodsPatients hospitalized after moderate to severe TBI, were trained by observation for the finger opposition sequence (FOS) motor task. They were then tested for the observation-trained sequence (A) and a similar control sequence (B), at two different time-points (24 h post-training and 2 weeks later).Results revealed(i) a significant difference in performance between the trained (A) and untrained (B) sequences, in favor of the trained sequence. (ii) An increase in performance for both sequences A and B toward the second (retention) session. (iii) The advantage for sequence A was stable and preserved also in the second session. (iv) Participants with lower moderate Functional Independence Measure (FIM) scores gained more from observational-procedural learning, compared with patients with higher functional abilities.ConclusionOverall, these findings support the notion that TBI patients may achieve procedural memory consolidation and retention through observational learning. Moreover, different functional traits may predict the outcomes of observational training in different patients. These findings may have significant practical implications in the future, regarding skill acquisition methods in TBI patients. (shrink)

Severe Traumatic Brain Injury (TBI) remains a major cause of death and disability afflicting mostly young adult males and elderly people, resulting in high economic costs to society. Therapeutic approaches focus on reducing the risk on secondary brain injury. Specific ethical issues pertaining in clinical testing of pharmacological neuroprotective agents in TBI include the emergency nature of the research, the incapacity of the patients to informed consent before inclusion, short therapeutic time windows, and a risk-benefit ratio based on concept that (...) in relation to the severity of the trauma, significant adverse side effects may be acceptable for possible beneficial treatments. Randomized controlled phase III trials investigating the safety and efficacy of agents in TBI with promising benefit, conducted in acute emergency situations with short therapeutic time windows, should allow randomization under deferred consent or waiver of consent. Making progress in knowledge of treatment in acute neurological and other intensive care conditions is only possible if national regulations and legislations allow waiver of consent or deferred consent for clinical trials. (shrink)

IntroductionConcussion is a growing public health concern. No uniformly established therapy exists; neurofeedback studies report treatment value. We use infralow frequency neuromodulation to remediate disabling neurological symptoms caused by traumatic brain injury and noted improved outcomes with a novel concussion protocol. Postconcussion symptoms and persistent postconcussion symptoms are designated timelines for protracted neurological complaints following TBI. We performed a retrospective study to explore effectiveness of ILF in PCS/PPCS and investigated the value of using this concussion protocol.MethodPatients with PCS/PPCS seen for (...) their first neurology office visit or received their first neurofeedback session between 1 August 2018 and 31 January 2021 were entered. Outcomes were compared following treatment as usual vs. TAU with ILF neurotherapy. The study cohort was limited to PPCS patients; the TAU+ILF group was restricted further to PPCS patients receiving at least 10 neurotherapy sessions. Within the TAU+ILF group, comparisons were made between those who trained at least 10 sessions using concussion protocol and those who trained for at least 10 sessions of ILF regardless of protocol.ResultsAmong our resultant PPCS cohort leading persistent neurological complaints were headache, memory impairment, and brain fog. PPCS patients in TAU+ILF+CP demonstrated greater net and percent improvement of symptoms compared to PPCS subjects in TAU. PPCS patients in TAU+ILF-CP trended toward significant symptom improvements compared to TAU, and TAU+ILF+CP trended toward greater efficacy than TAU+ILF-CP.ConclusionPPCS patients who received TAU+ILF+CP demonstrated significantly greater improvement as a group when compared to TAU. When used as an integrative modality to treatment as usual in managing patients with PPCS, ILF neuromodulation with use of concussion protocol provided significant symptom improvements. (shrink)

Comparisons have been made between the tobacco industry’s historic tactics in defending their products with the responses of some key actors in the sports world to head injuries. Both, it is said, have deployed deceptive marketing and advertising techniques to entice youth to engage with a subjective pleasure-producing product that has undeniable short- and long-term health detriments. Unlike what is called euphemistically, ‘Big Tobacco’, however, the National Football League (NFL) has evaded legal restrictions on the promotion of an inherently dangerous (...) product that targets youth. By contrast, in 1997, the Federal Trade Commission charged tobacco company R.J. Reynolds with violating federal law by using a cartoon character, Joe Camel, to allure children under age 18. The NFL has partnered with Nickelodeon to produce programs such as NFL Rush Zone and NFL Slimetime that target youth by using cartoon mascots, bright colors, 3D iconography, and other child-friendly symbols. In addition to fostering positive associations between tackle football and cartoons, these broadcasts have explicitly minimized the risks of tackling. For example, one NFL Playoffs on Nickelodeon announcer equated a forceful head collision with a scrape of the knee that a child might experience during school recess. The NFL’s marketing strategies deflect public attention away from the risks of repetitive head collisions, concussions, traumatic brain injury (TBI), and chronic traumatic encephalopathy (CTE), portraying football as an appealing activity. The ongoing connections between the NFL and youth-oriented television programming raise crucial questions about how risk is communicated in a sport with inherent dangers of long-term cognitive damage. As long as tackle football is portrayed alongside beloved cartoon characters such as Spongebob Squarepants, impressionable children are likely to form undilutedly positive perceptions of the NFL and ignore the substantial risks of repeated, full-body collisions when enchanted by brightly-colored slime, animated bubbles, and goofy dance moves. (shrink)

Until recently, the problem of traumatic brain injury in sports and the problem of performance enhancement via hormone replacement have not been seen as related issues. However, recent evidence suggests that these two problems may actually interact in complex and previously underappreciated ways. A body of recent research has shown that traumatic brain injuries, at all ranges of severity, have a negative effect upon pituitary function, which results in diminished levels of several endogenous hormones, such as growth hormone and gonadotropin. (...) This is a cause for concern for many popular sports that have high rates of concussion, a mild form of TBI. Emerging research suggests that hormone replacement therapy is an effective treatment for TBI-related hormone deficiency. However, many athletic organizations ban or severely limit the use of hormone replacing substances because many athletes seek to use them solely for the purposes of performance enhancement. Nevertheless, in the light of the research linking traumatic brain injury to hypopituitarism, this paper argues that athletic organizations’ policies and attitudes towards hormone replacement therapy should change. We defend two claims. First, because of the connection between TBI and pituitary function, it is likely many more athletes than previously acknowledged suffer from hormone deficiency and thus could benefit from hormone replacement therapy. Second, athletes’ hormone levels should be tested more rigorously and frequently with an emphasis on monitoring TBI and TBI-related issues, rather than simply monitoring policy violations. (shrink)

Background: Mild traumatic brain injury results from an external force to the head or body causing neurophysiological changes within the brain. The number and severity of symptoms can vary, with some individuals experiencing rapid recovery, and others having persistent symptoms for months to years, impacting their quality of life. Current rehabilitation is limited in its ability to treat persistent symptoms and novel approaches are being sought to improve outcomes following mTBI. Neuromodulation is one technique used to encourage adaptive neuroplasticity within (...) the brain.Objective: To systematically review the literature on the efficacy of neuromodulation in the mTBI population.Method: A systematic review was conducted using Medline, Embase, PsycINFO, PsycARTICLES and EBM Review. Preferred Reporting Items for Systematic Reviews and the Synthesis Without Meta-analysis reporting guidelines were used and a narrative review of the selected studies was completed. Fourteen articles fulfilled the inclusion criteria which were published in English, investigating an adult sample and using a pre- and post-intervention design. Studies were excluded if they included non-mild TBI severities, pediatric or older adult populations.Results: Thirteen of fourteen studies reported positive reductions in mTBI symptomatology following neuromodulation. Specifically, improvements were reported in post-concussion symptom ratings, headaches, dizziness, depression, anxiety, sleep disturbance, general disability, cognition, return to work and quality of life. Normalization of working memory activation patterns, vestibular field potentials, hemodynamics of the dorsolateral prefrontal cortex and excessive delta wave activity were also seen. The studies reviewed had several methodological limitations including small, heterogenous samples and varied intervention protocols, limiting generalisability. Further research is required to understand the context in which neuromodulation may be beneficial.Conclusions: While these positive effects are observed, limitations included unequal representation of neuromodulation modalities in the literature, and lack of literature describing the efficacy of neuromodulation on the development or duration of persistent mTBI symptoms. Better clarity regarding neuromodulation efficacy could have a significant impact on mTBI patients, researchers, clinicians, and policy makers, facilitating a more productive post-mTBI population. Despite the limitations, the literature indicates that neuromodulation warrants further investigation. PROSPERO registration number: CRD42020161279. (shrink)

While a number of empirical studies have appeared on impaired self-awareness (ISA) after traumatic brain injury (TBI) over the last 20 years, the relative role of denial (as a psychological method of coping) has typically not been addressed in these studies. We propose that this failure has limited our understanding of how ISA and denial differentially affect efforts to rehabilitate persons with TBI. In this selective review paper, we summarize early findings in the field and integrate those findings with more (...) recent observations (i.e., 1999–2019). We believe that this synthesis of information and expert clinical opinion will inform future research on ISA and denial as well as approaches to rehabilitation for persons with TBI. (shrink)

Purpose: To determine motives and attitudes towards life-sustaining treatments by clinical and preclinical medical students. Methods: This was a scenario-based questionnaire that presented patients with a limited life expectancy. The survey was distributed among 455 medical students in preclinical and clinical years. Students were asked to rate their willingness to perform LSTs and rank the motives for doing so. The effect of medical education was then investigated after adjustment for age, gender, religion, religiosity, country of origin, and marital status. Results: (...) Preclinical students had a significantly higher willingness to perform LSTs in all cases. This was observed in all treatments offered in cases of a metastatic oncologic patient and an otherwise healthy man after a traumatic brain injury. In the case of an elderly woman on long-term care, preclinical students had higher willingness to supply vasopressors but not perform an intubation, feed with a nasogastric tube, or treat with a continuous positive air-pressure ventilator. Both preclinical and clinical students had high willingness to perform resuscitation on a twelve-year-old boy with a TBI. Differences in motivation factors were also seen. Discussion: Preclinical students had a greater willingness to treat compared to clinical students in all cases and with most medical treatments offered. This is attributed mainly to changes along the medical curriculum. Changes in reasons for supplying LSTs were also documented. (shrink)

This study aims to assess Technology Business Incubators under (TBIs) the Higher Education Institution Readiness for Innovation and Technopreneurship (HeIRIT) with the auspices of the UPSCALE Innovation Hub, University of the Philippines-Diliman and the Department of Science and Technology-Philippine Council for Industry, Energy and Emerging Technology Research and Development (DOST-PCIEERD). Twenty TBIs were identified to give feedback and used as study participants using a questionnaire created by researchers based on the existing DOST metrics. The study's findings provided insightful information for (...) implementing authorities both internal and external reforms. (shrink)

It is well documented that people with moderate-to-severe traumatic brain injury (TBI) can undergo personality changes, including becoming more impulsive in terms of how they behave. Legal guidance and academic commentary support the view that impulsiveness can render someone decisionally incompetent as defined by English and Welsh law. However, impulsiveness is a trait found within the healthy population. Arguably, impulsiveness is also a trait that gives rise to behaviours that should normally be tolerated even when they cause harm to the (...) person enacting the behaviours. The purpose of this paper is to show why both of these considerations present as significant challenges to the law in England and Wales. (shrink)

Over the past decade, a flurry of media stories devoted to sports-related concussions have drawn attention to the previously “silent epidemic” of traumatic brain injury in athletes. From 2001 to 2009, the annual number of sports-related TBI emergency department visits in individuals age 19 and under climbed from 153,375 to 248,414, an increase of increase of 62 percent. Multiple head injuries place youth athletes at risk for serious health conditions, including cerebral swelling, brain herniation, and even death — postconcussive conditions (...) that have collectively been referred to as “second impact syndrome.” Studies have shown that children and teens — and girls, in particular — are more likely to sustain a concussion and have a longer recovery time than adults. Recent research also suggests that even subconcussive hits in children and adolescents may result in longer-term health effects such as decreased cognitive functioning, increased rates of depression, memory problems, and mild cognitive impairment. (shrink)

Recent research suggests that spiritual experiences are related to increased physiological activity of the frontal and temporal lobes and decreased activity of the right parietal lobe. The current study determined if similar relationships exist between self-reported spirituality and neuropsychological abilities associated with those cerebral structures for persons with traumatic brain injury (TBI). Participants included 26 adults with TBI referred for neuropsychological assessment. Measures included the Core Index of Spirituality (INSPIRIT); neuropsychological indices of cerebral structures: temporal lobes (Wechsler Memory Scale-III), right (...) parietal lobe (Judgment of Line Orientation), and frontal lobes (Trail Making Test, Controlled Oral Word Association Test). As hypothesized, spirituality was significantly negatively correlated with a measure of right parietal lobe functioning and positively correlated (nonsignificantly) with measures of left temporal lobe functioning. Contrary to hypotheses, correlations between spirituality and measures of frontal lobe functioning were zero or negative (and nonsignificant). The data support a neuropsychological model that proposes that spiritual experiences are related to decreased activity of the right parietal lobe, which may be associated with decreased awareness of the self (transcendence) and increased activity of the left temporal lobe, which may be associated with the experience of specific religious archetypes (religious figures and symbols). (shrink)

This study attempts to fill in two research gaps in the extant literature concerning the ecosystem for social innovation in the context of emerging market economies such as India. The study first attempts to assess the potential of corporate social responsibility (CSR) in not-for-profit entities such as technology business incubators (TBIs) to stimulate social innovations in the prevalent ecosystems in emerging markets. Further, using a random-effects Tobit model, the study examines the characteristics of firms that spend higher percentages of CSR (...) expenditure on not-for-profit TBIs/societies/trusts in India. The study provides policy suggestions to create an entrepreneurial ecosystem for promoting social innovation in emerging markets such as India. (shrink)

Rationale: Deep brain stimulation (DBS) of the hippocampus is proposed for enhancement of memory impaired by injury or disease. Many pre-clinical DBS paradigms can be addressed in epilepsy patients undergoing intracranial monitoring for seizure localization, since they already have electrodes implanted in brain areas of interest. Even though epilepsy is usually not a memory disorder targeted by DBS, the studies can nevertheless model other memory-impacting disorders, such as Traumatic Brain Injury (TBI). Methods: Human patients undergoing Phase II invasive monitoring for (...) intractable epilepsy were implanted with depth electrodes capable of recording neurophysiological signals. Subjects performed a delayed-match-to-sample (DMS) memory task while hippocampal ensembles from CA1 and CA3 cell layers were recorded to estimate a multi-input, multi-output (MIMO) model of CA3-to-CA1 neural encoding and a memory decoding model (MDM) to decode memory information from CA3 and CA1 neuronal signals. After model estimation, subjects again performed the DMS task while either MIMO-based or MDM-based patterned stimulation was delivered to CA1 electrode sites during the encoding phase of the DMS trials. Each subject was sorted (post hoc) by prior experience of repeated and/or mild-to-moderate brain injury (RMBI), TBI, or no history (control) and scored for percentage successful delayed recognition (DR) recall on stimulated vs. non-stimulated DMS trials. The subject’s medical history was unknown to the experimenters until after individual subject memory retention results were scored. Results: When examined compared to control subjects, both TBI and RMBI subjects showed increased memory retention in response to both MIMO and MDM-based hippocampal stimulation. Furthermore, effects of stimulation were also greater in subjects who were evaluated as having pre-existing mild-to-moderate memory impairment. Conclusion: These results show that hippocampal stimulation for memory facilitation was more beneficial for subjects who had previously suffered a brain injury (other than epilepsy), compared to control (epilepsy) subjects who had not suffered a brain injury. This study demonstrates that the epilepsy/intracranial recording model can be extended to test the ability of DBS to restore memory function in subjects who previously suffered a brain injury other than epilepsy, and support further investigation into the beneficial effect of DBS in TBI patients. (shrink)

Adequate temporal abilities are required for most daily activities. Traumatic brain injury (TBI) patients often present with cognitive dysfunctions, but few studies have investigated temporal impairments associated with TBI. The aim of the present work is to review the existing literature on temporal abilities in TBI patients. Particular attention is given to the involvement of higher cognitive processes in temporal processing in order to determine if any temporal dysfunction observed in TBI patients is due to the disruption of an internal (...) clock or to the dysfunction of general cognitive processes. The results showed that temporal dysfunctions in TBI patients are related to the deficits in cognitive functions involved in temporal processing rather than to a specific impairment of the internal clock. In fact, temporal dysfunctions are observed when the length of temporal intervals exceeds the working memory span or when the temporal tasks require high cognitive functions to be performed. The consistent higher temporal variability observed in TBI patients is a sign of impaired frontally mediated cognitive functions involved in time perception. (shrink)

El objetivo del presente artículo es doble. En primer lugar, mostrar con claridad cual es la estructura formal de la obra De causa Dei contra Pelagiurn et de virtute causarui’n de Thomas Bradwardine. brillante pensador del siglo xiv, de fecunda influencia en su siglo y en los posteriores. En segundo lugar, profundizar en el estudio del método, que podríamos denominar matemático, utilizado por Bradwardine en esta obra, intentando mostrar los motivos que le llevaron a estructuraría así y lo que esto (...) supone.The aims of tbis article are two. The first is to sliow what is dic structure of dic fon in dic more important book of Thomas Bradwardine’s work: De causa Dei contra Pelagium et de virtute causarunt Bradwardine was a brilliantthinker of dic XIV century, who hada prolific influence in that century andin later ones. The second is to study dic method he used in ibis work, trying to show wby Bradwardine structured «De causa Dei» so, and its consecuences. (shrink)

Rehabilitation For Traumatic Brain Injury (TBI) is a state-of-the-science review of the effectiveness of rehabilitation interventions.

In lieu of an abstract, here is a brief excerpt of the content:Disability Embodied: Narrative Exploration of the Lives of Two Brothers Living with Traumatic Brain InjuryDouglas E. KiddAny discussion of personal experiences with disability, inevitably lead me to recall the experiences of my brother, Richard Kidd. An examination of our journeys clearly illustrates the term disability. More so, our stories reveal the outcome of severe physical impairment dictates the limits of personal agency and autonomy. Perhaps an obvious conclusion, but (...) exploration of our experience is useful as we provide living testimony to eventualities that could similarly occur to others. In order to provide context for discussion of our disabilities, I will briefly recall how we acquired our traumatic brain injuries (TBI), as well as how our brain injuries are expressed. The article will demonstrate that due to the severity of the brain damage he acquired, Richard is entirely subject to the whim of the society he encounters, and thus disabled. The article will also discuss how the disabling attitudes I have encountered sought to diminish my humanity.Richard KiddRichard’s descent into impairment began in the early evening hours of December 31, 1987. As a pedestrian, Richard attempted to cross a street in Indianapolis, when a car without using headlights, slammed into him. In addition, the driver fled the scene of the accident. After stabilizing from the initial trauma—multiple compound fractures to both legs and severe brain injury—Richard spent approximately ten months in coma. After emerging from coma, Richard underwent months of therapy. Albeit with consistent direction from others, therapy enhanced Richard’s ability to hold a cup and use a spoon. These were significant victories for Richard and signaled the beginning of his recovery. However, within two years of his accident, monies ended for rehabilitation and Richard entered into custodial care at his first nursing facility. As time passed, his daily interactions with poorly supervised, unskilled, and underpaid nursing facility employees with little time to work with Richard meant it was more cost efficient for staff to simply spoon–feed Richard. Consequently, Richard lost the ability to participate in an aspect of his self–care. Richard’s humanity took years to gradually erode, but due to the severity of his impairments, he became viewed by those he encountered as an object of treatment, or reservoir of pain and pity, rather than an individual worthy of respect. Accordingly, [End Page 199] Richard became viewed as other. Thus began Richard’s descent into disability.A complete lack of dental care for decades provides a good example of Richard’s treatment as other. Richard’s experience also demonstrates that desensitized members of the medical, dental, and long–term care professions sometimes precipitate grave circumstances. The combination of an inattention to his needs and his limited ability to participate with his self–care meant that Richard typically went without dental treatment. His quality of life diminished further when aides at a nursing facility dropped him. During the fall, Richard’s face smashed into the floor and several teeth were shattered. More than a decade passed before Richard finally received follow–up dental treatment—that day nearly cost him his life. Due to prolonged neglect, all of Richard’s teeth required extraction. I do not question the dental surgeon’s assessment of Richard’s teeth. I am certain that all of his teeth needed to be removed; but Richard’s sedentary lifestyle meant that he had limited ability to cope with the trauma associated with having 24 teeth removed in one session. I feel certain the dental surgeon assumed Richard was like most other patients and could handle the stress associated with the procedures. However, Richard could not cope with trauma and blood loss the extractions produced. What is worse than the dental surgeon’s assessment of Richard’s ability to withstand surgery is the post–op personnel decision to discharge him to home, shortly after surgery. The nursing facility was ill–equipped to cope with the extent of the blood loss that ensued and soon Richard began to aspirate on his own blood. Accordingly, Richard was sent to the hospital where he proceeded to slip into coma. Richard remained in a coma for approximately four days and in hospital... (shrink)

En 1986, H.T. Engelhardt justifiait l'autonomie de la bioéthique à l'égard des éthiques religieuses en partant du fait que les hommes de notre temps sont « moralement des étrangers », les uns pour les autres. En 1991, il entreprit de mieux discerner les relations entre éthiques séculière et religieuse, en gardant la même orientation de pensée, mais en s'attaquant à l'idéologie d'un humanisme athée. Il cherche à établir sur les bases d'une rationalité universelle un « cadre de référence neutre », (...) commun à l'ensemble des partenaires du débat éthique contemporain, mais qui laisserait la place à une pluralité de visions philosophiques, religieuses et morales. Car ce serait ruiner toute éthique que de vouloir fonder la bioéthique sur le seul recours au consentement libre et éclairé du malade et sur le respect de son autonomie, à l'exclusion de toute recherche de « buts transcendants ». – La pensée d'Engelhardt n'est pas exempte d'ambiguïtés sinon de contradictions : il ne dit pas comment son humanisme séculier donnera satisfaction aux partisans des éthiques religieuses ni quel sera le statut institutionnel de ce cadre de référence commun ni quelle issue il propose entre le nihilisme et le relativisme moral ni sur quelle base pourrait se faire une hiérarchisation des valeurs dans une bioéthique séculière. Sa pensée devrait se prolonger en direction des droits de l'homme, mieux distinguer entre principes premiers et principes dérivés, creuser davantage le concept de subjectivité.In 1986 H. T Engelhardt justified the autonomy of bioethics as regards religious ethics by starting with the fact that people in our day are “moral strangers” in regard to each other. In 1991 he studied further the relations between secular and religious ethics while keeping the same line of thougbt, but in attacking the ideology of atheistic humanism. He is trying to establish, on the basis of a universal rationality, a “neutral framework “ that would be shared by all those debating contemporaneous ethics. It would leave room for a plurality of philosophical, religious, and moral visions, For it would destroy all ethics if one wished to base bioethics only on trying to get a free and enlightened agreement from the patient and on the respect of his autonomy, in exclusion of every search.for « transcendental ends ». The thougbt of Engelhardt is not free from ambiguities, if not contradictions: he doesn't say how his secular humanism will give satisfaction to the supporters of religious ethics; nor what the institutional status of tbis common framework would be; nor what he proposes as the way out between nihilism and moral relativism; nor on what basis a hierarchy of values could be created in secular bioethics. His ideas call for further reflection : found etbics on the rights of man; distinguish more clearly between first principles and principles that are derived ; and dig deeper into the concept of subjectivity. (shrink)

The pandemic has exposed the costs of job and income losses. Emergency cash transfers can mitigate the worst immediate effects on people who lack access to safety nets. This research note provides estimates for a potential Temporary Basic Income for poor and near-poor people across 132 developing countries, as well as the minimum cost of income support sufficient to mitigate the pandemic-induced poverty increase. The total monthly cost of the TBI ranges 0.27–0.63% of developing countries’ combined GDP, depending on the (...) choice: top-ups on each country’s average incomes up to a vulnerability threshold; transfers based on each country’s median standard of living; or uniform transfers. This note argues that some form of TBI is within reach and can inform a larger conversation about how to build comprehensive social protection systems that make the poor and near-poor more resilient to economic downturns in the future. (shrink)

Background: People with traumatic brain injury face a range of mental health challenges during the adjustment process post-injury, but access to treatment can be difficult, particularly for those who live in regional and remote regions. eHealth provides the potential to improve access to evidence-based psychological therapy for people with a severe TBI. The aim of the current study is to assess the efficacy of a psychological intervention delivered via video consulting to reduce psychological distress in people with TBI.Methods: This paper (...) outlines the protocol for a multi-center, three-arm, parallel, non-inferiority randomized controlled trial of an evidence-based manualized psychological intervention, ACT-Adjust. ACT-Adjust provides nine sessions for adults with a moderate to severe TBI experiencing clinical levels of psychological distress. Fifty-six participants referred from Brain Injury Rehabilitation Units across New South Wales and the NSW icare scheme will be randomly allocated to three conditions; video consulting, face-to-face and, a waitlist control.Discussion: This is the first RCT to evaluate the efficacy of a psychological therapy delivered via video consulting for individuals with a moderate to severe TBI.Trial Registration:www.anzctr.org.au, Australian New Zealand Clinical Trials Registry ANZCTRN2619001602112. (shrink)

Objectives The potential effects of exposure to repetitive subconcussive head impacts through routine participation in sport are not understood. To investigate the effects of repetitive subconcussive head impacts we studied boxers following customary training (sparring) using transcranial magnetic stimulation (TMS), decomposition electromyographic (EMG) and tests of memory. Methods Twenty amateur boxers performed three 3-min sparring bouts. Parameters of brain function and motor control were assessed prior to sparring and again immediately, 1 h and 24 h post-sparring. Twenty control participants were (...) assessed following mock-sparring. Results One hour after sparring boxers showed increased corticomotor inhibition, altered motor unit recruitment strategies, and decreased memory performance relative to controls, with values returning to baseline by the 24 h follow up. Conclusion Repetitive subconcussive head impacts associated with sparring resulted in acute and transient brain changes similar to those previously reported in soccer heading, providing convergent evidence that sport-related head impacts produce a GABAergic response. These acute changes in brain health are reminiscent of effects seen following brain injury, and suggest a potential mechanism underlying the damaging long-term effects of routine repetitive head impacts in sport. (shrink)

In this study, we sought to assess the predictors of outcome in patients with disorders of consciousness (DOC) after severe traumatic brain injury (TBI) during neurorehabilitation stay. In total, 96 patients with DOC (vegetative state, minimally conscious state, or emergence from minimally conscious state) were enrolled (69 males; mean age 43.6 ± 20.8 years) and the improvement of the degree of disability, as assessed by the Disability Rating Scale, was considered the main outcome measure. To define the best predictor, a (...) series of demographical and clinical factors were modeled using a twofold approach: (1) logistic regression to evaluate a possible causal effect among variables; and (2) machine learning algorithms (ML), to define the best predictive model. Univariate analysis demonstrated that disability in DOC patients statistically decreased at the discharge with respect to admission. Genitourinary was the most frequent medical complication (MC) emerging during the neurorehabilitation period. The logistic model revealed that the total amount of MCs is a risk factor for lack of functional improvement. ML discloses that the most important prognostic factors are the respiratory and hepatic complications together with the presence of the upper gastrointestinal comorbidities. Our study provides new evidence on the most adverse short-term factors predicting a functional recovery in DOC patients after severe TBI. The occurrence of medical complications during neurorehabilitation stay should be considered to avoid poor outcomes. (shrink)

IntroductionIn highly developed countries, as many as 16 percent of children are physically abused each year. Traumatic brain injury (TBI) is the most common injury in non-accidental trauma (NAT) and is responsible for 80 percent of fatal NAT cases, with most deaths occurring in children younger than three years old. Cases of abusers who refuse withdrawal of life-sustaining medical treatment (LSMT) to avoid criminal charges have previously been reported. Therefore, we hypothesized that NAT is associated with a lower risk for (...) withdrawal LSMT in pediatric TBI.MethodsThe pediatric Trauma Quality Improvement Program database was analyzed (2014 to 2016) for patients aged 16 and younger with TBI and Glasgow Coma Scale (GCS) of 8 and lower on admission. Patients with a head Abbreviated Injury Scale (AIS) of 2 or less or who died within 48 hours were excluded. A multivariable logistic regression model was used for analysis.ResultsOf 2,209 TBI patients, 92 (4.2 percent) had withdrawal of LSMT. Compared to those without withdrawal of LMST, those with LMST had statistically similar median age (three years of age versus seven years, p = 0.07) and a higher rate of NAT (33.7 percent versus 13.5 percent, p < 0.001). The most common specified perpetrator was a father/stepfather/ male partner (70 percent). After adjusting for covariates, factors associated with higher risk for withdrawal of LSMT included age of less than three years (OR 2.38, CI 1.34-4.23, p < 0.05) and NAT (OR 1.86, CI 1.02-3.41, p < 0.05).ConclusionNAT is associated with increased risk for withdrawal of LSMT in pediatric TBI. Age of less than three years is similarly associated with a higher risk for withdrawal of LSMT. Future research in this population is needed to determine what other factors predict withdrawal of LSMT and what resources, such as social workers and/or ethics consults, are utilized. (shrink)

Le discours officiel de l'Église catholique met volontiers en cause, depuis plusieurs années, la rationalité des Lumières sous le nom de « modernité ». La raison occidentale qui se détourne de la transcendance est accusée de conduire l'humanité à sa perte, rendue responsable de la décadence des mœurs, et de toutes les formes de totalitarisme; la Shoah serait le fruit amer d'une telle perversion.Il est vrai que les Lumières ont été dénoncées depuis longtemps sous des aspects divers, par le Romantisme, (...) par l'École de Francfort, et le sont encore par toutes les critiques adressées à la raison instrumentale. Mais ces critiques émanent de la méme raison, elles s'inscrivent dans la ligne d'une évolution de la rationalité qui a commencé bien avant les Lumières, elles ne rejettent aucun de ses acquis, en particulier la liberté de penser face à tous les autoritarismes, notamment religieux, elles gardent la même vision d'un monde sécularisé.La pensée catholique devrait faire l'effort de mieux comprendre cette évolution pour rester en dialogue avec la raison des temps modernes.For many years now the official discourse of the Catbolic Cburcb bas, witbout besitation, questioned the rationality of the Enlightenment under the name of “modernity”. Western reason that turns away from transcendence is accused of leading bumanity to its destruction. It is held responsible for the decadence of morals and for all types of totalitarianism ; the Shoah would be the bitter fruit of such a perversion.It is true that the Enlightenment bas been denounced for a long time from different points of view, by Romanticism and the Scbool of Frankfurf, and continues to be by all the criticisms addressed to instrumental reason. But these criticisms emanate from the same reason; they are written in the line of an evolution of rationality that begun well before the Enlightenment; they don’t reject any of these gains, in particular the freedom of thougbt in face of all authoritarianisms, especially religious; they keep the same vision of a secularized world.Catholic thougbt ougbt to make an effort to better understand tbis evolution in order to stay in dialogue with the reason of modern times. (shrink)

Patient report of functioning is one component of the neurocognitive exam following traumatic brain injury, and standardized patient-reported outcomes measures are useful to track outcomes during rehabilitation. The Traumatic Brain Injury Quality of Life measurement system is a TBI-specific extension of the PROMIS and Neuro-QoL measurement systems that includes 20 item banks across physical, emotional, social, and cognitive domains. Previous research has evaluated the responsiveness of the TBI-QOL measures in community-dwelling individuals and found clinically important change over a 6-month assessment (...) interval in a sample of individuals who were on average 5 years post-injury. In the present study, we report on the responsiveness of the TBI-QOL Cognition–General Concerns and Executive Function item bank scores and the Cognitive Health Composite scores in a recently injured sample over a 1-year study period. Data from 128 participants with complicated mild, moderate, or severe TBI within the previous 6 months were evaluated. The majority of the sample was male, white, and non-Hispanic. The participants were 18–92 years of age and were first evaluated from 0 to 5 months post-injury. Eighty participants completed the 1-year follow-up assessment. Results show acceptable standard response mean values for all measures and minimal detectable change values ranging from 8.2 to 8.8 T-score points for Cognition–General Concerns and Executive Functioning measures. Anchor rating analysis revealed that changes in scores on the Executive Function item bank and the Cognitive Health Composite were meaningfully associated with participant-reported changes in the areas of attention, multitasking, and memory. Evaluation of change score differences by a variety of clinical indicators demonstrated a small but significant difference in the three TBI-QOL change scores by TBI injury severity grouping. These results support the responsiveness of the TBI-QOL cognition measures in newly injured individuals and provides information on the minimal important differences for the TBI-QOL cognition measures, which can be used for score interpretation by clinicians and researchers seeking patient-reported outcome measures of self-reported cognitive QOL after TBI. (shrink)

Riassunto: Tra i disturbi del linguaggio, il deficit di tipo pragmatico viene spesso osservato nelle persone a seguito di trauma cranio-encefalico. Nonostante sia negletta nella pratica clinica, questa componente gioca un ruolo centrale nella qualità di vita di persone con TCE. L’aspetto peculiare del deficit di tipo pragmatico è la sua natura intrinsecamente connessa sia ad altre capacità di tipo cognitivo che relazionali delle persone fin nella storia pre-morbosa. L’obiettivo di questo lavoro è proporre un punto di vista teorico che, (...) beneficiando del dialogo tra neuropsicologia e fenomenologia, possa costituire un paradigma utile per considerare in modo più sistematico il deficit di tipo pragmatico. Piuttosto che frammentarlo e ridurlo solo a una lista di singoli sintomi, esso viene analizzato come conseguenza di un’alterazione non storica dell’ ipseità, mettendolo in relazione con il concetto di “ embodiment ”. Si avanza, in conclusione, una possibile proposta di presa in carico di tale neuropsicopatologia. Parole chiave: Trauma cranio-encefalico; Pragmatica; Comunicazione; Embodiment; Fenomenologia Pragmatic disorder due to TBI: A phenomenological approach to rehabilitation –: People who suffer from traumatic brain injury are frequently affected by pragmatic disorder, among other communicative impairments. While largely neglected in terms of rehabilitation strategies, the skills impaired by PD play a fundamental role in the quality of life of people who suffer from TBI. PD uniquely impacts a person’s cognitive and interpersonal abilities, including those from their pre-morbid history. The aim of this work is to propose a theoretical framework, based on a dialogue between neuropsychology and phenomenology, that may provide a useful paradigm in approaches to rehabilitation in PD. Instead of fragmenting this disorder into a list of symptoms, we address it as a consequence of a non-historical alteration of “ ipseity” in connection with the concept of “ embodiment”. In conclusion, we suggest an intervention for this neuropsychopathology. Keywords: Traumatic Brain Injury; Pragmatics; Communication; Embodiment; Phenomenology. (shrink)

Neural substrates of fatigue in traumatic brain injury are not well understood despite the considerable burden of fatigue on return to productivity. Fatigue is associated with diminishing performance under conditions of high cognitive demand, sense of effort, or need for motivation, all of which are associated with cognitive control brain network integrity. We hypothesize that the pathophysiology of TBI results in damage to diffuse cognitive control networks, disrupting coordination of moment-to-moment monitoring, prediction, and regulation of behavior. We investigate the cingulo-opercular (...) and frontoparietal networks, which are engaged to sustain attention for task and maintain performance. A total of 61 individuals with mild TBI and 42 orthopedic control subjects participated in functional MRI during performance of a constant effort task requiring altering the amount of effort utilized to manually squeeze a pneumostatic bulb across six 30-s trials. Network-based statistics assessed within-network organization and fluctuation with task manipulations by group. Results demonstrate small group differences in network organization, but considerable group differences in the evolution of task-related modulation of connectivity. The mild TBI group demonstrated elevated CO connectivity throughout the task with little variation in effort level or time on task, while CO connectivity diminished over time in controls. Several interregional CO connections were predictive of fatigue in the TBI group. In contrast, FP connectivity fluctuated with task manipulations and predicted fatigue in the controls, but connectivity fluctuations were delayed in the mild traumatic brain injury group and did not relate to fatigue. Thus, the mTBI group’s hyper-connectivity of the CO irrespective of task demands, along with hypo-connectivity and delayed peak connectivity of the FP, may allow for attainment of task goals, but also contributes to fatigue. Findings are discussed in relation to performance monitoring of prediction error that relies on internal cues from sensorimotor feedback during task performance. Delay or inability to detect and respond to prediction errors in TBI, particularly evident in bilateral insula-temporal CO connectivity, corresponds to day-to-day fatigue and fatigue during task performance. (shrink)

In this series of eight articles, the Australian Traumatic Brain Injury Initiative (AUS-TBI) consortium describes the Australian approach used to select the common data elements collected acutely that have been shown to predict outcome following moderate-severe traumatic brain injury (TBI) across the lifespan. This article presents the unified single data dictionary, together with additional measures chosen to facilitate comparative effectiveness research and data linkage. Consultations with the AUS-TBI Lived Experience Expert Group provided insights on the merits and considerations regarding data (...) elements for some of the study areas, as well as more general principles to guide the collection of data and the selection of meaningful measures. These are presented as a series of guiding principles and themes. The AUS-TBI Aboriginal and Torres Strait Islander Advisory Group identified a number of key points and considerations for the project approach specific to Aboriginal and Torres Strait Islander peoples, including key issues of data sovereignty and community involvement. These are outlined in the form of principles to guide selection of appropriate methodologies, data management, and governance. Implementation of the AUS-TBI approach aims to maximize ongoing data collection and linkage, to facilitate personalization of care and improved outcomes for people who experience moderate-severe TBI. (shrink)

Visual disturbances are amongst the most commonly reported symptoms after a traumatic brain injury despite vision testing being uncommon at initial clinical evaluation. TBI patients consistently present a wide range of visual complaints, including photophobia, double vision, blurred vision, and loss of vision which can detrimentally affect reading abilities, postural balance, and mobility. In most cases, especially in rural areas, visual disturbances of TBI would have to be diagnosed and assessed by primary care physicians, who lack the specialized training of (...) optometry. Given that TBI patients have a restricted set of visual concerns, an opportunity exists to develop a screening protocol for specialized evaluation by optometrists—one that a primary care physician could comfortably carry out and do so in a short time. Here, we designed a quick screening protocol that assesses the presence of core visual symptoms present post-TBI. The MOBIVIS protocol takes on average 5 min to perform and is composed of only “high-yield” tests that could be performed in the context of a primary care practice and questions most likely to reveal symptoms needing further vision care management. The composition of our proposed protocol and questionnaire are explained and discussed in light of existing protocols. Its potential impact and ability to shape a better collaboration and an integrative approach in the management of mild TBI patients is also discussed. (shrink)

For public health professionals, traumatic brain injury and its possible protracted repercussions are a significant source of worry. In opposed to patient neurorehabilitation with developed brain abnormalities of different etiologies, neurorehabilitation of affected persons has several distinct features. The clinical repercussions of the various types of TBI injuries will be discussed in detail in this paper. During severe TBI, the medical course frequently follows a familiar first sequence of coma, accompanied by disordered awareness, followed by agitation and forgetfulness, followed by (...) return of function. Clinicians must be aware of common medical issues that might occur throughout the various stages of neurorehabilitation, for example, posttraumatic hydrocephalus, paroxysmal sympathetic hyperactivity and posttraumatic neuroendocrine disorders, at each step of the process. Furthermore, we address problems about the scheduling of various rehabilitation programs as well as the availability of current data for comprehensive rehabilitative neuropsychology techniques. (shrink)

Unresponsive wakefulness syndrome (UWS, previously known as vegetative state) occurs after patients survive a severe brain injury. Patients suffering from UWS have lost awareness of themselves and of the external environment and do not retain any trace of their subjective experience. Current data demonstrate that neuronal functions subtending consciousness are not completely reset in UWS; however, they are reduced below the threshold required to experience consciousness. The critical factor that determines whether patients will recover consciousness is the distance of their (...) neuronal functions from this threshold level. Recovery of consciousness occurs through functional and/or structural changes in the brain, i.e., through neuronal plasticity. Although some of these changes may occur spontaneously, a growing body of evidence indicates that rehabilitative interventions can improve functional outcome by promoting adaptive functional and structural plasticity in the brain, especially if a comprehensive neurophysiological theory of consciousness is followed. In this review we will focus on the pathophysiological mechanisms involved in UWS and on the plastic changes operating on the recovery of consciousness. (shrink)

Measuring neuronal activity with electrophysiological methods may be useful in detecting neurological dysfunctions, such as mild traumatic brain injury (mTBI). This approach may be particularly valuable for rapid detection in at-risk populations including military service members and athletes. Electrophysiological methods, such as quantitative electroencephalography (qEEG) and recording event-related potentials (ERPs) may be promising; however, the field is nascent and significant controversy exists on the efficacy and accuracy of the approaches as diagnostic tools. For example, the specific measures derived from an (...) electroencephalogram (EEG) that are most suitable as markers of dysfunction have not been clearly established. A study was conducted to summarize and evaluate the statistical rigor of evidence on the overall utility of qEEG as an mTBI detection tool. The analysis evaluated qEEG measures/parameters that may be most suitable as fieldable diagnostic tools, identified other types of EEG measures and analysis methods of promise, recommended specific measures and analysis methods for further development as mTBI detection tools, identified research gaps in the field, and recommended future research and development thrust areas. The qEEG study group formed the following conclusions: 1. Individual qEEG measures provide limited diagnostic utility for mTBI. However, many measures can be important features of qEEG discriminant functions, which do show significant promise as mTBI detection tools. 2. ERPs offer utility in mTBI detection. In fact, evidence indicates that ERPs can identify abnormalities in cases where EEGs alone are nondisclosing. 3. The standard mathematical procedures used in the characterization of mTBI EEGs should be expanded to incorporate newer methods of analysis including nonlinear dynamical analysis, complexity measures, analysis of causal interactions, graph theory and information dynamics. 4. and 5. are too long to include here. (shrink)