Predictors of disability among military personnel following a traumatic blast concussion

It is no surprise that military personnel who suffer a blast related brain injury are likely to experience post-traumatic stress disorder (PTSD) and depression. A recently published study out of the University of Washington in St. Louis has shown that when these early symptoms, which include anxiety, depression, flashbacks, and PTSD, occur within one week of the injury, they are a better predictor of long term disability than the results of common tests such as memory, thinking, and balance.

The prospective, observational study enrolled 38 U.S. military members who sustained a concussive traumatic brain injury. They were compared with 34 controls. All subjects who suffered injury were evaluated within 7 days at two sites in Afghanistan. The subjects were also re-evaluated again between 6 and 12 months post injury in the U.S. Service member’s ages ranged from 19 to 44 years old. Mental health was evaluated using a standardized military post-traumatic stress disorder questionnaire. Depressive symptoms and post-traumatic stress symptoms were elevated during the initial assessments while cognitive function was worse in subjects with a traumatic concussive injury. After the 6 – 12 month assessments, 63% of the subjects had moderate overall disability versus 20% in the control group. Moderate disability in this case is defined by inability to work in the same capacity as prior to injury, are unable to engage in normal social or leisure activities, and/or have disrupted relationships secondary to mental health disturbances.

It was believed that traditional measures including memory, attention, balance, and coordination would be the best predictors of long term disability. In this study these measures were not correlated with outcomes, but rather the psychological symptoms that were better predictors. It is unknown whether the psychological symptoms result from the brain injury, from stress related to war, or from other combined factors.

Having the knowledge that symptoms of PTSD and depression start much sooner than suspected in some cases, psychological evaluations should begin earlier and allow for earlier targeted care. The long term effect of this is unknown, but may offer the best chance to improve the quality of life. Researchers from the study also are planning to apply these findings in future studies looking at concussive brain injuries in the civilian world.

This study was conducted by investigators at the University of Washington in St. Louis and The U.S. Naval Medical Center in Portsmouth, Virginia.

References:

MacDonald CL, Adam OR, Johnson AM, Nelson EC, Werner NJ, Rivet DJ, Brody DL. Acute post-traumatic stress symptoms and age predict outcome in military blast concussion. Brain. 2015 Mar 4.

TitleGlobal study of disease and disability

A very interesting and eye opening study was published this month in THE LANCET in regards to the burden of disease across the world. Collaborators involved in the study analyzed over 35,000 sources of information on injury and disease from 188 countries with populations greater than 50,000 people between 1990 and 2013. Three hundred and one acute diseases, chronic diseases and injuries were included. Additionally 2337 sequelae that results from one or more of the studied disorders was also reviewed. There were many interesting findings. First and foremost, only 1 in 20 people had no health problems in 2013. Over 2.3 billion people (approximately 1/3 of the population) were experiencing more than 5 health ailments!

When researchers looked at the leading causes of years spent in less than optimum health, low back pain, depression, iron-deficient anemia, neck pain, and age related hearing loss have remained on top for nearly 23 years. The study collaborator’s attributed aging as the primary source leading to increasing disease and injury rates.

The study methodology including a review of published systematic reviews, re-analysis of household survey, data taken from hospital discharges, and from other administrative databases. Case reports to the World Health Organization (WHO) were also utilized. Disease estimates were calculated using a Bayesian meta-regression method. Bayesian refers to a method in statistics that utilizes probabilities of events. This allowed for computation of incidence and prevalence statistics for each country and time period. Specific data analyzed showed that under the category of acute disease, upper respiratory illness, interstitial nephritis, urinary tract infection, Dengue, pancreatitis, intestinal obstruction, and unintentional suffocation had the highest rates of increasing incidence during the study period. Similarly, for chronic disease (present for greater than 3 months), oral disorders, neurologic disease, skin disorders, musculoskeletal disorders, neglected tropical diseases, gynecologic disorders, and vision loss had the highest age-standardized rates.

Of the key findings noted from the study, rates of disability are declining at a much slower rate than mortality rates.

The data from this enormous research study have shown that there are many large causes of disability, or less than optimal health, that are largely preventable but require a greater focus or rates will continue to climb.

The study was funded by the Bill and Melinda Gates Foundation. The study funder reportedly had no role in the study design, data collection, data analysis, or data reporting.

http://dx.doi.org/10.1016/S0140-6736(15)60692-4

The combination of gene therapy and an adeno-virus vector to treat eye inflammation

More than 12 million American’s suffer from dry macular degeneration. This is an eye disease in which the retina deteriorates from the formation of small yellow deposits known as drusen. This leads to drying out of the macula causing it to lose its function. While many with dry macular degeneration may have good central vision, they may have limitations and difficulty with reading, limited vision at night and loss of vision may still occur. Macular degeneration tends to progress slowly in time. This is a common problem for people over the age of 50 years old.
Recently, researcher’s at the University of Florida have found what they believe is a promising treatment to limit inflammation that leads to macular degeneration. The researcher’s used an adeno-viral vector (AVV) to deliver an inflammation blocking protein into the eye. The protein comes from a myxoma virus that is normally found in rabbits found in parts of Europe in Australia. This gene inhibits the body’s immune response that causes inflammation that leads to eye disease.
Researchers also found that this is effective in cases of uveitis which is an inflammation within the middle levels of the eye.
At present, there is no FDA approved treatment for dry macular degeneration. Some of the published recommendations to manage symptoms of macular degeneration include the use of over-the-counter supplements, specific foods which are rich and antioxidants, the use of Lutein, smoking cessation, controlling hypertension, and the use of blue blocker sunglasses. Uveitis has typically been treated with long-term use of steroids. This does increase risks of developing glaucoma.
This new potential treatment may last a lifetime and only requires a single treatment based on current research. Adeno-associated virus vectors may prove to be the next-generation of treatments for many chronic diseases as they were able to deliver anti-inflammatory genes to diseased and damage parts of the body.
Further research is planned after these recent results in a mouse model were published. The study from the University of Florida was funded by grants from the National Eye Institute, and National Institute of Allergy and Infectious disease, The Macula Vision Research Foundation and the Florida Biomedical Research Foundation.

References:
IIdefonso CJ, Jaime H, Rahman MM, Li Q, Boye SE, Hauswirth WW, Lucas AR, McFadden G, Lewin AS. Gene delivery of a viral anti-inflammatory protein to combat ocular inflammation. Human Gene Therapy. 2015 Jan; 26(1):59-68.

Vitamin D: More than just a vitamin

While many think of vitamin D as a just another vitamin, the reality is that it is a strong hormonal regulator. The body produces vitamin D from direct exposure to sunlight which trigger synthesis of vitamin D. Vitamin D can also be obtained from food sources and through supplementation. One of the main roles of Vitamin D is to promote calcium absorption and is involved in the formation of new bone. The true significance of vitamin D as a regulator of other functions including modulating cell formation, immune function, and reducing inflammation within the body, has come to light in many recently published studies.

Evidence:

In one of the most recent publications, researchers looked at vitamin D levels in children and teenagers and found that those with low levels had greater risks of atherosclerosis as adults. This study included over 2148 volunteers who had vitamin D levels during childhood years and then had carotid intima-thickness assessed between the ages of 30 to 45. Thickening of the arteries is believed to be a strong risk factor for cardiovascular disease

Juonala M, Voipio A, Pahkala K, Viikari JS et al. Childhood 25-OH levels Vitamin D Levels and Carotid Intima-Media Thickness in Adulthood: The Cardiovascular Risk in Young Finns Study. Journal of Endocrinology and Metabolism. 2015 Feb 10.

Taken from a randomized, double blind, placebo controlled study that was published in the American Journal of Clinical Nutrition looking at the role of Vitamin D in preventing influenza, the group that was given 1200 IU of Vitamin D3 had comparatively lower rates of flu (influenza A) versus placebo. The study also suggested lowered rates of asthma attacks in children.

Urashima M, Segawa T, Okazaki M, Kurihara M, Wada Y, Ida H. Randomized trial of Vitamin D supplementation to prevent seasonal influenza A in schoolchildren. American Journal of Clinical Nutrition. 2010 May; 91(5): 1255-1260.

In a 2014 published study from the University of London, researchers conducted a randomized trial, looking at the use of Vitamin D levels in patients with COPD. The findings of this study which included 240 patients showed that adequate Vitamin D supplementation can reduce COPD flare-ups by 40%

Martineau AR, James WY, Hooper RL, Barnes NC, Jolliffe DA et al. Vitamin D3 supplementation in patients with chronic obstructive pulmonary disease (ViDico): a multicentre double blind, randomized control trial. The Lancet. Respiratory Medicine. 2014 Dec 1. Pii: S2213-2600(14).

A recent study (2015) presented at the American Stroke Association’s annual meeting that looked at 100 patients who suffered an ischemic stroke. Those with low levels of Vitamin D (<30 ng/mL had a greater risk of developing a stroke and had approximately a two times greater area of stroke related brain dead tissue versus those with normal vitamin D levels. http://newsroom.heart.org/news/low-vitamin-d-predicts-more-severe-strokes-poor-health-post-stroke

Researchers from the University of California published a meta-analysis that encompassed over 32 studies that looked at Vitamin D levels and mortality. The findings show that those with inadequate Vitamin D levels (< 30 ng/mL) were 90% more likely to die prematurely when compared with those who had levels over 30 mg/Ml

Garland CF, Kim JJ, Mohr SB, Gorham ED, Grant WB, Givannuci El, Baggerly L, Hofflich H, Ramsdell JW, Zeng K, Heaney RP. Meta-analysis of all-cause mortality according to serum 25-hydroxvitamin D. American Journal of Public Health. 2014 Aug; 104(8):e43-50.

These are just a handful of the studies looking at the interaction between levels of Vitamin D and various disease processes.