Transitional Learning Center

The Japanese Society of Neurology's Special Committee on Measures for Transition from Pediatric to Adult Health Care held a workshop to discuss the activities of the transitional care support centers (TCSCs). The following points were addressed: (1) from Kanagawa Prefecture, the activities of the TCSC, which is set up alongside the Intractable Disease Consultation Support Center and the Intractable Disease Information Coordination Center, separated from medical institutions, and the efforts addressing cases of difficult transitions and consultations where patients cannot transition from specific pediatric chronic diseases to designated intractable diseases; (2) from Nagano Prefecture, the supporting the health care transition undertaken by the neurologist as intractable disease medical coordinator, and (3) the efforts of the transitional health care support coordinator at the TCSC established at the university hospital in collaboration with the Nagano Children's Hospital and the government. For the creation of a seamless support system, we hope that the pioneering activities reported at this time will spread nationwide.

Pituitary dysfunction with reduced growth hormone (GH) secretion is common in patients following traumatic brain injury (TBI), and these patients often develop chronic symptoms including fatigue and altered cognition. We examined 18 subjects with a history of mild TBI, fatigue, and insufficient GH secretion. Subjects received GH replacement in a year-long, double-blind, placebo-controlled, crossover study, and were assessed for changes in physical performance, body composition, resting energy expenditure, fatigue, sleep, mood, and neuropsychological status. Additionally, magnetic resonance imaging (MRI) was used to assess changes in brain structure and resting state functional connectivity. GH replacement resulted in decreased fatigue, sleep disturbance, and anxiety, as well as increased resting energy expenditure, improved body composition, and altered perception of submaximal effort when performing exercise testing. Associated brain changes included increased frontal cortical thickness and gray matter volume and resting state connectivity changes in regions associated with somatosensory networks. GH replacement altered brain morphology and connectivity and reduced fatigue and related symptoms in mild TBI patients. Additional studies are needed to understand the mechanisms causing TBI-related fatigue and symptom relief with GH replacement.

Posttraumatic hypopituitarism (PTH) can occur following various modes of acquired brain injury at all levels of severity (i.e., mild, moderate, and severe). Chronic dysfunction of the pituitary axis is observed in approximately one-third of individuals who experience a moderate-to-severe traumatic brain injury (TBI). Many of the sequelae associated with TBI have typically been attributed to cortical and subcortical damage. However, analyses of the signs and symptoms of pituitary axis dysfunction suggest that in a significant proportion of patients with TBI, the observed cognitive, psychiatric, and physical/functioning impairments may actually be the result of abnormal growth hormone secretion and could potentially be reversed with growth hormone replacement therapy. Early diagnosis of PTH and subsequent treatment can improve outcomes; however, PTH typically is not identified or treated due to masking effects of impairments secondary to damage to brain parenchyma other than the pituitary.

Objective: Supervision needs typically increase following moderate-to-severe traumatic brain injury (TBI). Research assessing the impact of TBI residential rehabilitation programmes on supervision needs is limited.Research design: Prospective cross-sectional study.Methods and procedures: Ninety-four participants with moderate-to-severe TBI admitted to a post-acute brain injury rehabilitation programme (PABIR) were administered the supervision rating scale (SRS) at admission and at 1 month post-discharge. To account for spontaneous neurological recovery, patients were separated into those who were less than 1 year (L1Y, n = 55) or greater than 1 year (G1Y, n = 39) post-injury.Experimental intervention: None.Main outcomes and results: A mixed factorial design yielded a significant interaction (F(1, 92) = 18.2; p < 0.0001) with post-hoc results revealing that the L1Y group improved more dramatically in terms of supervision needs than the G1Y group. Using reliable change methodologies, 52.7% of the L1Y demonstrated decreasing scores on the SRS vs 20.5% of the G1Y group.Conclusions: Decreases in supervision needs following PABIR can be found, even after accounting for the impact of spontaneous neurological recovery both at the group and individual level.

Anxious individuals selectively attend to threatening information, and defensiveness may influence the experience and expression of anxiety. Fifty-eight undergraduates scoring high and low on measures of anxiety and defensiveness viewed pleasant, neutral, and unpleasant pictures. Acoustic startle probes were presented 60, 240, or 2,000 ms after picture onset. At 60 ms and 240 ms, repressors (low anxiety, high defensiveness) showed weaker blinks during both pleasant and unpleasant compared to neutral pictures, suggesting enhanced early attention to affective stimuli, regardless of valence. At 2,000 ms, high-anxious but not low anxious participants showed potentiated startle responses during unpleasant compared to pleasant pictures. Although this result replicated previous research on anxiety and valence modulation of startle, exploratory analyses suggested that the valence effect was restricted to trait anxious individuals tending toward a defensive coping style. Across probe conditions, defensiveness was associated with heightened startle reactivity independent of self-reported anxiety and foreground stimulus characteristics.

To assess selected cognitive functions of persons with traumatic brain injury using a computer-simulated virtual reality environment. A computer-simulated virtual kitchen was used to assess the ability of 30 patients with brain injury and 30 volunteers without brain injury to process and sequence information. The overall assessment score was based on the number of correct responses and the time needed to complete daily living tasks. Identical daily living tasks were tested and scored in participants with and without brain injury. Each subject was evaluated twice within 7 to 10 days. A total of 30 tasks were categorized as follows: information processing, problem solving, logical sequencing, and speed of responding. Persons with brain injuries consistently demonstrated a significant decrease in the ability to process information (P = 0.04-0.01), identify logical sequencing (P = 0.04-0.01), and complete the overall assessment (P < 0.01), compared with volunteers without brain injury. The time needed to process tasks, representing speed of cognitive responding, was also significantly different between the two groups (P < 0.01). A computer-generated virtual reality environment represents a reproducible tool to assess selected cognitive functions and can be used as a supplement to traditional rehabilitation assessment in persons with acquired brain injury.

Assessment of current level of functioning among clients with traumatic brain injury (TBI) often guides the establishment of realistic outcome goals for post-acute rehabilitation. Further, data generated from neuropsychological testing provide a clinician with a better understanding of a client's pattern of cognitive strengths and weaknesses. The Disability Rating Scale (DRS) is commonly used by TBI rehabilitation facilities to assess a client's general level of functioning in terms of impairment, disability, and handicap. Previous studies have used clients' neuropsychological test results to predict future level of functioning. These studies have shown mixed results regarding the predictive validity of the test findings; however, they usually employ only a limited number of tests for prediction representing a limited number of cognitive domains. Using a concurrent validity design, the present study investigated the bivariate associations between various neuropsychological testing domains (i.e. intellectual, academic, language, visuoperceptual, memory, and executive functioning) and level of functioning as indexed by the DRS. Participants were administered the DRS and the neuropsychological evaluation during the initial part of post-acute rehabilitation. Composite scores were derived for each of the neuropsychological domains. Most participants were categorized as sustaining a severe TBI. The mean age and education of this predominately male sample was 28.84 years (SD = 9.13) and 11.83 years (SD = 1.7), respectively. Results revealed a significant positive relationship between performances in intellectual, executive, academic, and visuoperceptual domains and level of functioning.

The utility of the Peabody Picture Vocabulary Test-Revised (PPVT-R) as a surrogate for the Wechsler Adult Intelligence Test-Revised (WAIS-R) was investigated in 61 brain-injured adult participants in a postacute rehabilitation setting. Idiographic comparison revealed substantial disagreement in clinical classification between the two instruments, and it is concluded that the PPVT-R is not a good surrogate for the WAIS-R for this purpose. In contrast, the PPVT-R was judged an adequate surrogate for the WAIS-R for the purpose of group comparison, as is common in biomedical research. Finally, contrary to prior report, the PPVT-R was demonstrated to measure more than simply Vocabulary. As such, in the absence of independent validation research, perhaps the most parsimonious conclusion regarding what the PPVT-R is measuring is that like each of the various subtests of the WAIS-R, the PPVT-R shares some of the variance of the construct termed intelligence, as well as demonstrates some unique variance that is likely comprised of error and, perhaps, a unique or different facet of intelligence.