Brain Injury Society: Spring/Summer 1999 Issue

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Spring/Summer 1999 Issue
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Serving Acquired (Includes Traumatic)
Brain Injured Individuals and Their Families

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Pat LaFontaine's Neurologist and Director of the Brain Injury Program at the Rehab Institute of Chicago

I applaud Pat LaFontaine's courage and wisdom for recognizing that his brain is more important to his life than another MV Paward or record. When he returned to play this past season, I advised him that while he had recovered from his devastating concussion in 1997, he was more vulnerable than ever and another concussion could end his career. He took that chance and had a record breaking year before he suffered an other concussion in March.

Behind his decision is an important message for every athlete, amateur or professional. THERE IS NO SUCH THING AS A MINOR CONCUSSION! Athletes - as well as their coaches, trainers, doctors and, yes, their parents - must recognize that a concussion should never be trivialized by such expressions as a "ding" to the head, or "getting their bell rung." A concussion is at least as serious an injury as a sprain or a deep bruise, and potentially much, much more serious.

A single concussion may not require a player to sit out the rest of the game, but he or she should not be allowed to return to the game until the severity of the injury has been assessed. What is particularly dangerous is sustaining a second concussion before fully recovering from a first one.

As we see with Pat, a concussion can end a career. It can destroy dreams and aspirations. And as at least a dozen families of young athletes discovered last year, a concussion can kill.

There is another message in Pat's retirement for those who set the rules that govern play in our sports leagues: Shots to the head must be outlawed and penalized with suspension, and even expulsion, from the sport. The seriousness of concussion needs to be addressed with serious consequences for those who inflict them. As we see, a career can be ended by concussion. So should the career of habitual head injury perpetrators.

I encourage everyone engaged in managing the care of athletes to familiarize themselves with the American Academy of Neurology's guidelines for "Managing Concussion in Sports." Use this tool to help you properly assess an athlete's head injury and determine whether or when it's safe to send the player back into the game. Your proper management of concussion could save a career...and a life.

In the world of sports, the year 1994 will stand out historically for the baseball and hockey strikes and as the year George Forman captured the heavy-weight title at the age of 45. We the public have been better able to understand these events through the eyes of media. Those of us in the field of injury prevention and injury control must acknowledge the media's ability to finally heighten public awareness about the dangers of football injuries, the most important of which is brain injury, preferably called concussions in the football arena.

On a Thanksgiving weekend last year, the New York Jets faced the Miami Dolphins. The game had to be halted because wide receiver Rob Moore, while catching a pass, was tackled with enough force to put him in a stupor. His symptoms were consistent with a diagnosis of mild brain injury. He experienced confusion, dizziness, nausea and headaches. In this current football year, we have seen quarterbacks such as Troy Aikman for the Dallas Cowboys, Dave Brown for the New York Giants and Vinnie Testaverde for the Cleveland Browns all sustain mild brain injuries, with some players sustaining head injuries more than once. Most of the injuries that football players sustain are referred to as "mild blows," "dingers" or "bell ringers." However, despite the reluctance of the football world, plain and simple, these injuries should be referred to as mild brain injuries. Most notably, these injuries have the ability to alter the career moves of a football player. For example, Jets receiver Al Toon retired in 1992 after sustaining ten career concussions. According to the National Football League Commissioner's office, the player concussions occur at a rate of about one in every 3-5 games. The incidence of concussions may be no more common than in past years, but fortunately there is now a heightened awareness among coaches, players and team physicians.

At the high school level, it has been estimated that each season one in every five high school football players sustains a concussion. Given that there are approximately 1.5 million high school football players in the United States each year, more than 250,000 concussions occur annually.

A concussion is defined by the Professional Football Athletic Trauma Society as a "jarring injury of the brain resulting in dysfunction." To date there is no universal agreement on the definition of concussion. The Committee of Head Injury Nomenclature of the Congress of Neurological Surgeons defines concussion as "a clinical syndrome characterized by immediate and transient post-traumatic impairments of neurofunctions, such as alteration of consciousness, disturbances of vision, disequilibrium, etc. due to the brain stem involvement." The primary mechanisms for the concussion are thought to be due to the following:

1) Rotation acceleration -- This is best demonstrated by a hit on the chin in which rotation in 3 different planes can occur.

3) Sequential acceleration/deceleration -- A common example of which is whiplash where the head is catching up to the torso in a cervical extension/flexing motion.

All of these mechanisms have the potential for histopathological findings such as:

It should be pointed out that the magnitude of forces involved in the mechanism does not always correlate with the severity of histopathology, which in turn may not correlate with the athlete's level of function.

Evaluation

It is imperative that concussions not be taken for granted. The injured athlete requires an immediate neurological evaluation. In the case of an athlete who has sustained an altered level of consciousness, the team physician must be assured that the athlete has an adequate airway, is breathing steadily and has a good pulse. Immediately following this assessment, a team physician should then concentrate on assessing the neurological status of the athlete. The physical examination should begin by ascertaining whether the athlete is alert, confused or unconscious. In addition, pupillary findings should be documented. There should be a testing of the cranial nerves, deep tendon reflexes, sensation, motor function, memory, concentration and attention.

Complications

The major morbidity associated with a concussion is Post-Concussive Syndrome. The common symptoms are headaches, tinnitus (ringing or buzzing in the ear), disequilibrium, easy fatigability, irritability and impairment of memory and concentration.

A potentially lethal consequence of concussion is Second-Impact Syndrome. A player who has not fully recovered from a previous concussion and then sustains even a minor head trauma can develop fatal brain swelling. The brain loses vascular autoregulation, resulting in massive vascular engorgement, swelling, herniation and death. This underscores the need for a player to be fully symptom-free before returning to play.

Prevention

The first step to preventing a injury is recognition. For the year 1994, the media has helped crystallize the impact of concussions in the world of football. The next phase is education. For example, the education of coaches on proper techniques of tackling and blocking is necessary. It has been shown that head up tackling rather than head first is safer and more efficient. Another important factor is the physical conditioning of the athlete. It is well known that the better the physical conditioning, the less chance of injuries. Equipment is extremely important, starting with the proper fit to help reduce brain injuries. An additional answer is the helmet. Make the helmet better to absorb the blow to the brain. Currently, a. inflatable sack within the helmet designed to decrease impact of blows to the brain is available.

Finally, it is important that team physicians and trainers take a very proactive role in protecting the athlete from primary and secondary injuries. Physicians and trainers must be well trained and qualified at both professional and amateur level. With the collaboration of physicians, trainers, coaches and athletes, the issue of brain injury in football should ultimately become a minor or non-existent issue

The Visual System involves complex actions and interactions of the eyes and the brain. To simplify this description, the Visual System is being placed into three areas of function: acuity, perception, and eye movement. Any one of these functions can be impaired without impairment to the remaining two functions. Or, all functions may be impaired as the result of MTBI. The extent of injury will depend upon the force to and location of trauma in the brain. Dysfunction in any of these areas may contribute to headaches, fatigue, and/or dizziness.

As light enters the eye it travels through the cornea, lens and retina (the neural part of the eye). At this point, the image of what is being seen is processed, reversed and transmitted along the optic tracts (visual pathways). The image is carried via the optic tracts through the brain to the Occipital Lobe (primary visual cortex) at the back of the brain.

The eye can be injured by a direct blow which may injure the cornea, lens, retina, and/or optic tract. Blurred vision or partial visual loss can result from this injury which may be transient or improve with treatment or may be permanent.

This lobe sits at the back of the brain and receives the images transmitted to it from the optic tracts. A blow to the occipital lobe (back of the head) may result in an inability to make sense of what you see (visual agnosia) in your environment or read in a book or newspaper. The worst result would be "cortical blindness", an inability to see anything secondary to impaired interpretation of what is seen. This condition may be permanent or transient.

The superior colliculus and paramedian pontine reticular formation (brainstem)

Each eye has approximately six muscles. Each muscle independently controls an eye movement. Each muscle is individually controlled by one of three Cranial Nerves: III, IV, and VI. Normal eye movements are synchronized to present reflections onto the retina to result in a single image. If any one or all of the three Cranial Nerves are damaged the eye movement and synchronization are altered and two images may be seen. This is double vision or diplopia. Double vision may exist in all fields of vision or only in certain areas.

This sacred holiday commemorates God's liberation of the Israelites from slavery and the beginning of the Jewish people's exodus from Egypt to the Promised Land. Their journey through the desert was long and difficult, but they were guided by the light of their faith and sustained by their dream of liberty. When at last they arrived in the Promised Land, they rejoiced in their freedom to worship God, to rebuild their communities, and to raise their children in the traditions and beliefs of the Jewish religion.

As a people who have always cherished the values of faith and freedom, all Americans can draw inspiration from the story of Passover. It reminds us of our ongoing journey to build our own Promised Land, where all people

are free to worship according to their conscience and where our children can grow up safe from the shadows of intolerance and oppression.

As families across the nation and around the world gather to remember the liberation of the Israelites and to teach a new generation the ancient tradition of the Passover Seder and the reading of the Haggadah, let us all give thanks for God's sustaining love and for the Jewish heritage that has so strengthened and enriched our national life.

Today Christians across America and around the world commemorate with great joy the central mystery of their faith: the Resurrection of Jesus. In this season, we celebrate Christ's victory over sin and death, and we rejoice in the new life that He won for us through His suffering, death, and rising from the dead.

That new life empowers us to overcome sin and to recognize our capacity for forgiveness and love. We have seen in our own communities and in other nations across the globe the violence and human tragedy spawned by hatred, intolerance, and fear born of ignorance. If we are to destroy the roots of hatred, we must examine our own hearts and actions and learn what we can and must do to build just communities united in understanding and mutual respect. May this sacred season of renewal, hope, and new beginnings inspire our efforts and light our way to a brighter, more

Hillary joins me in extending best wishes for a blessed and joyous Easter celebration.

PTSD is one of the anxiety disorders. Symptoms of PTSD develop in people who have experienced an event that is outside the range of usual human suffering and that would be extremely stressful for nearly anybody. Such an event would impose "a serious harm or threat to one's life or physical integrity, a serious threat to one's children, spouse, or other close relatives or friends." PTSD may develop after seeing sudden destruction of the patient's home or the entire community, or witnessing someone's being killed or injured. (DSM-IV, 1994).

The traumatic events that can trigger PTSD may be classified into several categories. First, the person may experience naturally occurring disaster, such as earthquakes, floods or volcano eruptions. Second, the disorder may be precipitated by tragic accidents, such as air crash, very serious car accident. Third, the stressor can be one of category of manmade catastrophes, which may be exemplified by wars, concentration camps and torture. The rape trauma syndrome is a special case of PTSD. in which the rape victim suffers from symptoms caused by the experience of sexual assault (DSM-IV, 1994).

The symptoms are similar for all types of PTSD. Obviously, not all patients who suffer from PTSD experience all the symptoms. Also, the symptoms vary slightly according to the precipitating trauma. The DSM-IV (1994) states these symptoms:

1.recurrent, persistent and distressing re-experiencing of the trauma through distressing recollections, dreams, sudden acting and feeling as if the event was reoccurring (reliving the trauma, illusions, hallucinations, flashbacks)

2.persistent avoidance of stimuli that remind of the trauma, for example, the patient avoids thoughts and feelings associated with the trauma, or he/she may avoid situations and activities that arouse the traumatic recollections

4.numbing of general responsiveness (that was not present before the trauma occurred), for example, the patients show markedly diminished interest in significant activities; they may feel detachment or estrangement from others; their range of affect may be restricted or they may have sense of a foreshortened future

5.persistent symptoms of increased arousal, which involve irritability and outburst of anger, troubled concentrating, hypervigilance, exaggerated startle response; they show physiological reaction to events or situations that symbolize or resemble the trauma

6.the disturbance causes significant distress or impairment in social, occupational, or other important area of functioning

7.patient has to experience symptoms for at least one month before PTSD may be diagnosed

April 2, 1999 New York Times The concept of regenerative medicine -- using the body's own stem cells and growth factors to repair tissues -- has come closer to reality with a discovery about the special human cells from which all bone and connective tissues are derived.

The discovery bolsters the hope that the cells can in principle be used to repair bone, cartilage, tendon and many other injured or aged tissues. The cells would in many cases be derived from the patient's own bone marrow and thus present no problem of immune rejection.

Biologists at Osiris Therapeutics, a privately held biotechnology company in Baltimore, Md., have shown that the cells, called human mesenchymal stem cells, can be converted into bone cells, cartilage cells, fat cells and the stroma cells in the bone marrow that provide support for blood-forming cells.

The company, named after the ancient Egyptian god of regrowth and rejuvenation, also has identified special factors that can be used in the laboratory to drive the cells down each of these distinct lineages. Its work is described in Friday's issue of Science magazine.

Dr. Daniel R. Marshak, Osiris' chief scientific officer, said the mesenchymal stem cells could be formulated so that, when inserted in the right place in the body, they would change into the appropriate tissue.

Tests in animals show that when the cells are grown on ceramic and put into bone, they turn into bone-forming cells. If grown in a gel and inserted into cartilage, they metamorphose into cartilage cells. If injected into the bloodstream, the cells take up residence in the bone and turn into stroma cells.

There is no way of knowing how soon treatments derived from the techniques will be available, but a clinical trial is now under way with breast cancer patients to explore the cells' stroma-forming abilities. Lack of stroma to support blood-forming cells may be why the bone marrow transplants given to cancer patients after chemotherapy are not always successful.

With Novartis AG, the Swiss pharmaceutical company, Osiris also plans to test in humans the cells' abilities to form new bone, tendon and cartilage.

The cells can also be converted to fat cells, which could prove useful in cosmetic surgery and possibly as material for breast implants.

Dr. Mark F. Pittenger, who identified the various factors needed to convert the cells into bone, cartilage, and fat, said he is now working to change them into heart-muscle cells. People are born with a fixed number of heart-muscle cells and the heart grows by enlargement of these cells, not by growing more.

"We hope at the least we could prevent some of the scarring after a heart attack by implanting new cells," Pittenger said.

The human mesenchymal stem cells found in adult bone marrow are derived from the mesoderm, one of the three tissue types of the early embryo and the source of all the body's bone and connective tissue. The adult stem cells evidently retain much, and possibly all, of the mesoderm's magical plasticity, giving the Osiris biologists a wide range of tissue fates to explore for the cells.

Stem cell biologists independent of the company said the new report represented a promising advance, even though it remains to be seen if the clinical applications will work as hoped.

Dr. David J. Anderson of the California Institute of Technology said it was a "very important result" to have trained the stem cells to form different lineages in the laboratory. Dr. Ronald McKay of the National Institutes of Health described the Osiris report as a "very serious and interesting contribution."

Both Osiris and Dr. William Haseltine, president of Human Genome Sciences, have laid trademark claims to the evocative phrase "regenerative medicine," the idea that stem cells and the growth factors that shape their fate may provide a radically new approach to healing.

"The fundamental concept is that if we learn enough about how the body regenerates itself, we can use those same mechanisms to regenerate tissues that are damaged or worn down by age," Haseltine said.

In cases where the body's own repair mechanisms fail, however, are extra stem cells all that is needed to overcome the problem?

Marshak of Osiris said that often the body might not be able to get enough of its mesenchymal stem cells to an injury in time, especially in cartilage, for example, which has no blood supply, or when a large area of bone is missing.

McKay said the prospects for regenerative medicine and the clinical usefulness of stem cells were likely to depend on how deeply the genetic rules for fashioning an animal body are embedded in the cell's hereditary programming.

"If the cells have constant access to these rules, then the answer is that through this door we will go into a universe where there is real control over reshaping human tissues."

There is reason to be optimistic about the clinical uses of stem cells "but advances are not going to come as day follows night," said Dr. Robert Weinberg, a cancer biologist at the Whitehead Institute in Cambridge, Mass. Weinberg noted that complex tissues are formed by the interaction of many different types of cell, and that even though stem cells can be driven down certain lineages in the laboratory, it is not yet clear that the body will provide the same cocktail of factors.

"With the exception of certain special cell types like skin, the ability to reconstruct complex tissues is still years ahead of us, but work like this will be viewed as pioneering five to ten years down the road," he said, referring to the Osiris report.

HOUSE MEMBERS PROTEST USE OF FEDERAL MONEY IN RESEARCH ON STEM CELL RESEARCH

February 17, 1999, New York Times, In a letter, 70 members of the House of Representatives have asked the secretary of the Department of Health and Human Services to rescind a ruling that federal money may be used for research on human embryonic stem cells, the primordial cells from which all the tissues of the body are developed.

Human embryonic stem cells were isolated and cultivated for the first time last year in work that scientists have hailed as a first step to novel and far-reaching therapies, particularly to replace aged or damaged human tissues.

But the manner of obtaining the embryonic stem cells is viewed as morally unacceptable by opponents of abortion, including the National Conference of Catholic Bishops. The stem cells were derived by one group of biologists from long-frozen embryos that had been created in fertility clinics in excess of the patients' needs and by another group from aborted fetuses.

The congressional letter to Health and Human Services Secretary Donna Shalala was drafted by the House pro-life caucus, chaired by Rep. Christopher Smith, R-N.J., and James Barcia, D-Mich. Most of its signatories, including Tom DeLay, R-Texas, the majority whip, and Richard Armey, R-Texas, the majority leader, and Henry Hyde, R-Ill., are anti-abortion Republicans, although eight Democrats are also among the signers.

The letter says that the position of the Department of Health and Human Services on stem cell research, enunciated in a ruling last month by Harriet S. Rabb, the department's general counsel, "would violate both the letter and spirit of the federal law" that bars federal support for research in which human embryos are destroyed.

The department has said federally supported biologists may not derive stem cells from embryos -- the specific prohibition of the law -- but may conduct research on the stem cells derived by other scientists using private funds.

The House letter asserts that Congress' ban on federal funds to derive the cells obviously extended to research conducted on such cells.

A spokeswoman for the department, Laurie Boeder, said it could not comment on the House letter without further study.

Congress' ban on federal financing for embryo research has been exerted in the form of a rider attached for the last three years to the appropriations bill that sets the budget for the National Institutes of Health. The rider has originated in the House, from Rep. Jay Dickey, R-Ark. But U.S. Sen. Arlen Specter, R-Pa., the chairman of the Senate appropriations subcommittee that handles NIH, is a strong supporter of stem cell research, as is the ranking minority member, Sen. Tom Harkin, R-Iowa.

Specter said on Tuesday that "we are in very deep water" on the issues raised by the House members and that he would hold a hearing on their concerns

"But what we are looking at in broader terms is the possible cure for major diseases like Parkinson's, Alzheimer's, cancer and heart disease, from the use of what are essentially discarded embryos," Specter said. Researchers hope stem cell research will lead to ways to grow replacement tissues for use in people with these and other conditions.

Specter said he had taken time out from the impeachment proceedings against President Clinton to discuss stem cell research with Dr. Harold Varmus, the director of the National Institutes of Health. In his view, Varmus should continue reviewing research applications while the House members' letter is being considered.

Richard Doerflinger, associate director for policy development at the National Conference of Catholic Bishops, said the House members' letter accorded with arguments he had made at two recent hearings on stem cell research held by Specter. He said the disagreement was not a clash between science and religion but "a clash between obtaining medical progress in morally acceptable and morally unacceptable means."

January 20, 1999 New York Times, Federally financed researchers will soon be able to work on human embryonic stem cells, the source cells from which the embryo develops, as a result of a ruling Tuesday by the Department of Health and Human Services that a congressional ban on human embryo research does not apply to the cells.

The decision was hailed as "an accurate interpretation of bad law," by the American Society for Reproductive Medicine and denounced by the National Conference of Catholic Bishops as a loophole that "violates the spirit of current law."

In its ruling, the department's Office of General Counsel said that because the cells by themselves do not have the capacity to develop into a human being, they cannot be considered embryos.

Human embryonic stem cells, isolated for the first time in November, are capable of developing into any of the body's cell types and thus have great potential for repairing any damaged tissue, such as failing heart muscles or the type of brain cells lost in Parkinson's disease.

The many biological researchers who receive their funds from the federal government have been unable to study human embryonic stem cells because of a congressional ban, originating in the House, that has been attached every year since 1995 to bills authorizing spending for the National Institutes of Health, the principal supporter of biomedical research.

The ban states that no federal funds may be used for "research in which a human embryo or embryos are destroyed, discarded, or knowingly subjected to risk of injury or death greater than that allowed for research on fetuses in utero." In a statement issued in November, Rep. Jay Dickey, R-Ark., said human embryonic stem cells should not be excluded from the ban.

The embryonic stem cells described in November by Dr. James Thomson of the University of Wisconsin were derived in from human embryos created in surplus amounts in a fertility clinic. Deriving the cells is legal, provided it is not done with federal funds. Dr. Harold Varmus, director of the National Institutes of Health, said it would still be illegal for researchers to use federal funds to derive their own stem cells in this way. But they can now use federal funds to work on the cells Thomson has already obtained.

"The prospect of doing amazingly interesting science is really quite wonderful," Varmus said. But research cannot begin, he said, until the NIH has drawn up guidelines to ensure that researchers do not do prohibited research, such as generating new embryos

Sen. Tom Harkin, D-Iowa, who in December called for speedy issuance of the ruling, said the decision would move researchers closer to finding cures for many diseases. "The government should not issue blanket bans on medical research," he said.

But the circumstance that federally-supported scientists can now conduct research on cells that they cannot legally derive was seized upon by Richard Doerflinger, associate director for policy development at the National Conference of Catholic Bishops. "They will destroy the embryos with private funds and experiment on the tissue with public funds," he said. Doerflinger believes that the medical benefits expected from stem cell research could be obtained with embryonic stem cells derived from spontaneously aborted fetuses. A pocket of embryonic stem cells, known as embryonic germline cells, is preserved in the fetus as a source to generate egg or sperm cells. One of the two lines of embryonic stem cells announced last November was developed by Dr. John Gearhart of Johns Hopkins University, who obtained the cells from aborted fetuses, but they were induced abortions, not spontaneous ones.

Doerflinger said that Gearhart's type of human embryonic stem cells would be acceptable had they been obtained from spontaneously aborted fetuses.

In a written statement he said, "The Clinton administration now seeks to do indirectly what Congress has forbidden it do to directly: Provide federal support for research in which human embryos are created and destroyed."

January 8, 1999, New York Times, Scientists in Sweden have identified for the first time the parent cells that give rise to many and maybe all of the different cell types in the adult brain. These neural stem cells, as they are called, are of great interest because, if they could be manipulated appropriately, they would be the obvious repair kit for replacing damaged neural tissues in everything from spinal cord injuries to Parkinson's disease.

The Swedish biologists worked with rats, but now that the cells' hiding place in the rat brain is known, the human counterpart cells are strongly expected to lie in the same place.

Discovery of the cells, announced by Dr. Jonas Frisen and colleagues at the Karolinska Institute in Stockholm in an article published in Friday's Cell, is part of a fundamental change in brain biology. Until recently, it had been thought that the brain never renewed itself or added new cells after gaining its mature form. The belief implied that the brain did not possess stem cells, the source cells from which tissues like blood and skin can constantly renew themselves.

This dogma started to crack when biologists showed in 1992 that a small percentage of cells in brain extracts could divide and develop into the principal types of brain cell. Much work has since been done on brain stem cells acquired by grinding up whole animal brains. But no one knew where in the brain the stem cells come from.

In their paper, Frisen and his team say they have now identified the brain's stem cells. The cells were already known as ependymal cells, described by one biologist as the most boring cells in the brain because their function is simply to line the cavities of the ventricles and spinal cord which hold the spinal fluid.

These cavity-lining cells are differentiated, meaning that they have taken up a mature form. In contrast, all stem cells identified so far are general, multipurpose cells, uncommitted to any specific fate.

Earlier experiments showed the cavity-lining cells did not divide, confirming their uninteresting nature. But Frisen has found the cells do divide, though at too slow a rate for the earlier tests to detect. Their progeny cells divide rapidly and can differentiate into both neurons and the support cells that are found copiously throughout the brain.

Frisen has found that neurons derived from the cavity-lining cells can migrate from the cavity surface and replace cells in the rat's olfactory bulb or smell-analysis unit, the one brain region known to undergo a rapid turnover of nerve cells.

The Clark Kent/Superman existence of the cavity-lining cells has surprised biologists. "You'd never guess it in a million years," said Dr. Ben Barres, a developmental biologist at Stanford University.

But the identification makes sense, he said, because in the developing embryo the brain cells grow out from stem cells that line a hollow tube. As the organism matures, the tube becomes the ventricles and spinal cord, and the stem cells disappear. It now seems they stay in place but turn into cavity-liners.

Frisen has found that the cavity-lining cells start dividing in earnest when the spinal cord is injured. They then turn into the support cells that make up much of the scar in spinal cord injuries.

"That's really cool because it wasn't clear where the glial cells in scar tissue were coming from," Barres said, referring to the support cells.

Frisen said he hoped to find out how the cavity-lining cells could be induced to make neurons instead of support cells at injury sites. If so, a new approach to spinal cord injury might be developed.

The neural stem cells may also prove relevant to treating Parkinson's disease, which is caused by the death of dopamine-producing cells in a certain region of the brain. Embryonic cells, such as those derived from fetuses, will develop into these cells if placed in the dopamine region. But ethical problems aside, there are not enough fetuses available to treat everyone.

Frisen said the big advantage of the neural stem cells "is that maybe you could use the patient's own stem cells, avoiding both the ethical and immunological problems." The cells would be obtained through a biopsy of the cavity-lining cells of the spinal cord, assuming these prove to be the human reservoir of neural stem cells.

Frisen identified the brain stem cells through his studies of spinal cord injuries. He noticed that some of the cells at the injury site were making a substance called nestin, which had been shown by Dr. Ron McKay of the National Institutes of Health to be produced by brain stem cells. The clue made him suspect the cavity-liner cells were also the stem cells, a thesis it has taken four years to establish.

The neural stem cells are descendants of the primordial stem cells that form in the earliest embryo.

November 6, 1998 New York Times Pushing the frontiers of biology closer to the central mystery of life, scientists have for the first time picked out and cultivated the primordial human cells from which an entire individual is created.

The cells, derived from fertilized human eggs just before they would have been implanted in the uterus, have the power to develop into many of the 210 different types of cell in the body -- and probably all of them. Because they can divide indefinitely when grown outside the body without signs of age that afflict other cells, biologists refer to them as immortal.

Eventually, researchers hope to use the cells to grow tissue for human transplants and introduce genes into the body to remedy inherited disease.

But there is a thicket of ethical and legal issues, as well as technical problems, to be tackled. The cells are obtained from embryos created at in-vitro fertilization clinics and so far do not seem definably different from the handful of primordial cells from which an entire individual is created.

Though the scientists involved in the work consider use of the cells justified because they come from embryos that would otherwise have been discarded, other believe the cells have a special status in that they retain the potential to develop into an individual, and that the use of the cells may draw criticism if this status is not taken into account.

The new cells, known as human embryonic stem cells, have eluded capture until now because they exist in this state only fleetingly before turning into more specialized cells, and need special ingredients to be kept alive outside the body.

The cells have many possible uses, of which the most promising is to grow new tissue, of any kind, for transplant into a patient's body. The cells may also offer effective routes to human cloning, although both the researchers and their sponsor deny any interest in this application. Another likely use is in gene therapy, the insertion of new or modified genes into body tissue.

Two forms of human embryonic cells have been developed, one by a team under Dr. James A. Thomson of the University of Wisconsin in Madison, the other by Dr. John Gearhart and colleagues at the Johns Hopkins University School of Medicine in Baltimore, Md. Dr. Thomson's work is reported in this week's issue of Science, Dr. Gearhart's in the Proceedings of the National Academy of Sciences.

Congress in 1995 banned Federal financing of research on fetal cells, including those derived from embryos, and the university researchers whose work was announced today were funded by the Geron Corporation of Menlo Park, Calif., a biotechnology company that specializes in anti-aging research.

The research "has potential health benefits which I think are extremely promising, and I am sorry that the law prevented us from supporting it," said Dr. Harold Varmus, director of the National Institutes of Health.

After an egg is fertilized, it divides several times and forms a blastocyst, a hollow sphere with a blob of 15 to 20 cells, known as the inner cell mass, piled up against one wall. It is from these cells that the embryo develops. Dr. Thomson grew his embryonic stem cells from the inner cell mass of blastocysts that had been left over from fertility treatments and were due to be discarded. The donors of the blastocysts granted permission for them to be used in research.

As an embryo grows and develops, its cells become irreversibly committed to their fates as specialized components of the body's organs. A pocket of cells, known as embryonic germ cells, is protected from the commitment process so as to create the next generation of eggs and sperm. Dr. Gearhart's group has developed embryonic stem cells from the germ cells of aborted fetuses. The cells developed by the two groups may well be equivalent but this has yet to be proved.

If researchers are able to use the cells to grow new tissues, the work could alleviate the shortage of livers and other organs for transplant. Cultures of the cells in the laboratory could be nudged down different developmental pathways to become heart or bone marrow or pancreatic cells. Before reaching their final stages, the about-to-become heart cells, for example, could be injected into a patient's ailing heart. Guided then by the body's own internal regulatory signals, the cells would develop into new, young heart tissue, supplementing or replacing the heart cells already there.

The same approach should in principle work with any tissue of the body. Human embryonic stem cells would thus serve as a universal spare parts system. Because the cells grow and divide indefinitely in the laboratory, very few blastocysts would be needed.

Many technical problems remain to be resolved. The art of directing embryonic stem cells down specific pathways is in its infancy. But heart muscle cells have been grown from mouse embryonic stem cells and successfully integrated with the heart tissue of a living mouse.

Dr. Thomson in 1995 isolated the embryonic stem cells of a monkey, and Geron intends to do pilot experiments in these cells.

Another problem lies in making grafted cells compatible with the patient's immune system.

Dr. Thomas B. Okarma, Geron's vice president for research, said Geron would explore several ways of doing this. One, the least preferred, would be to set up a bank with enough different human embryonic cells that most patients could be matched. Another would be to suppress the self-recognition genes that make the stem cells appear foreign to the patient's immune system or, more elegantly, to replace them with copies of the patient's own self-recognition genes.

A third, approach would be to convert one of the patient's own body cells back to embryonic form by fusing it with a human embryonic stem cell whose own nucleus had been removed. Embryonic cells may have the power, not yet understood, to rescue an adult cell's nucleus from its specialized state by flicking all the switches on its DNA back to default mode. This reprogramming of DNA is presumably what happened when mice were cloned in July from adult cells.

The ethical status of the cells is also likely to be a matter of discussion. They cannot become a fetus, as their blastocyst no longer exists, yet they are very similar, if not identical, to the 20 or so primordial cells from which the embryo develops.

Both research groups refer to their cells as "pluripotent" because, when injected into a mouse with no immune system, the cells develop into many of the major tissues of the body. The tissues are disorganized and do not develop into a normal embryo.

The cells may also be "totipotent," meaning they can form every one of the body's cell types. The test for totipotency, developed with mouse embryonic stem cells, is to inject stem cells into another blastocyst. A normal mouse will usually develop, but it is composed of a patchwork of cells, some from the blastocyst and some from the injected embryonic stem cells, proving the stem cells retain all their powers.

It would be unethical to perform such an experiment on people, but if it could be done, it seems likely that the human embryonic cells cultured by the researchers would also prove to be totipotent. If so, they may be capable in principle of contributing to the generation of a new individual.

But ethicists say great care must be taken in work involving human embryonic cells.

"Any time you take a cell off a blastocyst, that cell could be used itself to create a human being, so some groups in our society believe in making it transplantable you have derailed it into becoming a kidney or some other tissue," Dr. Lori Andrews, an expert on the laws governing reproductive technology at the Chicago Kent College of Law, said.

"Some researchers say, 'It's just a bunch of cells, why should people care?' But that totally avoids the fact that some people do care, and I'm concerned that if the researchers don't take into consideration the variety of viewpoints about embryos, they might ultimately end up with more restrictive regulations."

Geron, which has exclusive licenses to use the cells, under patents held by the researchers' universities, says it regards them as qualitatively different from other cells used in research.

"Because these cells are derived from human blastocysts there is a moral authority here, so we take these cells seriously," Dr. Okarma, of Geron, said.

Dr. Okarma said he believes that use of the cells is justified because they are something less than a living embryo, and life-saving treatments may be derived from them. "We are not saying the ends justify the means, but that given that the moral authority of these cells is subordinate to that of the embryo, the work we contemplate with them is appropriate," he said.

But Dr. Gearhart said he did not consider the cells that he and Dr. Thomson have isolated to have a special moral status because "they cannot form a fetus -- you cannot take one of these cells and form a being out of it."

Still, Dr. Gearhart said he would not argue with the view of Dr. Okarma at Geron that the cells had a different standing from ordinary cells. Dr. Johnson, too, said that they were "special cells."

Dr. Kevin T. Fitzgerald, a geneticist and Jesuit priest at Loyola University Medical School, said that if the human embryonic stem cells are totipotent, "then you are disrupting the viability of life and we are back to the question of how to justify destroying life for the purposes of scientific advancement."

The new cells may well reawaken fears of human cloning, although many ethicists have now come around to believing that the public's fears, despite science fiction writers' portrayal of clonal armies of frenzied despots, are largely beside the point. Many experts now predict human cloning is more likely to end up as a rare treatment offered in fertility clinics, no different from others like in-vitro fertilization and egg donation in that they were first bitterly denounced and are now regarded as routine.

"Human cloning will likely also be accepted once it becomes a reality. Most of today's ethical arguments against it were previously used against in-vitro fertilization and turned out to be false," writes Dorothy C. Wertz, a bioethicist at the Shriver Center, in the current issue of Gene Letter.

The availability of human embryonic stem cells suggests a quite different possibility to biologists, who are well aware of how mouse embryonic stem cells have long been used to generate genetically altered mice.

The belief that humans can now be modified like the mouse "will be the kneejerk reaction of the academic community," Dr. Thomson said.

He said human embryonic stem cells were unlikely to be used in this way because there were more promising approaches for gene therapy in people. For one thing, the mouse method requires the creation of many embryos in order to obtain the few in which new genes integrate in exactly the correct position, as well as the breeding of a male and female mouse that have been genetically altered. In its present form, the technique is evidently inapplicable to humans.

The National Institutes of Health and the university scientists it funds often play a leading role in reviewing new biomedical technologies.

But because of the Federal funding ban, university scientists cannot get Government support to study human embryonic stem cells. But industry can do whatever research it pleases, without necessarily obtaining government approval. Academic biologists believe this asymmetry is unfortunate and that the new technique would receive better and more detached review if the agency and its scientists could take part in the discussion.

Dr. Varmus said that an expert panel on human embryo research had recommended to the health institutes that attempts to derive stem cells from human embryos should be permitted, but Federal efforts along this line were thwarted in 1995, with the Congressional funding ban. Dr. Varmus said he believed the public "will see how important the benefits of this research might be."

A Senate bill to ban human cloning was defeated in February this year, the principal argument of its opponents being that its overly broad language would prohibit promising research on human embryonic stem cells.

In any event, any ultimate use of human embryonic stem cells may face legal hurdles in the nine states that have outright bans on research on human fetal tissues, Dr. Andrews said.

Some laws also prohibit payment for embryos, a restriction that might extend to cells and tissues derived from embryos.

The technique reported today reaches to the central mysteries of life and death. As biologists have recently begun to understand, the body's cells are not inherently mortal. They become mortal only when committed to developing into one or another of the body's mature cell types. These specialized cells have mostly lost the ability to grow and divide, but a few, typically those of the skin and intestinal lining, can divide in culture about 50 times and then die.

In January this year, biologists at Geron learned how to manipulate the section of DNA that marks off the 50 or so permissible divisions. By reversing the changes in this section of DNA, called the telomere, they created lines of cells that divided well beyond the usual limit and are still going strong, while retaining their youthful vigor and appearance. Biologists refer to these cultured cells as immortal because they are expected to grow and divide indefinitely.

Embyronic stem cells are also immortal because, until they become committed to specialized fates, their telomeres are renewed each time they divide. Unlike ordinary cells, they grow indefinitely in culture.

In the lineage of living organisms, they cycle indefinitely from the embryo to the germ line to a new embryo, forever avoiding specialization into the mortal cell types that comprise the body.

Geron biologists believe they can manipulate the telomeres of the human embryonic stem cells so that the cells stay immortal even as they turn into specialized tissues. Can the mortal body therefore be repaired with new, tissues that remain youthful indefinitely? "Exactly," Dr. Okarma said.

Critics have said it would be folly to tamper with the telomere division-counting system because it probably arose in evolution as the body's last-ditch defense against any runaway cell likely to become a cancer. Dr. Okarma said that new experiments had largely laid this concern to rest by showing that telomerised cells are no more likely to become malignant than are normal cells.

These grand schemes may or may not come to pass, but the techniques now at hand for manipulating human embryonic stem cells will at least allow them to be seriously attempted.

ST. PAUL, MN – Survivors of traumatic brain injuries are less likely to recover well if they have the gene variant ApoE-4, or apolipoprotein E-4, according to a study published in the current issue of Neurology, the scientific journal of the American Academy of Neurology. The ApoE-4 gene type is also associated with an increased risk for the development of Alzheimer’s disease.

In the study, 69 people who suffered blunt head injuries were evaluated for six to eight months by researchers in Israel.

Those who did not adequately recover from the brain damage were 5.6 times more likely to have the ApoE-4 gene than those who did recover well, according to study author Zeev Groswasser, MD, MPH, of Tel Aviv University. A good recovery was considered the ability to live independently and the lack of language or behavioral problems and severe cognitive abnormalities.

"This study shows that a person’s genetic constitution is important in the ability to recover from trauma to the brain," Groswasser said. "This could be very important in tailoring the proper treatment to each patient and in identifying patients who need more intensive rehabilitation after an injury."

Only one of the 27 study participants with the ApoE-4 gene had an excellent recovery, compared to 13 of the 42 participants without the E-4 gene. Those with the E-4 gene were also more likely to remain unconscious following the brain injury for more than seven days.

Apolipoprotein E is a type of protein that carries cholesterol and fats in the blood. People inherit different types of the gene – type 1, 2, 3 or 4. The protein produced by the gene helps cells repair damaged membranes, or cell walls, by transferring the fats needed to repair the walls. But people with the ApoE-4 gene have a decreased ability to transfer the fats properly, according to Groswasser.

Grosswasser said methods need to be developed to treat people with ApoE-4 to improve the cell repair ability. "Also more effective treatments need to be developed for such patients during recovery from traumatic brain injury," he said. "This could include gene therapy, which could perhaps prevent development of Alzheimer’s disease."

Improving care for patients with traumatic brain injuries and other neurological disorders is the goal of the American Academy of Neurology, an association of more than 15,000 neurologists and neuroscience professionals.

American Academy of Neurology: Editor’s Note: Neurology is now published 18 times per year, with two issues in January, March, April, July, September and October. This study is published in the second January issue.

ST. PAUL, MN (March 23, 1998) Seizures caused by video games and television occur less often when higher frequency screens are used, according to a study published in the March issue of Neurology, the scientific journal of the American Academy of Neurology.

Seizures triggered by flashing or flickering lights affect about 10 percent of all new epilepsy patients ages seven to 19, according to the study. In a recent, well-publicized case, more than 700 people in Japan, mainly children, suffered epilepsy-type symptoms after watching a popular cartoon.

The frequency of flashing light that makes up a television image is measured in hertz, or flashes per second. The study was conducted in Europe, where screens operate on a lower frequency than in the United States and are more likely to trigger seizures. In Europe, 50 Hz screens are used; in the United States, 60 Hz screens are used.

In the study, 30 people with prior sensitivity to television or video games - 23 with a history of seizures -- were tested with conventional European 50 Hz screens and 100 Hz screens during television viewing and video game playing. With the 50 Hz screens, more than half of the participants showed signs of seizures during tests of brain activity, or electroencephalograms (EEGs). With the 100 Hz screen, only one participant showed signs of seizure.

In addition, with the 50 Hz screen, moving closer to the screen caused more people to have reactions. With the 100 Hz screen, there was no difference based on distance from the screen, according to neurologist Federico Vigevano, MD, of Bambino Gesù Children's Hospital in Rome, Italy.

Improving care for patients with epilepsy and other neurological disorders through education and research is the goal of the American Academy of Neurology, an association of more than 15,000 neurologists and neuroscience professionals.

Minneapolis, MN (April 28, 1998) -- Epilepsy patients with an implanted device that electrically stimulates the left vagus nerve in the neck continue to have fewer seizures after three years with few side effects, according to a study released during the American Academy of Neurology's 50th Anniversary Annual Meeting, April 25 - May 2, in Minneapolis, MN.

George Morris, MD, study co-author and a neurologist at the Medical College of Wisconsin in Milwaukee, said, "We examined the long-term progress of the patients, including the effect vagus nerve stimulation had on seizure frequency and whether or not that positive effect would be sustained over time. We found evidence of continued seizure reduction and few side effects, most of which diminished over time."

The study followed 253 epilepsy patients who received the implants between 1988 and 1995. After one year, 95 percent of the patients in the study continued receiving stimulation. At two years, 82 percent were still involved in the study and 69 percent after three years. Reduction in seizure frequency improved from 31 percent at one year, to 41 percent at two years and 40 percent at three years.

The impulse generator implanted in the patient's chest stimulates the left vagus nerve in the neck for 30 seconds at five-minute intervals, 24 hours per day. The vagus nerve is the main thoroughfare for communication between the brain and major internal organs.

"Appropriate adjustments in the stimulation intervals must to be made for each patient to optimize the benefit," said Morris. "By the second year the dose may be more accurate, which may account for the improvements in seizure reduction reported during the second and third years. Another explanation is that this therapy works through a long-term modification of seizure pathways, and that it takes time to affect."

Morris said patient continuation rates were high, in part because less than 10 percent reported adverse effects. Side effects reported included hoarseness, headache and shortness of breath, all of which decreased in frequency by the third year. Researchers also noted that twice as many patients decreased their seizure medication over the three years as those who increased it.

"Vagus nerve stimulation is a viable and safe, long-term alternative for some epilepsy patients," said Morris. "The stimulation does not interact with other epilepsy medications, allowing patients to continue other therapies."

Vagus nerve stimulation was approved for use in epilepsy patients in the United States in August 1996. Epilepsy, a brain dysfunction typically manifested by attacks of altered awareness or convulsive seizures, is estimated to affect more than two million Americans.

The American Academy of Neurology, an association of more than 15,000 neurologists and neuroscience professionals, is celebrating its 50th year of improving patient care for people with neurological disease through education and research.

ST. PAUL, MN - New guidelines may help women with epilepsy make decisions about contraception, pregnancy and breast-feeding while managing the disease. The guidelines were issued by the American Academy of Neurology in the October issue of its scientific journal, Neurology.

"The issues are complex for the more than one million women with epilepsy in the United States," said neurologist and co-author Catherine Zahn, MD, of the University of Toronto. "Many women and their health care providers need more information about these issues. It's heartbreaking to hear about women who've been told they should never have children because of their epilepsy or their medications."

Birth defects - The drugs women take to control their seizures can increase the risk of birth defects. The risk of major defects is two to three times higher than the general population risk of approximately two percent. That risk must be weighed against the risks of seizures to mother and fetus, Zahn said.

"Overall, women should be optimistic," she said. "Most women with epilepsy who become pregnant will have successful pregnancies and healthy babies."

•Using only one antiepileptic drug should be the goal of women of childbearing age, as women taking multiple medications may be at higher risk for children with birth defects.

•All women of childbearing age should take folic acid supplements; this recommendation is especially important for women with epilepsy, Zahn said. Folic acid supplementation has been shown to decrease the risk of neural tube defects such as spina bifida in infants of women without epilepsy. Women taking some antiepileptic drugs have an increased risk of having a child with this defect.

Contraception - Some epilepsy drugs can decrease the effectiveness of oral contraceptives. "Even given this reduced effectiveness, oral contraceptives are still as effective as IUDs and more effective than barrier methods such as condoms, when user error is factored in," Zahn said.

•Women and their doctors should discuss this decreased effectiveness in determining the preferred method of birth control.

Breast-feeding - As with all medications, epilepsy drugs will appear in small amounts in breast milk, but this usually does not affect the baby.

•Overall, the benefits of breast-feeding for the infant and the mother are felt to outweigh the small risk of adverse effects due to epilepsy drugs, Zahn said, and breast-feeding can be advocated as an option for women with epilepsy.

•Drugs that are sedating for the mother may cause drowsiness and poor feeding in the baby; those babies should be closely monitored.

•For example, information isn't available regarding the risk of birth defects with several new drugs approved for use in epilepsy in the last five years.

•In another area, many women report that changes in their seizure frequency are related to their menstrual cycle. "Animal studies have shown that estrogen can increase brain seizure activity and progesterone can suppress this activity," Zahn said. "But not enough research has been done on this relationship and how it could be manipulated to reduce seizure frequency in some women."

Researchers also recommend that women with epilepsy develop and maintain a strong relationship with a neurologist or other health care professional knowledgeable about these issues.

To develop the guidelines, researchers conducted a search of 30 years of scientific literature for information on women with epilepsy. The American Academy of Neurology developed the guidelines in conjunction with the American Epilepsy Society, the Epilepsy Foundation of American and the Child Neurology Society.

Each month an article will be published on What is Traumatic Brain Injury. This is done as each month new victims are introduced to traumatic brain injury and it is the victims’ need that Brain Injury Society is concerned with. Articles will also be repeated, as to inform and empower the new victims and families of traumatic brain injury with information and a resource organization to reach out to.

A person with mild traumatic brain injury is a person who has had a traumatically induced physiological disruption of brain function. Such injury is manifested by at least one of the following (Source: Definition of the American Congress of Rehabilitation Medicine Journal Head Trauma Rehabilitation 1993:8(3)86-7):

Individual fibers can be damaged by stretching and tearing when the brain moves (shearing).

These same fibers can also be damaged because of pressure changes caused by the movement of the brain in the closed skull cavity (cavitation).

Typically, traumatic brain injuries occur in falls, auto accidents, sporting accidents, recreational and leisure activities or being struck by an oncoming object. They can also occur from violent shaking, (shaken baby syndrome), from falls in playgrounds, unsafe equipment or surfaces, by being struck by a car or by failing to wear a safety helmet while riding a bicycle, skating, skiing, skateboarding, horseback riding or playing football.

Shaken baby syndrome (shaking the head vigorously) where the infant’s brain is damaged by shaking is a perfect example of a type of situation where TBI occurs.

Broadly-speaking, any type of accident can cause a traumatic brain injury. Any type of traumatic impact event that causes excess movement of the head, or causes the head to strike an object or be struck by an object causes brain injury.

The American Academy of Neurology has defined "concussion" as any alteration in consciousness. It can be (Source: Neurology 1997: 48:581-585):

2.Delayed verbal and motor responses (slow to answer questions or follow instructions); 3.Confusion and inability to focus attention (easily distracted and unable to follow through with normal activities);

4.Disorientation (walking in the wrong direction; unaware of time, date and place); 5.Slurred or incoherent speech (making disjointed or incomprehensible statements); 6.Gross observable incoordination (stumbling, inability to walk tandem/straight line); 7.Emotions out of proportion to circumstances (distraught, crying for no apparent reason);

8.Memory deficits (exhibited by the athlete repeatedly asking the same question that has already been answered, or inability to memorize and recall 3 of 3 words or 3 of 3 objects in 5 minutes); and

9.Any period of loss of consciousness (paralytic coma, unresponsiveness to arousal).

The disability that an individual sustains depends upon the portion of the brain that was injured. Because the frontal and temporal lobes of the brain are exposed to the sharp protrusions on the inside surface of the skull, they are most prone to injury.

In addition to the healthcare costs associated with cognitive rehabilitation services, household assistance and appliances, there are vocational costs that must be addressed.

Loss of earnings must be evaluated. A vocational economic analysis will calculate past and future wage losses based upon the survivor’s diminished earning capacity caused by the brain injury.

Traumatic brain injury can be determined by the use of neuro-psychological tests that are administered by trained neuro-psychologists. PET scan, SPECT scan, and functional MRI’s also provide useful information.

No age is indicative of TBI occurrence. Children as well as adults are not immune to TBI.

Because often a person who has sustained a traumatic brain injury will look normal. If MRI, CT Scans or x-rays of the brain were taken, they can also be normal. These normal findings do not mean that an individual has not sustained a traumatic brain injury. In fact, a MRI or CT scan cannot tell a physician if the patient is awake or asleep, alive or dead. They are not tests of functional impairments.

Every 12 seconds someone in the United States suffers from a brain injury; each year an estimated 500,000 to 700,000 people in this country require hospitalization due to a brain injury, and an estimated 100,000 die as a result of their injury. It is important to remember that a person may physically look fine and yet have sustained a traumatic brain injury that affects his or her memory, day-to-day functioning, and personality.

The overlooked head injury disorder. As sighted beings, seeing is 80% of what we do. Even a small change in vision can have a powerful impact on cognitive and general functioning.

There are vision trauma clinics that utilize in new techniques and rehabilitation therapies. there is also holistic vision care clinic specializing in rehabilitative therapies. Both treat vision related problems resulting from head trauma, whiplash and stroke. In addition, the specialists train the individuals’ eyes to returning to a more normal sight restored and relief of eyestrain resulting from additional strain of reading and the use of computers’.

If you feel there is a vision blurriness that "new" glasses and rest that has not cured, Please call our office and we will be refer you to a vision specialist.

It seems that when confronted with barriers and obstacles, Brain Injury Society comes through. So the appropriate mascot… the bumblebee.

When the universe was created, many experiments in species were created as well. Some could not stand the test of time and elements, such as the dinosaur. Some worked and stayed throughout the ages, such as the bumble. Atomically incorrect, it does the impossible. It has its job. So, too Brain Injury Society.

BIS assists those who call or walk in to the office with going forward for themselves, their families and those interested in helping the acquired and traumatic brain injured individuals.

Volunteers always needed to assist with planning of forums, workshops and conferences, call 718 645-440133. Help graciously welcomed.

Our deepest thanks to Dr. Al Musella, President of the Musella Foundation for Brain Tumor Research & Information, for donating his services to create and continual upgrades our new website, http://www.virtualtrails.com/bis. He not only has kept BIS in hyperspace but also has built the most important brain tumor site http://virtualtrials.com, and set up a company, A1webs, which creates websites. He can be reached at 516 295-4740.

6:00 – 7:00PM 2nd Thursday of each month Please contact: Yehuda Schwartz, Ph.D., Aharon Glustein

Bellevue Hospital Center, East 27^th and First Avenue, Room 6E35, New York, New York 10016

6:00 – 7:00PM, 3^rd Wednesday of each month Please contact: Harold Lifshutz, Ph.D. or Menucha Fogel, B.S., SDS

St. Mary’s Hospital for Children, 29-01 216^th Street, Bayside, New York 11360

7:00 – 8:00PM, 3^rd Wednesday each month Facilitator: Paul Berger-Gross, Ph.D. @ 718 281-8824 or Michelle 718 645-4401

Please call for additional Support Group Schedule. Schedule may change without notice

*Additional support groups to be announced for day and evening to accommodate schedules individual and family schedules.

Beth Israel Medical Center, Second Avenue and East 17^th Street, Manhattan, New York

in Adults and Children after Brain InjuryThursday, December 2 1999, 8:00AM to 4PM

Contributions helped start our library, including from advisory members, K. Menucha Fogel, B.S., SDS, Rolland Parker, Ph.D., Jonathan Silver, M.D., Mark Ylvisaker, Ph.D.

The next step is up to you. All written, audio, software, visual matter pertaining to head injury and trauma, we are interested in. Books, journal materials, booklets, information on all levels. Material packets on community integration, activities in daily living, etc. Call 718 645-4401. We’ll arrange for pick up, with thanks.

Cognitive Science is the interdisciplinary study of the human mind and intelligence. Its aim is to develop an understanding of how humans think and reason; how humans communicate with each other and with machines; and how humans adapt to their environments. Objects of study range from micro-level neurosystems through to complete cognitive systems, and from individuals to groups. These objects of study amount to different levels of cognitive function. But research at one level usually interacts with research at another.

Research methods in Cognitive Science normally fuse together methodologies from more than one discipline, with emphasis placed on: artificial intelligence, computer science, computational and theoretical linguistics, computational neuroscience, philosophy and psychology. The study of cognition involves empirical work within the controlled environment of the laboratory, formal analysis, and the formal and computational simulations of cognitive phenomena. Overall, emphasis is placed on computational work, because cognitive science aims to understand the fundamental computational processes that underly human information processing. Moreover, computational models of some aspect of human behavior can serve as `proof of concept' for formal theories, and they can lead to practical computer technology. Computational modeling encompasses symbolic, stochastic and connectionist approaches. These are often combined, to form hybrid processing systems.

This is the discipline of relating to the study, prescription and appropriate use of drugs for psychiatric illness and for neuropsychiatric conditions. It is sometimes used synonymously with neuropharmacology although technically not so. The neuropharmacologist concentrates on neurologic agents for the brain, the psychopharmacologist on psychiatric agents. Sometimes the term neuropsychopharmacology is used to embrace both these areas. Psychopharmacology is not an official medical specialty in that there is no current specialist board. Additionally, certain non-medical pharmacologists specializing in the brain also call themselves Psychopharmacologists and both medical and pharmacological specialties may be involved in drug prescription - clinical psychopharmacology as opposed to basic lab research - non-clinical psychopharmacology.

The long historical relationship between neurology and psychiatry impacts the area of transient traumatic head injury. This neuropsychiatric link impacts both the actual brain injury facets as well as the psychological elements. Historically, physicians interested in the central nervous system focused either globally on behavior or more specifically on demonstrated pathology of the central nervous system reflecting such terms as "post-traumatic" and "post-concussional" in the brain injury context and interpretations of etiology that were polarized. Most practitioners in the area have had very little exposure, if any, to neuropsychiatry.

Three specialties have approached the area but from rather diverse origins and conceptual frameworks. Behavioral neurologists define brain behavior relationships often through the single case study with generalizations made about the anatomical basis of the manifested behavior and specific localization of similar types of behavior. Neuropsychiatrists emphasize the phenomenology of behavioral disorders and how these correlate with diseases in neurology and the neurologic aspects of behavioral disorders (Tucker and Neppe, 1988). In head injury, the psyche as well as the brain are both recognized as interplaying with each other. Finally, neuropsychologists employ standardized and objective assessments of intellectual, cognitive and psychological functioning, emphasizing a more actuarial and statistical methodology of evaluating behavior.

While each group appears to look at different aspects of the same animal, each has identified important areas of knowledge that are missing in traditional psychiatric, psychological and neurologic training. We will focus here primarily on the comparison of behavioral neurology and neuropsychiatry and make the case for a time-based neuropsychiatric approach applied to the head injury population.

In the context of head injury, exacerbation of pre-existing conditions commonly occurs. In this context, neuropsychiatrists recognize that marked behavior disturbance may correlate with paroxysmal discharges in the temporal lobe on the electroencephalogram (Tucker and Neppe, 1994). While these patients would not be considered to have a seizure disorder by most behavioral neurologists, many neuropsychiatrists believe these patients represent a form of seizure disorder which we for non-prejudicial reasons have called "Paroxysmal Neurobehavioral Disorder" (Blumer and Neppe, in press). We have characterized the individual events as "atypical spells" (Neppe and Tucker, 1992 and 1994; Tucker and Neppe, 1991). Many of these patients respond to anticonvulsant treatment. Similarly, a patient on neuroleptic medication who develops an atypical movement disorder with neuroleptic medication different biochemically or clinically from extrapyramidal reactions may still be labeled "tardive dyskinesia" with a recommendation that the medication be stopped by the Behavioral Neurologist; the Neuropsychiatrist may be prepared to recognize such atypicality and delineate movement disorders different from those of tardive dyskinesia.

There is a need to incorporate the neuropsychiatric approach to the often misunderstood population of patients with closed head injury (Tucker and Neppe, 1991). A gap exists in the evaluation and management of patients with closed head injury primarily because of the differences in approach between neurology and neuropsychiatry. The neuropsychiatric emphasis can be a practical and helpful adjunct to the primary health care providers (neurologists and neuropsychologists) who are primarily responsible for services provided to the closed head injury population. The purpose of this chapter is to discuss the neuropsychiatric approach and offer some clinical ideas to assist health care providers in providing a more comprehensive and thorough evaluation.

The experimental and scientific understanding of mild traumatic head injury (MTHI) has evolved over the past twenty years, with a plethora of research being generated and documented within the scientific literature. At the same time, clinical experience across multidisciplinary lines has increased as health care professionals have continued to interact with this population of patients. It has recently been estimated that approximately two million people annually in the United States experience closed head injury (Brown, & Fann, 1994). Closed head injury represents a significant cause of morbidity and mortality, especially within the younger populations. This has resulted in a considerable increase in health problems associated with the residual sequelae of closed head injury.

Epidemiological studies have documented that within the incidence of closed head injury in general, injuries that are classified as mild or minor typically account for the greater percentage of cases evaluated in emergency room and out patient settings (Goodwin, 1989). This is also the case outside the United States, where estimates range as high as eighty percent (Cohadon, Richer, & Castel, 1991).

While the current body of research literature and experience from clinical practice has provided a greater understanding of MTHI, there continues to be controversy with respect to definition and classification (Kibby, & Long, 1996). Any approach for neuropsychiatric and/or neuropsychological evaluation of MTHI must take into account the confusion that exists in understanding this injury as it is differentiated from more severe injuries and from other neuropsychiatric disorders. Earlier attempts at defining the parameters of MTHI have been seen in the research literature (Colohan, Dacey, Alves Rimel, Jane, 1986, Davidoff, Kessler, Laibstain, & Mark, 1988). The Mild Traumatic Brain Injury Committee of the Head Injury Interdisciplinary Special Interest Group of the American Congress of Rehabilitation Medicine has proposed definitive guidelines, which have been utilized by the research community in more recent studies (Kay, et al, 1993). More current proposals for classification of the spectrum of MTHI have also been suggested (Esselman & Uomoto, 1995).

Despite the clearer definitive guidelines, there continues to be clinical confusion in evaluating and understanding the pathophysiology, symptomatology, and differential diagnosis of MTHI. The use of the terms postconcussive syndrome (PCS)and posttraumatic syndrome (PTS) has been used to describe the pattern of symptom presentation seen in this population of patients. However, this has not led to a clearer understanding of MTHI with respect to evaluation and assessment. In addition, there have been suggestions that mild head injuries should be differentiated from mild brain injuries. Furthermore, there is often the development of secondary psychiatric disorders that may have a physiological and/or psychosocioenvironmental basis, typically referred to among clinicians as psychological overlay, that complicate the clinical presentation of MTHI and make the evaluative process more complex.

Clearly, the greatest scientific and clinical controversy has been associated with the postconcussive nomenclature (Binder, 1986, Lowden, Briggs & Cockin, 1989, Alves, Macciocchi, & Barth, 1993, Kibby & Long, 1996). In general, PCS has been understood to represent the synergistic and interactive effects of physical, cognitive and psychological symptoms seen upon clinical presentation. The assumption is made that there may be physiologic, pharmacologic, psychologic, socioenvironmental, circumstantial, and medicolegal bases underlying the perpetuation of symptomatology. There is also typically a presentation of chronic pain syndrome that may have both physical and psychological factors contributing to the pattern of symptoms and complaints. Neuropsychiatric and neuropsychological evaluation of these patients presents the clinician with a complex task of deciding how to explain the nature of PCS and more importantly what to recommend with respect to treatment.

There is also disagreement among researchers and clinicians as to the duration of PCS and what factors predispose individuals to developing a persistent PCS. Within this context, the issue of premorbid factors such as personality characteristics, past psychiatric history, previous substance abuse, prior incidence of MTHI, and general health problems certainly appears to have an influence on the chronicity of symptoms (Goodwin, 1989).

Because of the confounding issues inherent in the diagnostic assessment of the MTHI patient, a comprehensive time based neuropsychiatric evaluation is proposed to clinically deal with the complexities seen in this patient population. Such a time based evaluation process may not always be necessary, but in cases where there are confusing diagnostic differentials, a time based approach will be helpful in guiding the clinician through the evaluation process. The time based approach will be presented later on in this chapter.

We further propose a neuropsychiatric nomenclature and classification based on the practical aspects of evaluation, which are more meaningful to the clinician in everyday practice. These clinical distinctions should not be considered distinct entities, but rather as clinical aspects of a dynamic post head trauma spectrum that can be useful in guiding the clinician in the evaluation process. We will attempt to integrate current research findings and clinical experience into a methodology for neuropsychiatric evaluation that is first of all useful to the patient and secondly reflects clinical acumen and multiclinical diversity.

lectroencephalograms or EEGs are a basic screening measure of brain waves which is performed in neuropsychiatry both to detect abnormal firing in the brain and to find local (focal) abnormalities. Both sleep and wake EEGs with activating procedures such as hyperventilation and photic stimulation are useful as each can give valuable information and demonstrate abnormalities. Hyperventilation - overbreathing - which changes the proportion of carbon dioxide in the body and therefore the acidity / alkalinity level should be performed only in the absence of medical conditions contra-indicating it. EEGs appear reasonable in neuropsychiatric evaluations when there are seizure history possibilities or possible temporolimbic features (as reflected on the INSET), or with the episodic nature of symptoms or a history of atypical spells . Sleep records have been well demonstrated to more likely find focal pathology than waking EEGs which is why they are generally routinely performed now. However waking EEGs have also have a high pick up rate and sleep EEGs cannot be interpreted without the wake EEG justifying a wake record.

Prior to the development of the EEG, by the neuropsychiatrist, Hans Berger in the 1930's, all seizure disorders were classified with mental disorders. EEG technology still remains rather primitive and reflections of brain waves from the perspective of analysis of psychopathology somewhat limited. Nevertheless, the only definitive way of demonstrating that a symptom or physical sign such as, for example, an olfactory hallucination is definitely epileptic, is the demonstration while the person is having that experience of correlates of seizure phenomena on EEG, such as spike-wave paroxysms - episodes of half to several seconds of usually sharp abnormal brain waves, sometimes localized in the brain e.g. in the right temporal lobe. This demonstration is unusual unless the seizure phenomena are relatively uncontrolled, as an EEG is just a short cross-sectional measure for an hour or two of a patient's life-cycle. Even in the event of the patient having an experience which may be a seizure, the EEG correlate may not necessarily be of a spike wave kind but depending on location, it could be normal or show a marked slowing, with a non-specific theta rhythm generally of limited help unless focal or a delta rhythm, which is frankly abnormal unless the patient is asleep (theta is 4 to 7 cycles per second, delta is less than 4). It is occasionally extremely difficult to localize such features on scalp EEG even when firing is occurring because symptoms may occur from the mesial temporal or deep structures within the brain which do not easily manifest on surface EEGs.

Routine Electroencephalograms (EEGs) involve both waking records with special activating procedures such as hyperventilation and photic stimulation (in the absence of medical conditions contra-indicating these) as well as sleep records. EEGs should be ordered not only in possible seizure disorder , but appears reasonable given any possible temporolimbic features, episodic nature of symptoms or history of atypical spells. Sleep records may increase the potential delineation of focal abnormality such as a temporal lobe focus by approximately fourfold than waking EEGs. However waking EEGs have a high pick up rate and sleep EEGs cannot be interpreted without the wake EEG so both should be performed. A normal EEG does not imply absence of epilepsy.

EEGs are possibly under-used in psychiatry partly because electroencephalographers have a broader range of what constitutes normality searching mainly for focal and seizure phenomena. They are generally not psychiatrists and potentially valuable research and clinical information may be lost. For example, testable hypotheses are that relatively flat EEG tracings may be more common in certain personality disorders, with certain psychotropics, or in a subpopulation of schizophrenia. Seldom is this kind of background even reported on.

The administration of chloral hydrate (e.g. 1 gram as premedication) prior to the sleep record is useful as this induces sleep with little changes of significance in the electroencephalogram and does not prevent the demonstration of focal abnormalities. Certain medications should be particularly avoided in EEGs. The benzodiazepine group are the worst offenders as by virtue of their very strong anti-epileptic effects, they have profound effects in normalizing the EEG. Such effects at a receptor level may last weeks even with the apparent short acting benzodiazepines so that the yield of demonstrating epilepsy after the patient has had benzodiazepines administered apparently decreases substantially, although adequate data in this regard is not easily available.

Special electrode placements may increase yield by a few percent, but are seldom used today: With nasopharyngeal electrodes, the greater yield was insubstantial; and sphenoidal electrodes placement, unfortunately, requires time and expertise and cause discomfort limiting their use. A recent suggestion, which I recommend, has been the placement of electrodes on the buccal skin surface in the area of the submandibular notch - possibly as effective in picking up foci as sphenoidal placements. Specialized centers use cerebral cortical or submeningeal strip placements during neurosurgery procedures and these may show firing, for example, in patients with temporal lobe epilepsy and psychosis, in the region of the hippocampus. The direct placement of intracranial electrodes shows how commonly spike firing may be occurring in this area with no correlate of any kind on surface EEGs.

Developments in this regard have been rapid over the past few years. EEG Telemetry involves prolonged monitoring over periods of time varying from 12 hours to 2 weeks while the patient is generally confined to a particular room. Cable telemetry is most commonly used. This involves, for example, a 25 foot cable connected to the EEG montage on the patient's head. Very often no seizure manifestations are picked up for prolonged periods of time because seizures only occur paroxysmally. Moreover, those patients evaluated in a specialized center with EEG telemetry are invariably so atypical that the hypothesized seizure originates deep within the brain. The apparatus is very expensive and the costs involved in monitoring patients are thousands per day at times for two weeks. Instead, home ambulatory electroencephalograms are easily available and should in psychiatry become the state of the art.

Home Ambulatory Electroencephalograms (EEG) with the patient not modifying medication is a valuable test as the patient's symptomatology can be monitored day and night in a natural environment of home using computerized filtering of artefact. The advantage of this technique is to establish if any scalp electrode can detect events such as atypical spells alerted to by pushbuttons, which could be reflecting deep brain electrical activity . It has limited availability at this point, however, but our pick up rate for atypical spells (paroxysmal neurobehavioral disorder) and seizures is very high - a major advance over routine electroencephalography. Recent advances in EEG technology may ultimately change the whole perspective in its use in psychiatry. Computerized EEG monitoring allows breakdown of wave forms and allows correlation with evoked potentials including cognitive evoked potentials. It also facilitates demonstrations of changes in particular areas of the brain, which can be easily delineated at a visual level. This should prove to be a useful psychophysiological correlate of psychopathology. Indeed, this may be the beginning of an important new era. However, at this point in time it is still experimental.

Ambulatory Electroencephalogram (EEG) with the patient not modifying medication is a valuable test given episodic symptomatology, which can be monitored day and night in a natural environment of home using computerized filtering of artefact. One advantage of this technique here is to establish if any scalp electrode can detect events such as atypical spells alerted to by pushbuttons reflecting deep brain electrical activity.

Simply stated, the time based evaluation presupposes that traditional evaluation procedures may not always be sufficient in properly understanding the etiology and manifestations of the CHITS. The traditional neuropsychiatries evaluation has routinely consisted of a diagnostic interview process, review of background information, mental status examination and possibly some lab testing. This is often accomplished in a single session or over two sessions with the patient. If predominant cognitive sequelae exist, a referral to a neuropsychologist is often made.

The neuropsychologist or neuropsychiatrist in turn completes another one time clinical interview, administers a battery of neuropsychological tests, reviews available medical and other pertinent records, and forms a clinical impression based on this limited time with the patient. At times, there may be additional collateral information obtained from significant others, usually obtained during a single session.

This traditional process of evaluation gives the clinician a sample of the patients physical, cognitive and psychological behavior that is essentially a snapshot view much like the instant results obtained from the Polaroid picture. The information obtained from this snapshot approach gives the clinician a small slice of how the patient is functioning at a given point in time. This represents a very limited sample of the patients behavior.

Yet as health care providers, we continue to evaluate patients with CHITs in this way and we make inferential leaps and generalizations affecting our conclusions and our recommendations. While this approach may be sufficient in assessing many clinical syndromes, it can lead to many false positives and false negatives within the population of head trauma patients. The current data base of research findings and multidisciplinary clinical experience would suggest that this snapshot approach does not give the evaluator enough information to clearly understand the dynamics presented in many patients with CHIT.

There are obviously many cases of CHIT where the findings derived from a single snapshot approach to evaluation will be sufficient to make appropriate recommendations. However, clinical experience has shown that there is often a need to defer final clinical impression until the clinician has had more time with the patient. This is encountered frequently among clinicians who work with the head injured patient on a daily basis.

When clinicians begin the evaluation process with a patient, we often make underlying assumptions with respect to the patients abilities as a historian. We usually collect our data directly from the patients report. We fail to realize that with patients experiencing head trauma symptoms, there is usually a diminished ability to be aware of ones self and insight is often reduced. Furthermore, there are concurrent deficits in expressive speech that limit the patient in their attempt to completely express the full range of their ideas and recollections about their functioning. These patients almost always complain of difficulty expressing their thoughts and ideas and formulating a self-analysis of their behavior. When the very part of us as human beings that we refer to as "self" is experienced as changed because of underlying pathophysiological disruption, it is difficult to fully appreciate the meaning and effects of this change, let alone try to express this clearly and cogently during the brief time period of diagnostic interviewing. We must always remember that when we refer to head trauma we are also referring to trauma to the mind and its ability to experience and cope with the after effects of the trauma and in turn communicate these after effects to health care providers.

When these patients present their complex constellation of physical, cognitive and psychological changes following head trauma, the clinician needs to give them the time to render a comprehensive self report. Because of diminished awareness and insight, a patient may not be able to fully convey the qualitative aspects of their complaints. They also may not be able to remember everything they need to tell the provider. Memory problems are typically one of the chief complaints in the CHIT syndrome. This makes it difficult for patients to organize and recall their experience of changes in their perception of self.

With a time based approach, we interact with the patient over a number of sessions allowing for the time to obtain a film strip version of the patients experiences, symptoms and complaints. This approach minimizes the tendency to over or under diagnose and increases the validity and reliability of the data collected from the diagnostic interviewing.

The clinician gathers data from a variety of the patients life experiences over time and establishes greater validity to the spectrum of symptomatology. Patterns of symptoms and complaints become clearer as the patient interacts within their familial, social and occupational environment over the course of days and weeks. The health care provider begins to obtain a time based sample from the diverse topography of everyday life. This topographic elicitation of symptom manifestation within the context of the patients personal ecology of life circumstances gives a three dimensional perspective of symptomatology over time, across situations, and within different environments. We refer to this as a time based topographic validity. More simply stated, this validity is based on the presupposition that there is no substitute for time when it comes to case formulation of the dynamics involved in CHIT.

Over the course of time spent with the patient, we advocate utilizing a variety of assessment procedures to attempt to substantiate the patterns of physical, cognitive and psychological problems being presented.

In essence, premorbid and predisposing features are often missed with single evaluations. Undetected problems are regarded as not existing instead of not diagnosed because evaluations are too short. In some instances, particular conditions are especially undiagnosed: in our experience, many have CPSzs which remain undetected and moreover false reassurance by practitioners doing such single or cursory evaluations ultimately may harm the patient: the condition is not diagnosed and the patient regards his/ her symptoms as psychological when there is a good physical base. Moreover, sometimes when symptoms have persisted over months, the patient is investigated neuroradiologically and when no positive findings are found, this is in error could be regarded as proof of the post-traumatic syndrome etiology and the absence of organicity. In actuality, invariably changes which may have been detected neuroradiologically early on in the first month, no longer can be found and this implies not psychological etiology but incorrect timing of the neuroradiologic evaluation.

Finally, we emphasize the real world approach, Neuropsychological testing in a quiet office, with encouragement and one on one testing with one single task at a time may be insensitive to the subtle changes that a bustling office of multitasked demands may bring. Many people require such multitasking in their regular occupation e.g. physicians.

e have chosen to modify the definition proposed by the Interdisciplinary Special Interest Group of the American Congress of Rehabilitative Medicine (Kay, et al, 1993). Proposed instead is the use of the term closed head injury of transient kind (CHIT) to describe a traumatic induced psychophysiologic event that occurs to the head which produces initially little or no unconsciousness, limited retrograde and anterograde amnesia and alteration of consciousness that does not last longer than a day. We feel the term "closed" head injury should be used because injuries involving skull fractures and open exposure of the brain have their own special characteristics such as infection, vascular phenomena and focal disease. We prefer terms like "head" to "brain" because this way psychiatric sequelae are not necessarily implied to have a definite organic base. We understand that there is an observable and diagnosable cluster of physical, cognitive and psychological symptoms that is associated with CHIT and is most usefully defined as posttraumatic CHIT syndrome (PTCHITS). Because injury usually implies "traumatic" we see redund

Vernon M Neppe MD, PhD, FRCPC, FFPsych, MMed, DipABPN, DPsM, DABFE, DABFM, FACFE, MB, BCh, BA,

Director, Pacific Neuropsychiatric Institute, Seattle, WA , Adj. Professor of Psychiatry , St Louis University, St Louis, MO and Glenn T. Goodwin PhD , Pacific Neuropsychiatric Institute

The brain is a vital part of the central nervous system and serves as the control center for all of the body's functions including conscious activities such as walking and talking, and unconscious ones such as breathing, heart rate, etc. Additionally, the brain controls thought, comprehension, speech and emotion. Injury to the brain--whether the result of severe head trauma such as a gunshot wound or a fall, or a closed head injury in which there is no fracture or penetration of the skull - can disrupt some or all of these functions.

Enclosed within the skull, the brain is a gelatinous material that floats within a protective sea of cerebrospinal fluid. This fluid supports the brain and acts as a shock absorber in rapid head movements. Both the brain and the cerebrospinal fluid are protected to some degree within the bony framework of the skull. The outer surface of the skull is smooth, but the inner surface is rough and jagged and can cause significant damage in closed head injuries. In such injuries, the head and body in motion are abruptly stopped, causing the brain to rebound within the skull and move over these rough bony structures.

There are three main areas of the brain: 1. the cortex (cerebrum), 2. the cerebellum, and 3. the brain stem (diencephalon). The cortex is the largest of the three and is the center where most thinking functions occur. It is divided into four lobes, each of which controls particular functions and skills. Additionally, the cortex is divided into two hemispheres: the right and the left. The left hemisphere is usually the dominant of the two and controls verbal functions such as speaking, writing, reading, and calculating. The right hemisphere usually controls more visual-spatial functions such as visual memory, copying, drawing, and rhythm. The cerebellum controls coordination, balance and posture.

The brain stem acts as a relay station between incoming sensations and the cortex, which processes and interprets those sensations. The brain stem connects the two hemispheres of the brain to the spinal cord and is also the point of origin for 12 cranial nerves. When incoming stimuli travel through the brain stem and are received by the cortex, a response is generated and then relayed back through the brain stem to the body. Because of its vital role as a relay station and its function in controlling consciousness, alertness and basic bodily functions, the brain stem is perhaps the most critical area in terms of damage to the brain.

Traumatic brain injury can have serious and lifelong effects on the physical and mental functioning of the survivor. Loss of consciousness, permanently altered memory and/or personality, partial or complete paralysis, and persistent vegetative state are just some of the devastating possibilities brain injury survivors and their families face.

The term "brain injury" refers to any injury of the brain and can be caused by fracture or penetration of the skull (such as in the case of a vehicle accident, fall or gunshot wound), a disease process (neurotoxins, infections, tumors, metabolic abnormalities, etc.) or a closed head injury such as in the case of Shaken Baby Syndrome or rapid acceleration or deceleration of the head. These injuries can have devastating lifelong effects on the physical and mental functioning of the survivor.

Depending on the location and severity of the injury, the body can be affected in a myriad of ways. When the injury results from head trauma, damage to the brain may occur at the time of impact or may develop later due to swelling (cerebral edema) and bleeding into the brain (intracerebral hemorrhage) or bleeding around the brain (epidural or subdural hemorrhage). When the head is hit with sufficient force, the brain turns and twists on its axis (the brain stem), interrupting normal nerve pathways and causing a loss of consciousness. If this unconsciousness persists over a long period of time, the injured person is considered to be in a coma, a condition caused by the disruption of the nerve fibers going from the brain stem to the cortex.

If the injury is severe, as in the case of an acceleration-deceleration injury in which the moving head impacts against a hard, fixed surface, multiple areas of the brain are damaged. For example, a compression fracture occurs in the area where the head impacted the fixed surface. Upon impact, the brain rebounds forward and backward against the skull (this is called coup-contracoup), which tears the subdural veins, causes damage to the temporal lobes as they move across the rough bony structures within the skull, and results in bleeding, swelling of the brain stem, and shearing of the blood vessels and nerve fibers.

The term "closed head injury" is used when the brain has been damaged without penetration of the skull by another object. One example of this is Shaken Baby Syndrome, in which the brain is damaged by severe and violent shaking or twisting. Such injury often occurs without leaving obvious external signs. The difference between closed and penetrating injuries can be profound. In a bullet wound to the head, for example, a large area of the brain may be destroyed but the resulting neurologic deficit may be minor if that area was not a critical one. In contrast, closed head injuries result in more widespread damage and can result in more extensive neurologic deficits. These deficits can include partial to complete paralysis, cognitive, behavioral, and memory dysfunction, persistent vegetative state, and death. These last two are the most feared outcomes in cases of brain injury, however advances in trauma care have led to decreased rates for both in recent years.

Beyond the obvious physical effects of brain injury, survivors frequently cope with depression, anxiety, loss of self esteem, altered personality, and in some cases, a lack of self-awareness by the injury survivor of any existing deficits.

•A conservative estimate puts the total number of traumatic brain injuries (TBI) at over two million per year, with 500,000 severe enough to require hospitalization.

•Every 15 seconds someone sustains a brain injury in the U.S.; every five minutes, one of those people will die and another will become permanently disabled.

•Each year 75,000 to 100,000 Americans will die as a result of a TBI. Most deaths occur at the time of injury or within the first two hours of hospitalization.

•Of those who survive their initial injury, approximately 70,000 to 90,000 will endure lifelong debilitating loss of function. An additional 2,000 will exist in a persistent vegetative state.

•Young men between the ages of 14 and 24 have the highest rate of injury. Males are more likely to suffer serious brain injuries than are females.

The risk of TBI among men is more than twice that of women. The ratio of male to female incidence is approximately 2.5 to 1. Mortality ratios are approximately 3.5 to 1 (Kraus 1995; Kraus and McArthur 1995). This is probably due to gender differences in risk-taking activities and exposure to occupational hazards. Populations at highest risk include males aged 14 to 24 years, followed by infants and children, then the elderly (Kraus 1993: 10). Over 50% of TBI injuries occur among this population age range.

Ethnic and socio-economic origin are significant risk factors in the occurrence of TBI. The Afro-American population has a higher rate of TBI than other ethnic groups in the United States. Most of these incidents are related to homicide. The TBI risk pattern of economically-disadvantaged groups is significantly higher in comparison to high-income populations (Kraus 1993:11).

Another significant risk factor in the incidence of brain injury is the occurrence of a previous brain injury. After a TBI incident, the potential risk for subsequent multiple injuries is extremely common. Among people with an initial TBI incident, the risk of a second injury is three times that of the general population, and after a second brain injury, the potential risk for a third one increases to eight times that of the normal average (Solomon and Sparadeo 1992).

Children are at a particular risk of bicycle-related injuries and deaths. Most brain injuries occur during the summer months (i.e. May, June and July) (Mazurek 1994). 76% of TBIs occur among children less than 15 years of age. Boys are more likely than girls to sustain a brain injury.

•A survivor of a severe brain injury typically faces 5 to 10 years of intensive services with an estimated lifetime cost of $4 million.

•The economic cost of TBI in the United States approaches $25 billion per year.

Source: Head Injury Task Force Reports, National Institute of Neurological Disorders and Stroke, National Institutes of Health, 1990.

Disclaimer: The exact percentage of TBI mortality and morbidity is rather unknown. It is, however, estimated based on epidemiological studies using different statistical methodologies and approaches. Because methodologies differ in defining and identifying significant cases of TBI mortality and morbidity, statistical data on this issue may vary.)

Worldwide TBI mortality rates range from about 15 to 30 per 100,000 population annually. Based on current census reports, it is estimated that TBI claims approximately 1,165,000 lives per year (Kraus 1995). Of the five to ten percent of deaths related to general injuries, approximately 40% is associated with traumatic brain injury (Kraus 1995).

In the United States, it is estimated that 300,000 people were admitted to the hospital with a TBI in 1992. 5 to 10% of the number of people hospitalized with an injury die from TBI (Kraus 1995). Among the hospitalized survivors, one in five will suffer significant long-term disability (Kraus 1995).

TBI results in long-term disabilities for more than 75,000 people each year (Committee on Trauma Research, National Research Council. Injury in America: A Continuing Public Health Problem. Washington, D.C.: National Academy Press, 1985.)

The Centers for Disease Control and Prevention estimates that TBI claims more than 50,000 lives each year. At this rate, American deaths from TBI since 1977 exceed the total of war dead from all US wars, including the Civil War. In the meantime, 70,000 to 90,000 people have moderate to acute brain injuries that result in disabling conditions which may last a lifetime. (NAGHSR NEWS).

More than half of all TBI deaths occur at the scene of the injurious event. Half of all fatalities among TBI occur within 10 minutes of the incident (Kraus 1995).

•Motor vehicle crashes account for 50% of all fatal and non-fatal TBIs. This includes all crashes involving cars, trucks, motorcycles, bicycles, and pedestrians. The majority of fatal brain injuries are due to motor vehicle crashes (43%) and firearms (34%) followed by falls (9%).

•Between 32 and 73% of all brain injuries resulting in hospitalization are accompanied by a high blood alcohol level. Fatality crashes involving men are much more likely to be alcohol related than those involving women (The Insurance Institute for Highway Safety 1994). One study found a positive history of alcohol abuse or dependence prior to injury in 58% of TBI survivors. Heavy drinkers are much more likely to be intoxicated at the time of injury (57%) than those without a history of heavy drinking (31%) (Solomon and Sparadeo 1992).

•Among the elderly, falls are second only to motor vehicle crashes as the leading cause of TBI (Heath 1994).

•Each year in the United States, 50,000 children sustain bicycle related brain injuries. Over 400 of these children die as a result of their injuries.

•PHYSICAL: Impairment of speech, vision and hearing loss, headaches, muscle spasticity, paralysis and seizure disorders.

•COGNITIVE: Memory deficits (short and long-term), limited concentration, impaired perception and communication, difficulties with reading, writing, planning, and judgment.

•PSYCHO-SOCIAL/BEHAVIORAL/EMOTIONAL IMPAIRMENTS: Fatigue, mood swings, denial, anxiety, depression, sexual dysfunction/dyscontrol, lack of motivation, and problems with interpersonal skills.

Helmets, seat belts, airbags, and car seats have been proven to reduce TBI incidents and death (Heath 1991). Brain injury is the leading cause of death in bicycle incidents. It causes 75% of the approximately 1,000 bike-related deaths that occur each year, according to the May 1990 Consumer Reports. Bicyclists are at greater risk of brain injury than motorcyclists. When collision occurs, bicyclists tend to land on their heads, whereas motorcyclists usually hit another part of their body first.

Universal use of helmets by all bicyclists could prevent as many as 2,500 deaths and 757,000 brain injuries (i.e. one death every day and one brain injury every four minutes). According to the National Association of Governors' Highway Safety Representatives, brain injury is the leading cause of death in bicycle crashes.

Wearing helmets can reduce the risk of TBI by 85 percent. The use of helmets significantly reduced the incidence of severe brain injury in the nonintoxicated individual but provided no such protection for the intoxicated (Solomon and Sparadeo 1992). Mortality is reduced by 38% when motorcyclists wear helmets, and the frequency of hospitalization and severity of injuries decline significantly (Kraus 1995b). Studies suggest that mortality can be reduced to 40% in people who sustained brain injuries with timely surgical intervention and case monitoring (Miller 1993).

Maintaining a trauma center with enhanced emergency transport may reduce TBI by 20% (Kraus 1995a). Among survivors, outcome seems to depend on two factors: a) tear necrosis or nerve tissue degeneration and b) swelling of the brain tissues leading to the nerve tissue necrosis. Unless these factors are prevented, permanent brain damage will certainly follow (Kraus 1995b).

Head trauma is the number one cause of death and disability among people between the ages of one and 44 -- but it doesn't take a miracle for patients to come out of a coma and do well -- it takes the application of good science. There's a revolution in the making in the treatment of coma patients. Bookmark this site, and inform yourself.

Sunday, April 25, 1999 Tillison Tumor Care Foundation had the Founder and Executive Vice President of Brain Injury facilitated on the symposium. The friendship between the Fillison Research Center and Brain Injury Society started just over a year ago and the both founders have exchanged information and ideas for survivors of brain tumors, brain cancers, traumatic brain injuries, resources and techniques in therapy.

Menucha Fogel was asked to speak on the topic "TBI Survivor - the forgotten victim. How Brain Injury Society with brain injury recovery from a dual survivor's point of view" Notable speakers from across the country were on the website conference. They included: Dr Peter Black from Brigham and Woman's Hospital in Boston Mass.; Dr Arno Fried Pediatric Neurosurgeon from Hackensack University Medical Center; . Penny Price, Founder of the Tillison Research Center, Topic.. The TRC and programs it offers and how to find the help that you need.; Kathleen McCarthy RNBSN, A brain tumor patient and nurse. Topic " Rehab and brain injury ... from tumor to treatments "

Tillison Research Center c/o Penny Price, 837 Miner Street , South Bend, IN 46617 , 219-287-6337

Contact Menucha Fogel, B.S., SDS, 1901 Avenue N - Suite 5E, Brooklyn, New York 11230, 718 645-4401

Professional TBI Monthly Seminars at Hospital of Joint Disease, Manhattan, NY – No Admission Charge

Contact Rolland Parker, Ph.D., 50 West 96^th Street, - 9C, New York, NY 10023, 212 222-4543

That was easy, huh? Well, sure, after all you're in your house a lot, so it makes sense that you would know where stuff was. But can you think of anything else you are with day in and day out--while you are awake and asleep, while you are inside and outside of your house--that you may not know your way around?

What about your brain? It's with you everyday. It regulates your breathing, tells your feet when to walk or run, and allows you to be happy and sad. But where exactly inside your head does all that stuff happen? With a little help from your hands, a friend, a small ball, and a pencil, you can become your own brain geographer, and find out.

Photograph of hands held together, holding a ping-pong ball, with a pencil trapped between the two arms. You're trying to make something that looks like this. First place the palms of your hands together. Now bring your elbows together and curl in your fingers to create two fists. Have a friend place a golf ball or table tennis ball in between your fists.

Now inch down the tips of your thumbs until they meet with the tips of your index fingers. Finally, have a friend place a pencil in between your closed forearms.

The golf ball represents the limbic system, which is involved in basic emotions and feelings that, in part, make up your personality. When something scares you, it is this part of the brain that makes you want to run away or stay and stand up to whatever frightened you, e.g. commonly referred to as the "fight or flight response". The limbic system is also associated with your ability to remember.

The bulge created by your thumbs represents the cerebellum, the part of your brain that coordinates all of your body movements. The cerebellum performs many functions, including storing learned body movements. For example, if you haven't ridden a bike in a long time and get back on one, your body "remembers" what it needs to do to keep the bike stable. This is why you "practice" sports, so that your cerebellum automatically can remember all the right moves.

The pencil represents the spinal cord, which receives information from your skin and muscles and passes it up to the brain and also sends messages back down. The spinal cord is a fragile bundle of nerves protected by the spinal column. The column, represented by your forearms, is made up of a chain of disc-shaped bones.

Your wrists represent the brain stem, a small but important extension of your spinal cord. The brain stem manages messages going between the brain and the rest of the body, and it also controls basic body functions such as breathing, swallowing, heart rate, and blood pressure. Your brain stem also controls your consciousness, being awake, or being sleepy.

Your fists represent the cerebral cortex, the most complex area of your brain. Notice how it is divided into two equal half balls, or spheres, called hemispheres. The left hemisphere is dedicated to processing information logically in a step-by-step manner. For example, it helps you read, speak, and write language or compute an equation. The right hemisphere is responsible for more processing of spatial information, such as recognizing a friend's face, or appreciating a piece of artwork. Quite simply, your left hemisphere sees the "trees" (details), while your right hemisphere sees the "forest" (big picture).

Only in America...at the entrances of skating rinks there are handicap parking places.

Only in America...do drugstores make the sick walk all the way to the back of the store to get their prescriptions. Oly in America...do people order double cheese burgers, a large fry, and a diet coke...

Only in America...do we use the word "politics" to describe the process so well: "Poli" in Latin meaning "many", and "tics" meaning "blood-sucking creatures"...

Only in America...is spending 40 million plus on a political sex scandal permissible and then cut Medicare and health benefits to the disabled and the elderly.

She came home one beautiful spring day to tell me she had competed in "field day" –

Because of her leg support, my mind raced as I tried to think of encouragement for my Sarah, things I could say to her about not letting this get her down - but before I could get a word out, she said, "Daddy, I won two of the races!"

Ah. I knew it. I thought she must have been given a head start... some kind of physical advantage.

Every day, with words we speak, we have a remarkable opportunity to do good and to improve the lives of those around us.

When we speak to family, friends’ even strangers, in a gentle, considerate way, our words become conductors of tremendous positive power. We can alleviate loneliness and despair, build self-confidence and respect, and even turn a tense, volatile household into a peaceful, harmonious one.

Speaking gently is an act of kindness. A good deed can be preformed in almost every conversation and with no expenditure of time or money. All that’s is needed is awareness.

When we greet an acquaintance on the street, at work or in school, we can make that person feel sincerely acknowledged. When we ask a child, a spouse or colleague to perform a task, we can make them fee needed and appreciated. When we need to reproach others, we make them feel our loving concern for their welfare. And when we speak to someone, who is facing difficulties, we can make him or her feel understood and supported.

Bu gearing our speech to accomplish these positive effects, we have the ability to create tremendous good in our immediate world.

For free copy of this message, send SASE attn: LTP to The Chofetz Chaim Heritage Foundation, 6 Melnick Dr., Monsey, NY 10952, 914 352-3505

Psychiatrists say that 1 of 4 people is mentally ill. Check three friends. If they are OK, you are in a world of trouble.

Paranoids are people too; they have their problems. It's easier to criticize, but if everybody hated you, you'd be paranoid to.

When you're having a really bad day and it seems like people are trying to get the better of you,

remember it takes 42 muscles to frown and only 2 to make them wonder what you are smiling about.