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Background/aimTo evaluate the association of genetic polymorphisms APOE,APOEG-219T promoter, microtubule associated protein(MAPT)/tauexon 6 Ser53Pro, MAPT/tauHist47Tyr,IL-6572 G/C andIL-6RAsp358Alawith the risk of concussion in college athletes.MethodsA 23-centre prospective cohort study of 1056 college athletes with genotyping was completed between August 2003 and December 2012. All athletes completed baseline medical and concussion questionnaires, and post-concussion data were collected for athletes with a documented concussion.ResultsThe study cohort consisted of 1056 athletes of mean±SD age 19.7±1.5 years,89.3% male, 59.4% Caucasian, 35.0% African-American, 5.6% other race. The athletes participated in American football, soccer, basketball, softball, men’s wrestling and club rugby. A total of 133 (12.1% prevalence) concussions occurred during an average surveillance of 3 years per athlete. We observed a significant positive association betweenIL-6RCC (p=0.001) and a negative association betweenAPOE4 (p=0.03) and the risk of concussion. Unadjusted and adjusted logistic regression analysis showed a significant association betweenIL-6RCC and concussion (OR 3.48; 95% CI 1.58 to 7.65; p=0.002) and between the APOE4 allele and concussion (OR 0.61; 95% CI 0.38 to 0.96; p=0.04), which persisted after adjustment for confounders.ConclusionsIL-6RCC was associated with a three times greater concussion risk andAPOE4 with a 40% lower risk.

This article reports on a case of a glandular odontogenic cyst (GOC) in the posterior mandible of a 25-year-old male treated with peripheral ostectomy, bone allograft, and an implant-supported fixed dental prosthesis. During a routine 3-month postoperative visit, a radiograph suggested vertical bone loss on the implant in the location of the mandibular right first molar. The three-walled defect was surgically treated with debridement, bone allograft, and a membrane. Healing of this site has been uneventful. This case report demonstrates that implants can be successfully placed and restored in previously affected GOC sites.

Background: Neurocognitive status may be a risk factor for anterior cruciate ligament (ACL) injury. Neurocognitive domains such as visual attention, processing speed/reaction time, and dual-tasking may influence ACL injury risk via alterations to neuromuscular performance during athletic tasks. However, the relationship between neurocognition and performance during athletic tasks is not yet established. Hypothesis: Athletes with low baseline neurocognitive scores will demonstrate poorer jump landing performance compared with athletes with high baseline neurocognitive score. Study Design: Controlled laboratory study. Methods: Neurocognitive performance was measured using the Concussion Resolution Index (CRI). Three-dimensional kinematic and kinetic data of the dominant limb were collected for 37 recreational athletes while performing an unanticipated jump-landing task. Healthy, nonconcussed subjects were screened using a computer-based neurocognitive test into a high performers (HP; n = 20; average CRI percentile, 78th) and a low performers (LP; n = 17; average CRI percentile, 41st) group. The task consisted of a forward jump onto a force plate with an immediate rebound to a second target that was assigned 250 milliseconds before landing on the force plate. Kinematic and kinetic data were obtained during the first jump landing. Results: The LP group demonstrated significantly altered neuromuscular performance during the landing phase while completing the jump-landing task, including significantly increased peak vertical ground-reaction force (mean ± SD of LP vs HP: 1.81 ± 0.53 vs 1.38 ± 0.37 body weight [BW]; P < .01), peak anterior tibial shear force (0.91 ± 0.17 vs 0.72 ± 0.22 BW; P < .01), knee abduction moment (0.47 ± 0.56 vs 0.03 ± 0.64 BW × body height; P = .03), and knee abduction angle (6.1° ± 4.7° vs 1.3° ± 5.6°; P = .03), as well as decreased trunk flexion angle (9.6° ± 9.6° vs 16.4° ± 11.2°; P < .01). Conclusion: Healthy athletes with lower baseline neurocognitive performance generate knee kinematic and kinetic patterns that are linked to ACL injury. Clinical Relevance: Neurocognitive testing using the CRI may be useful for identification of athletes at elevated risk for future ACL injury.

Background AESKUSLIDES ANCA is an indirect immunofluorescence assay used to detect anti-neutrophil cytoplasmic autoantibodies (ANCA) in human serum. This in vitro diagnostic assay is used as an aid for the diagnosis of ANCA-associated vasculitis (AAV) in conjunction with other clinical and laboratory findings. Methods A method comparison of ethanol and formalin fixed granulocytes was carried out between AESKUSLIDES ANCA (AESKU. Diagnostics) and the NOVA Lite ANCA of INOVA. 507 clinical serum samples (comprising 135 serum samples from patients with AAV and 375 samples from patients with other diseases) were analysed by standard IFA protocols. Results were obtained by manual processing and reading. Results In this cohort, AESKUSLIDES ANCA Ethanol slides show higher sensitivities (48.5% vs. 36.4%) and specificities (69.3% vs. 55.2%) compared to INOVA. AESKUSLIDES ANCA Formalin slides show higher sensitivities (50.0% vs. 37.9%) and similar specificities (90.7% vs 91.5%) compared to INOVA. Conclusions AESKUSLIDES ANCA Ethanol showed higher diagnostic sensitivity (48.5%) and specificity (69.3%) compared to the predicate assay NOVA Lite provided by INOVA (36.4%, 55.2%). This is due to the fact, that AESKU assay detects more positives in the AAV cohort, and less positives in the other disease groups. AESKUSLIDES ANCA Formalin showed a diagnostic sensitivity (50.0%) compared to the predicate assay NOVA Lite provided by INOVA (37.9%). However, the diagnostic sensitivity was comparable between the two (90.7% vs 91.5%). Disclosure of Interest None declared

IntroductionTraumatic brain injury (TBI) and post-traumatic stress disorder (PTSD) are two of the signature injuries in military service members who have been exposed to explosive blasts during deployments to Iraq and Afghanistan. Acute stress disorder (ASD), which occurs within 2–30 d after trauma exposure, is a more immediate psychological reaction predictive of the later development of PTSD. Most previous studies have evaluated service members after their return from deployment, which is often months or years after the initial blast exposure. The current study is the first large study to collect psychological and neuropsychological data from active duty service members within a few days after blast exposure.Materials and MethodsRecruitment for blast-injured TBI patients occurred at the Air Force Theater Hospital, 332nd Air Expeditionary Wing, Joint Base Balad, Iraq. Patients were referred from across the combat theater and evaluated as part of routine clinical assessment of psychiatric and neuropsychological symptoms after exposure to an explosive blast. Four measures of neuropsychological functioning were used: the Military Acute Concussion Evaluation (MACE); the Repeatable Battery for the Assessment of Neuropsychological Status (RBANS); the Headminder Cognitive Stability Index (CSI); and the Automated Neuropsychological Assessment Metrics, Version 4.0 (ANAM4). Three measures of combat exposure and psychological functioning were used: the Combat Experiences Scale (CES); the PTSD Checklist-Military Version (PCL-M); and the Acute Stress Disorder Scale (ASDS). Assessments were completed by a deployed clinical psychologist, clinical social worker, or mental health technician.ResultsA total of 894 patients were evaluated. Data from 93 patients were removed from the data set for analysis because they experienced a head injury due to an event that was not an explosive blast (n = 84) or they were only assessed for psychiatric symptoms (n = 9). This resulted in a total of 801 blast-exposed patients for data analysis. Because data were collected in-theater for the initial purpose of clinical evaluation, sample size varied widely between measures, from 565 patients who completed the MACE to 154 who completed the CES. Bivariate correlations revealed that the majority of psychological measures were significantly correlated with each other (ps ≤ 0.01), neuropsychological measures were correlated with each other (ps ≤ 0.05), and psychological and neuropsychological measures were also correlated with each other (ps ≤ 0.05).ConclusionsThis paper provides one of the first descriptions of psychological and neuropsychological functioning (and their inter-correlation) within days after blast exposure in a large sample of military personnel. Furthermore, this report describes the methodology used to gather data for the acute assessment of TBI, PTSD, and ASD after exposure to an explosive blast in the combat theater. Future analyses will examine the common and unique symptoms of TBI and PTSD, which will be instrumental in developing new assessment approaches and intervention strategies.

The pathology of mild head injury, its common behavioral sequelae, the nature of the recovery process, and the psychosocial consequences are reviewed. Acceleration-deceleration head trauma, causing brief unconsciousness, and leaving no frank neurological deficit, is associated in primates with axonal and terminal degenerative changes in brain stem nuclei. Although the presence of clinical demonstrable neurological abnormality increases the likelihood of subsequent deficits, their absence does not guarantee full recovery. Among mildly injured children, the relationships between persistent behavioral deficits and their age of onset correspond closely with those observed in children with overt damage, making it unlikely that psychological-behavioral deficits are attributable to non-neurological aspects of the injury. Deficits observed include distractability, irritability, headaches, inability to maintain a prior level of cognitive competence, and impulsivity. Although longer periods of unconsciousness are associated with permanent memory deficits, minimal unconsciousness is also followed by consistent deficits in complex memory tasks. Detailed neuropsychological testing of mildly injured children has revealed persisting deficits even after 5 years. Furthermore, deficits arising from repeated injuries are cumulative. The importance of adequate neuropsychological assessment and accurate information to the patient are stressed as important in helping satisfactory adjustment.

Over the past 2 decades, major progress has been achieved toward advancing the translational science of sport-related concussion (SRC), paving the way for evidence-based guidelines for injury diagnosis, evaluation and management. Several key empirical questions on the basic and clinical science of SRC, however, remain unanswered. The aim of this summary article is to highlight gaps in the existing science of SRC and to propose a platform for the next generation of SRC research. The article is framed around addressing two key questions that have major significance to protecting the health and safety of athletes affected by SRC, including: (a) Who is at risk of slow recovery or poor outcome after SRC, and why? (b) How does one modify the risks of slow recovery and poor outcome after SRC? Another aim of this article is to stimulate thought among researchers who will carry the science of SRC into the future, including neuropsychology leaders in the field. Implications for the broader science of traumatic brain injury are also discussed.

PURPOSE: To determine if motor evoked potentials (MEPs), postconcussion signs and symptoms, and neurocognitive functions follow a similar recovery pattern after concussion. METHODS: Nine collegiate athletes with acute concussion (>24 hours after injury) participated in this retrospective time series design. Transcranial magnetic stimulation was applied over the motor cortex, and MEPs were recorded from the contralateral upper extremity. Self-reported symptoms were evaluated using the Head Injury Scale, and the Concussion Resolution Index was used to assess neurocognitive function. All measures were repeated on days 3, 5, and 10 after injury. RESULTS: Composite scores on the Head Injury Scale were significantly higher on day 1 after injury (F3,51 = 15.3; P = 0.0001). Processing speed on the Concussion Resolution Index was slower on days 1, 3, and 5 compared with that on day 10 (F3,24 = 6.75; P = 0.0002). Median MEP latencies were significantly longer on day 10 compared with day 1 after concussion (t8 = -2.69; P = 0.03). Ulnar MEP amplitudes were significantly smaller on day 3 after concussion compared with day 5 (t8 = -3.48; P = 0.008). CONCLUSIONS: Acutely concussed collegiate athletes demonstrate changes in MEPs, which persist for up to 10 days after injury and do not follow the same recovery pattern as symptoms and neuropsychological test performance. The apparent differential rates of recovery most likely indicate different pathophysiological processes occurring in the immediate postconcussion period. Language: en

Background Children with obstructive sleep disordered breathing (OSDB) have both impaired cognitive performance and frequent movements during sleep. It is not known whether movements during sleep are related to cognitive function. Methods We studied 56 children with adenotonsillar hypertrophy suspected of having OSDB with actigraphy for six consecutive days and nights, followed by cognitive and performance tests. Attended polysomnography was performed on the seventh night. Results Slower reaction time correlated with both higher sum of all movements during Time in Bed ( r 2 =0.19, p =0.001) and higher number of minutes with >5 movements/night ( r 2 =0.23, p =0.0003). Low Vocabulary, Similarities and General Memory Index scores correlated with more consolidation of movements (consecutive minutes with >5 movements) ( r 2 =0.16, p =0.002, r 2 =0.16, p =0.0026, respectively). Correlation with Vocabulary and Similarities scores improved when Time in Bed was added as an independently significant covariate ( r 2 =0.25, p =0.0006, r 2 =0.27, p =0.00028, respectively). Actigraphy correlated with Vocabulary and Similarities scores as well as polysomnography. Other cognitive or behavioral scores were not correlated with actigraphy or polysomnography. Children with more consolidation of movements had higher values for log10(OAHI+1) ( r 2 =0.38, p =0.000001). Conclusions (1) Frequency of movement during sleep correlated with impaired vigilance while consolidation of movements correlated with impaired verbal and memory skills. (2) OAHI was associated with more consolidation of movements.

This study examined the effect of psychological distress on neurocognitive performance measured during baseline concussion testing.Archival data were utilized to examine correlations between personality testing and computerized baseline concussion testing. Significantly correlated personality measures were entered into linear regression analyses, predicting baseline concussion testing performance. Suicidal ideation was examined categorically.Athletes underwent testing and screening at a university athletic training facility.Participants included 47 collegiate football players 17 to 19 years old, the majority of whom were in their first year of college.Participants were administered the Concussion Resolution Index (CRI), an internet-based neurocognitive test designed to monitor and manage both at-risk and concussed athletes. Participants took the Personality Assessment Inventory (PAI), a self-administered inventory designed to measure clinical syndromes, treatment considerations, and interpersonal style.Scales and subscales from the PAI were utilized to determine the influence psychological distress had on the CRI indices: simple reaction time, complex reaction time, and processing speed.Analyses revealed several significant correlations among aspects of somatic concern, depression, anxiety, substance abuse, and suicidal ideation and CRI performance, each with at least a moderate effect. When entered into a linear regression, the block of combined psychological symptoms accounted for a significant amount of baseline CRI performance, with moderate to large effects (r = 0.23-0.30). When examined categorically, participants with suicidal ideation showed significantly slower simple reaction time and complex reaction time, with a similar trend on processing speed.Given the possibility of obscured concussion deficits after injury, implications for premature return to play, and the need to target psychological distress outright, these findings heighten the clinical importance of screening for psychological distress during baseline and post-injury concussion evaluations.

In two separate and independent experimental series it was studied, whether 8-arginine-vasopressin (AVP) or 8-lysine-vasopressin (LVP) administered daily in microgram amounts to pregnant rats, and/or to their offspring postnatally for 30 days, induce alterations that can be registered by a behavioral test. The realization of the test used, a foot-shock motivated brightness discrimination (BD) reaction, includes learning and memory processes. There is one general result of the two experimental series, which include 263 rats divided up in different combinations of pretreatment. Vasopressin (VP), AVP or LVP, pre- and postnatally administered, induces a significantly improved BD performance of approximately 40%, compared to the control groups. The improvement is detectable in different ages of the offspring, in females as well as in males. A smaller though also significant improvement was observed when AVP or LVP was injected only postnatally. The critical period in which the peptides are able to induce the alterations measured probably includes prenatal and postnatal periods in the lives of the rats. What molecular interactions actually underly the improved behavioral performance remain to be clarified.

Mild head injury is a controversial topic because patients may have subtle deficits and widely varied outcomes. Accordingly, neuropsychologists are frequently asked to provide expert testimony about the nature of mild head injury. This article discusses how the sports-related concussion literature, including the concept of baseline assessment, can inform expert witnesses who are asked to provide such testimony. We first provide a review of several of the controversies surrounding mild head injury, both within and outside of the forensic context. This is followed by a review of the sports as a laboratory assessment model literature, which demonstrates consistent and meaningful evidence of cognitive sequelae following mild head injury. We conclude with a description of how the sports as a laboratory assessment model literature may be utilized in a forensic neuropsychology context to address some of the identified controversies. We end with a call for more research that will further inform the forensic neuropsychologist about mild head injury and those factors that may result in poor recovery.

In 2005, an international symposium was convened with over 100 neuroscientists from 13 countries and major research centers to review current research in traumatic brain injury (TBI) and develop a consensus document on research issues and priorities. Four levels of TBI research were the focus of the discussion: basic science, acute care, post-acute neurorehabilitation, and improving quality of life (QOL). Each working group or committee was charged with reviewing current research, discussion and prioritizing future research directions, identifying critical issues that impede research in brain injury, and establishing a research agenda that will drive research over the next five years, leading to significantly improved outcomes and QOL for individuals suffering brain injuries. This symposium was organized at the request of the Congressional Brain Injury Task Force, to follow up on the National Institutes of Health Consensus Conference on TBI as mandated by the TBI ACT of 1996. The goal was to revi...

Object The management strategies and outcomes in pediatric patients with elevated intracranial pressure (ICP) following severe traumatic brain injury (TBI) are examined in this study. Methods This study was a retrospective review of a prospectively acquired pediatric trauma database. More than 750 pediatric patients with brain injury were seen over a 10-year period. Records were retrospectively reviewed to determine interventions for correcting ICP, and surviving patients were contacted prospectively to determine functional status and quality of life. Only patients with 2 years of follow-up were included in the study. Results Ninety-six pediatric patients (age range 3–18 years) were identified with a Glasgow Coma Scale score < 8 and elevated ICP > 20 mm Hg on presentation. The mean injury severity score was 65 (range 30–100). All patients were treated using a standardized head injury protocol. The mean time course until peak ICP was 69 hours postinjury (range 2–196 hours). Intracranial pressure control was achieved in 82 patients (85%). Methods employed to achieve ICP control included maximal medical therapy (sedation, hyperosmolar therapy, and paralysis) in 34 patients (35%), ventriculostomy in 23 patients (24%), and surgery in 39 patients (41%). Fourteen patients (15%) had refractory ICP despite all interventions, and all of these patients died. Seventy-two patients (75%) were discharged from the hospital, whereas 24 (25%) died during hospitalization. Univariate and multivariate analysis revealed that the presence of vascular injury, refractory ICP, and cisternal effacement at presentation had the highest correlation with subsequent death (p < 0.05). Mean follow-up was 53 months (range 11–126 months). Three patients died during the follow-up period (2 due to infections and 1 committed suicide). The mean 2-year Glasgow Outcome Scale score was 4 (median 4, range 1–5). The mean patient competency rating at follow-up was 4.13 out of 5 (median 4.5, range 1–4.8). Univariate analysis revealed that the extent of intracranial and systemic injuries had the highest correlation with long-term quality of life (p < 0.05). Conclusions Controlling elevated ICP is an important factor in patient survival following severe pediatric TBI. The modality used for ICP control appears to be less important. Long-term follow-up is essential to determine neurocognitive sequelae associated with TBI.

OBJECTIVE. The purpose of this study was to determine if reduced time in bed as well as the degree of obstructive sleep-disordered breathing predicted the risk of impaired cognitive function in children with adenotonsillar hypertrophy suspected of having obstructive sleep-disordered breathing. DESIGN. We studied 56 children, aged 6 to 12 years, with adenotonsillar hypertrophy referred for suspected obstructive sleep-disordered breathing. Children were given a sleep diary and underwent wrist actigraphy for 6 consecutive days and nights. On day 7, the children were given general cognitive tests, memory tests, and continuous performance tests followed by attended polysomnography that night. Parents completed snoring and behavior questionnaires. RESULTS. Shorter mean time in bed for 6 nights and a history of nightly snoring were highly predictive of lower scores for the vocabulary and similarities cognitive function tests. Children who had a mean time in bed of 557 minutes and did not snore nightly were predicted to have vocabulary and similarities scores more than 1 standard deviation higher than children who had a mean time in bed of 521 minutes and snored nightly. Shorter mean time in bed and the log of the apnea hypopnea index also predicted lower vocabulary and similarities scores. Greater night to night variability in time in bed was significantly predictive of lower vocabulary and similarities scores, but variability was not as predictive as mean time in bed. Neither mean time in bed nor the coefficient of variation of time in bed predicted other cognitive or behavioral scores. CONCLUSIONS. Short or variable time in bed and nightly snoring or higher apnea hypopnea index predicted impaired vocabulary and similarities scores in children with adenotonsillar hypertrophy suspected of having obstructive sleep-disordered breathing. The degree of cognitive impairment attributable to short time in bed and obstructive sleep-disordered breathing is clinically very significant.

This was a preliminary validation study of a multimodal concussion assessment battery incorporating eye-tracking, balance, and neurocognitive tests on a new hardware platform, the Computerized Brain Injury Assessment System. Using receiver-operating characteristics analyses, (1) we identified a subset of the most discriminating neurophysiological assessment tests involving smooth pursuit eye movement tracking errors, corrective saccade counts, a balance score ratio sensitive to vestibular balance performance, and two neurocognitive tests of response speed and memory/incidental learning; (2) we demonstrated the enhancement in discriminatory capability of detecting concussion-related deficits through the combination of the identified subset of assessments; and (3) we demonstrated the effectiveness of a robust and readily implemented global scoring approach was demonstrated for both eye track and balance assessment tests. These results are significant in introducing a comprehensive solution for concussion assessment that incorporates an economical, compact, and mobile hardware system and an assessment battery that is multimodal and time efficient and whose efficacy has been demonstrated on a preliminary basis. This represents a significant step toward the goal of a system capable of making a dependable return-to-play/duty determination based on concussion likelihood.

OBJECTIVE. The purpose of this study was to determine whether risks of impaired cognitive function could be predicted for children or groups of children with adenotonsillar hypertrophy who were suspected of having obstructive sleep-disordered breathing, from historical and polysomnographic variables used separately or in combination.METHODS. We studied 114 consecutive 6- to 12-year-old children with adenotonsillar hypertrophy, who were referred because of suspected obstructive sleep-disordered breathing, with questionnaires, assessment of tonsil size, general and memory cognitive tests, and attended polysomnography with the use of nasal pressure recording to detect flow.RESULTS. There were important significant relationships between snore group (snored every night versus less often), sleep efficiency, and race and 2 of 3 general cognitive tests (vocabulary and similarities). Significant but weaker relationships were observed between sleep latency and 2 memory indices (verbal memory and general memory) and between sleep efficiency and 2 behavior indices (attention-deficit/hyperactivity disorder summary and hyperactive-impulsive summary). The number of episodes of apnea and hypopnea per 1 hour of sleep predicted the vocabulary score as well as did the snore group, but it did not predict other tests as well as other variables. Tonsil size did not predict any cognitive or behavior score. Confidence intervals for group means were small, whereas prediction intervals for individual children were large.CONCLUSIONS. Risk of impaired cognitive function and behavior can be predicted from snoring history, sleep efficiency, sleep latency, and race but not tonsil size. The combination of snoring history and polysomnographic variables predicted impaired cognitive scores better than did either alone. The snoring history predicted more test scores than the number of episodes of apnea and hypopnea per 1 hour of sleep.

Cognitive screening measures for age-related cognitive impairment have been found to have only fair validity, and the risks of harm even may outweigh the benefits at this time (U.S. Preventative Service Task Force, 2003). A large-scale project designed to assess elder care in Primary Care Physician offices noted that dementia evaluation and treatment was one of the most overlooked aspects of care. Taken together, these studies cited the lack of time and technical expertise in test administration as the most prominent barriers to the accurate detection of dementia in Primary Care Physician offices. It was for these reasons that the Cognitive Screening Test (CST) was created. The CST requires no physician time or training to administer or interpret it. The current study investigated the clinical utility of this cognitive screening system by comparing the results of 102 patients to those of expert geriatricians, using consensus conference methods for diagnosis. Overall clinical utility demonstrated scores at .80 or above for sensitivity, specificity, and positive and negative predictive power. In contrast, the MMSE had only a .38 sensitivity. A Receiver Operating Curve (ROC) analysis indicated a .863 accuracy rating for the predetermined cut score on the CST.

Normal Pressure Hydrocephalus (NPH) is a neurological condition that challenges differential diagnosis, as the symptoms -- cognitive and gait impairment and urinary incontinence -- are similar to those of many aging disorders, including Alzheimer's disease and other forms of dementia. Since NPH is caused by abnormal accumulation of cerebrospinal fluid (CSF) around the brain, a high volume lumbar puncture (HVLP) to remove excess fluid is used as the stimulus for a suspected NPH patient, and a diagnosis is made based on the observed cognitive and functional response.Gait features have long been used as functional indicators in the pre- and post-HVLP assessment. However, these assessments are limited to visual observation in the clinic. Therefore, only simple gait features such as walking speed (based on time to walk 10m) and average stride length/time (based on the number of steps to walk 10m) are used. However, these features provide limited separability in the NPH diagnosis.This paper presents methods for enhanced diagnostic separability using additional gait features extracted from an inertial body sensor network (BSN), including stride time variability, double support time, and stability. A pilot study on six HVLP patients -- four of whom were ultimately diagnosed with NPH -- revealed that gait stability assessed by Lyapunov exponent provides better separability and can enhance the differential diagnosis. In addition, these results suggest that additional testing can be performed continuously outside of the clinic to account for patients' variable HVLP response times.

The continued development of the sport environment as a laboratory for clinical investigation of mild head injury has greatly advanced the use of neuropsychological assessment in evaluating brain-injured athletes, and tracking their symptoms and recovery in an objective manner. The use of neurocognitive baseline measures has become critical in determining whether a brain-injured athlete has recovered function sufficiently to return to play. The rapid growth of computerized and web-based neurocognitive assessment measures provides an efficient, valid technology to put such testing within the reach of most institutions and organizations that field sport teams. Moreover, the knowledge of the recovery curve following mild head injury in the sport environment can be generalized to the management of MTBI in general clinical environments where baseline measures are unlikely. What we know today is that sideline assessments of severity are not predictive of which athletes will show the most typical 5- to 10-day recovery period and which will report persistent PCS complaints and exhibit impaired neurocognitive performance for an extended time. The research on mechanisms of brain injury in MTBI suggests that unpredictable, diffuse white-matter damage may control much of the variability in functional impairments and recovery duration.

There has been a relative absence of studies that have examined the neuropsychological profiles of potential lung transplant candidates. Neuropsychological data are presented for 134 patients with end-stage pulmonary disease who were being evaluated as potential candidates for lung transplantation. Neuropsychological test results indicated that a significantly greater proportion of the patients exhibited impaired performances on a number of Selective Reminding Test (SRT) tasks as compared to the expected population frequency distributions for these measures. The highest frequencies of impairment were observed on the SRT’s Immediate Free Recall (46.43%), Long-term Retrieval (41.67%), and Consistent Long-term Retrieval (51.19%) variables. On the Minnesota Multiphasic Personality Inventory-2 (MMPI-2)/Minnesota Multiphasic Personality Inventory-Adolescent (MMPI-A), patients’ mean clinical profile revealed elevations on Scales 1 (Hypochondriasis) and 3 (Conversion Hysteria). This profile indicated that they were experiencing an array of symptomatology ranging from somatic complaints to lethargy and fatigue, and that they may have been functioning at a reduced level of efficiency. Findings are discussed in light of patients’ end-stage pulmonary disease and factors possibly contributing to their neuropsychological test performances. Implications for clinical practice and future research are also provided.

The Concussion Resolution Index (CRI) is an online assessment tool designed to track resolution of symptoms following sports-related concussion. The CRI is composed of six subtests measuring reaction time, visual recognition, and speed of information processing. Three factors are derived from the subtests: Simple Reaction Time (SRT), Complex Reaction Time (CRT), and Processing Speed (PS). Multiple alternate forms within subtests afford simple, reliable, assessment of change, relative to a baseline test completed by an athlete. The test also assesses self-reported neurophysiological symptoms at the time of injury and tracks resolution of these symptoms. The data demonstrate the CRI is a valid and reliable measure of cognitive performance in a relatively heterogeneous group of athletes aged 13-35. Two methods of statistical analysis for assessing change from baseline were compared to establish a psychometric basis for return-to-play decision-making: the Reliable Change Index (RCI) and multiple regression. Multiple regression was more accurate than the RCI in determining a decline in performance relative to the baseline.

Approximately 3.8 million sports related TBIs occur per year. Genetic variation may affect both TBI risk and post-TBI clinical outcome. Limited research has focused on genetic risk for concussion among athletes. We describe the design, methods, and baseline characteristics of this prospective cohort study designed to investigate a potential association between genetic polymorphisms of apolipoprotein E gene, APOE promoter G-219T, and Tau gene exon 6 polymorphisms (Ser53 Pro and Hist47Tyr) with: 1) the risk of prospective concussion; 2) concussion severity; and 3) postconcussion neurocognitive recovery.The prospective cohort study included a final population of 2947 college, high school, and professional athletes. Baseline data collection included a concussion/medical history questionnaire, neuropsychological (NP) testing, and genetic sampling for the genetic polymorphisms. Data collection on new concussions experienced utilized post-concussion history/mental status form, Lovell post-concussion symptom score, Standardized Assessment of Concussion (SAC) and/or the Sports Concussion Assessment Tool (SCAT)-1/SCAT-2, and post-concussion NP testing.This paper is focused on discussing the important methodological considerations, organizational challenges and lessons learned in the completion of a multi-center prospective cohort study. A total of 3740 subjects enrolled, with a total of 335 concussions experienced.Of critical importance to the success of a study of this type is to successfully recruit committed institutions with qualified local study personnel, obtain "buy-in" from study sites, and cultivate strong working relationships with study sites. The use of approved incentives may improve study site recruitment, enhance retention, and enhance compliance with study protocols. Future publications will detail the specific findings of this study. Collaborative research is very likely needed given the nature of this study population.

Evaluation and management of sport-related concussion have received much deserved attention in the wake of recent state legislation and congressional hearings centered on concussion management; however, neuropsychology as a field has been interested in the sequelae of concussive injuries for more than three decades. To provide the historical perspective of sport-related concussion, this chapter begins by exploring the shifts in concussion terminology. While clinically driven, societal and medicolegal influences have clearly exerted a force in shaping the clinical vernacular associated with brain injuries. After reviewing some of the more commonly referenced definitions of concussion proffered over the years, this chapter will examine the history of concussion evaluation and management from a sports neuropsychology perspective.

The management of sports concussion and an understanding of its risk factors are major foci in the literature on athletic injury. Although there is known influence of some genetic polymorphisms (GPs), such as APOE and the APOE promoter, on traumatic brain injury (TBI) outcome in non-athletic populations, very little work has focused on the role these GPs may play in sports concussion. We completed a large (n=3274) multi-center prospective cohort study of college athletes to study possible associations between various GPs and prospectively occurring sports concussion. We found no significant relationship between the APOE e4 allele, the APOE G-219T promoter, the tau exon 6 Ser53pro or the tau His47Tyr GPs on prospective concussion. Additional study of other GPs and haplotype combinations is a next logical step in the search for genetic predisposition to sports-related concussion.

Although there have been past literature reviews which have addressed the psychological adjustment, consequences, and impact/reaction to spinal cord injury, as well as reviews of depression after spinal cord injury, there appears to be an absence of reviews which have focused primarily on the relationship between spinal cord injury and anxiety. The purpose of this paper is to present a comprehensive review of the relatively recent (the past 23-31 years depending on the database utilized) scientific literature as it pertains to anxiety reactions in spinal cord injured individuals. Specifically, this paper provides reviews of the prevalence/presence of anxiety reactions, as well as the correlates of anxiety, in the spinal cord injured population. Furthermore, this paper reviews the relatively few articles which have addressed the treatment of such symptomatology in spinal cord injured individuals. Methodological concerns and limitations of the existing literature and directions for future research are also provided.

Study objectives End-stage lung disease is associated with poor quality of life and increased risk for psychological distress. Despite the significant number of individuals with end-stage lung diseases, the emotional health of these patients, as compared with those with other chronic organ diseases, is not well-known. The purpose of this article is to elucidate personality styles and the presence of psychopathology in a clinical sample of patients with end-stage lung disease presenting for possible lung transplantation. Design Cross-sectional survey. Setting Two academic medical center transplant programs. Participants Two hundred forty-three consecutively referred transplant candidates. Results Cluster analysis of the Minnesota Multiphasic Personality Inventory (MMPI)-2 indicated five different personality styles. The majority of patients evidenced mild somatic and depressive symptoms. Approximately one fourth of the sample exhibited marked anxiety and mood disturbances. A small cluster also evidenced features consistent with an antisocial personality style. Conclusions Separate and distinct personality styles that could affect quality of life, the need for adjunct treatments, and medical compliance emerged from this sample of individuals with end-stage lung disease. Results are discussed in light of prior research on other end-stage organ conditions and in relation to personality and coping theories.

Few studies have examined the neuropsychological sequelae associated with end-stage pulmonary disease. Neuropsychological data are presented for 47 patients with end-stage chronic obstructive pulmonary disease (COPD) who were being evaluated as potential candidates for lung transplantation. Although patients exhibited a diversity of neurocognitive deficits, their highest frequencies of impairment were found on the Selective Reminding Test (SRT). Specifically, over 50% of the patients completing the SRT exhibited impaired immediate free recall and consistent long-term retrieval deficits, while more than 44% of these individuals displayed deficient long-term retrieval. Deficient SRT long-term storage strategies, cued recall, and delayed recall were exhibited by between 26% and 35% of these patients, while more than 32% of this sample displayed elevated numbers of intrusion errors. Over 31% of the patients completing the Wisconsin Card Sorting Test (WCST) failed to achieve the expected number of categories on this measure, while more than 23% of these individuals demonstrated elevated numbers of perseverative errors and total errors. Clinically notable frequencies of impairment (greater than 20% of the sample) were also found on the Trail Making Test (TMT): Part B and the Wechsler Memory Scale-R (WMS-R) Visual Reproduction II subtest. Minnesota Multiphasic Personality Inventory-2 (MMPI-2) personality assessments indicated that patients were experiencing a diversity of somatic complaints and that they may have been functioning at a reduced level of efficiency. These findings are discussed in light of patients' end-stage COPD and factors possibly contributing to their neuropsychological test performances. Implications for clinical practice and future research are also included.

Dogs with clinical signs consistent with parvoviral enteritis and leukopenia (total leukocyte count 0 4, Fisher-Test) and other clinical findings. Similarly the total leukocyte count, neutrophil count and other haematologic and biochemical parameters did not differ significantly between the groups, based on differences from initial values (P > 0 05). Consequently, the use of rhG-CSF in the treatment of dogs with parvoviral enteritis cannot be recommended.

There has been a relative absence of studies that examine the neuropsychological profiles of patients suffering from cystic fibrosis. Data are presented here for 18 individuals with end-stage cystic fibrosis who were also potential candidates for lung transplantation. Neuropsychological test results indicated a diversity of memory and executive control deficits, the most frequent of which were immediate and delayed free recall and retrieval impairments on a memory measure involving noncontextual verbal material. The majority of this sample of patients suffering from cystic fibrosis also exhibited clinically significant elevations on the Minnesota Multiphasic Personality Inventory-2 and Minnesota Multiphasic Personality Inventory-Adolescent (MMPI-2/MMPI-A), which are suggestive of heightened levels of psychological distress (e.g., depressive symptomatology) and multiple somatic complaints. These findings are discussed in light of factors associated with end-stage cystic fibrosis. Implications for clinical practice and future research are also provided.

Psychologists are increasingly asked to make decisions regarding patient candidacy for transplantation. Despite the growing incidence of lung transplantation, normative research regarding cognitive functioning and end-stage obstructive lung disease is lacking. Hence, data are presented on 100 consecutively referred candidates for lung transplantation. The group data suggest essentially normal functioning on most cognitive tests for the majority of transplant candidates. Exceptions were seen on measures of attentional set shifting and short-term visual memory, which were impaired in nearly one fourth of this population. Additionally, one half of the patients displayed deficient performance on the Buschke Selective Reminding Test, with subjects at greater risk for severe rather than mild deficits. Unlike prior research, our group data suggest that there is potential risk of short-term noncontextual verbal memory difficulties because of end-stage pulmonary disease. Personality testing data, e.g., elevations on MMPI-2 scales measuring depression and anxiety, are also discussed.

In 1982, the Wall Street Journal coined the term ‘silent epidemic’ in a front page article based upon research findings on minor head injury or what is now refered to as mild traumatic brain injury...

Mild traumatic brain injury (mTBI) has been called the signature injury of recent wars in Iraq and Afghanistan. Estimates of mTBI in deployed personnel are as high as 20%. Postconcussive symptoms (PCS), regarded as the core problem following mTBI, comprise headaches, dizziness, sensitivity to light and sound, fatigue, and concentration deficits. Although PCS have traditionally been presumed to result from neurological insult, evidence points to a role of psychological factors in these symptoms. Current military evidence is limited by the reliance on retrospective reports collected after deployment through surveys. Research on mTBI in combat setting is needed to more accurately determine the nature of blast-related mTBI. This study reports the first analysis of military personnel assessed in theatre shortly after exposure to a blast.

There has been a relative absence of studies that have examined comprehensively the neuropsychological profiles of females with Triple X Syndrome across a battery of tests and measures. A case is reported of a 9 1/2-year-old female with Triple X Syndrome whose neuropsychological test results were suggestive of greater right- versus left-cerebral hemisphere dysfunction. Overall, the patient's neuropsychological profile was indicative of the syndrome of Nonverbal Learning Disabilities (NLD) as proposed by Rourke (Rourke 1987, 1988, 1995; Rourke & Tsatsanis, 1996). The results are discussed in light of Rourke's NLD Syndrome and the related white matter model.

Barrett's oesophagus is a premalignant condition. Recent reports have suggested that laser coagulation or photodynamic therapy combined with acid suppression may induce reconstitution of squamous mucosa. However, a high percentage of residual glands remain in cases treated with both techniques. Argon plasma coagulation (APC) appears to be an attractive alternative to other thermoablative techniques. The aim of this study was to investigate the reconstitution of squamous epithelium in Barrett's oesophagus after APC.Fifteen patients with histologically proven Barrett's oesophagus were included in a prospective study. After base-line documentation by videotaping and biopsies, Barrett's epithelium was treated by repeated APC at intervals of 4-6 weeks until complete squamous restoration was achieved. All patients were kept under high-dose proton pump inhibitor therapy.In 13 patients complete reconstitution of squamous epithelium was achieved. Buried glands after squamous restoration were detected transiently in only one case after the first session. As side effects seven patients had mild retrosternal discomfort. One patient reported severe retrosternal pain for 1 week. He then refused further APC sessions. Another patient was excluded because of noncompliance. During the follow-up period (6-13 months) recurrence of Barrett's epithelium was observed in one patient.APC is a suitable technique for achieving squamous restoration in Barrett's oesophagus. The rare occurrence of remaining buried glands may result from the homogeneous coagulation achieved by the ionized argon gas beam.

Commonly documented symptoms after mild head injury include impaired attention, concentration, information-processing speed, and memory, as well as complaints of headaches, dizziness, nausea, neurasthenia, hyperesthesia, and emotional lability. Most individuals who sustain mild head injury display few symptoms and are reported to recover completely after a brief period, whereas a minority of patients recount numerous complaints and continue to be symptomatic for extended periods. * Variability in postconcussive symptom presentation has focused debate on the cause of neuropsychological symptoms after mild cerebral trauma. Several factors, such as undetected parenchymal lesions, history of psychiatric illness or substance abuse, pending litigation, pain, and exaggeration of symptoms or malingering are presumed to be causative, particularly in determining symptom duration. 4 , 13 , 24 Despite these speculations, researchers have failed to find a strong relationship between some of these variables and the presence of extended postconcussive symptoms. 1 Controversy regarding the origin of postconcussive symptoms has been exacerbated by methodological limitations. Most studies of mild head injury suffer from various threats to internal and external validity including imprecise injury definition, selection bias, subject attrition, reliance on self-report measures, lack of baseline neuropsychological data, diverse outcome measures, variable test time sequences, and limited documentation or control of potentially influential subject factors. 13 Much of our knowledge about mild head injury has accumulated through retrospective investigations of selected populations, thus limiting conclusions regarding outcome. Although quasi-experimental retrospective or selected nonequivalent control comparisons have a place in research, using these paradigms to generate population-based predictions of outcome is problematic. Not surprisingly, there are even fewer controlled, prospective studies focused on mild sports-related head injuries. 1 , 13 Despite the limitations of existing research, a number of issues believed to influence outcome following sports-related mild head injury are discussed, including injury mechanism-pathophysiology, severity, frequency, complications (medical, neurologic, and psychological factors), and clinical management. This article attempts to integrate findings in various sports with the exception of boxing, principally because boxing has an inherent objective of rendering an opponent unconscious. Boxing also deviates from other sports in terms of injury biomechanics; the number of injuries sustained; and, presumably, the known morbidity. 35 , 39 In this discussion, we emphasize findings of well-controlled studies. When issues of internal-external validity arise, these concerns are discussed in context. Additionally, most past discussions of sports-related mild head injury rely heavily on research completed in clinical (nonsports) populations. Generalization from nonsports populations may or may not be warranted when discussing outcomes in sports injuries. For example, a recent, large (N = 586) prospective hospital study found only 8% of mild head-injured persons sustained their injuries during sports activity. 1 As such, findings from general clinical and sports studies are discussed independently.

Background: Chronic traumatic encephalopathy (CTE) is a recently revived term used to describe a neurodegenerative process that occurs as a long term complication of repetitive mild traumatic brain injury (TBI). Corsellis provided one of the classic descriptions of CTE in boxers under the name “dementia pugilistica” (DP). Much recent attention has been drawn to the apparent association of CTE with contact sports (football, soccer, hockey) and with frequent battlefield exposure to blast waves generated by improvised explosive devices (IEDs). Recently, a promising serum biomarker has been identified by measurement of serum levels of the neuronal microtubule associated protein tau. New positron emission tomography (PET) ligands (e.g., [ 18 F] T807) that identify brain tauopathy have been successfully deployed for the in vitro and in vivo detection of presumptive tauopathy in the brains of subjects with clinically probable CTE. Methods: Major academic and lay publications on DP/CTE were reviewed beginning with the 1928 paper describing the initial use of the term CTE by Martland. Results: The major current concepts in the neurological, psychiatric, neuropsychological, neuroimaging, and body fluid biomarker science of DP/CTE have been summarized. Newer achievements, such as serum tau and [ 18 F] T807 tauopathy imaging, are also introduced and their significance has been explained. Conclusion: Recent advances in the science of DP/CTE hold promise for elucidating a long sought accurate determination of the true prevalence of CTE. This information holds potentially important public health implications for estimating the risk of contact sports in inflicting permanent and/or progressive brain damage on children, adolescents, and adults.

Objective: To update the 1997 American Academy of Neurology (AAN) practice parameter regarding sports concussion, focusing on 4 questions: 1) What factors increase/decrease concussion risk? 2) What diagnostic tools identify those with concussion and those at increased risk for severe/prolonged early impairments, neurologic catastrophe, or chronic neurobehavioral impairment? 3) What clinical factors identify those at increased risk for severe/prolonged early postconcussion impairments, neurologic catastrophe, recurrent concussions, or chronic neurobehavioral impairment? 4) What interventions enhance recovery, reduce recurrent concussion risk, or diminish long-term sequelae? The complete guideline on which this summary is based is available as an online data supplement to this article. Methods: We systematically reviewed the literature from 1955 to June 2012 for pertinent evidence. We assessed evidence for quality and synthesized into conclusions using a modified Grading of Recommendations Assessment, Development and Evaluation process. We used a modified Delphi process to develop recommendations. Results: Specific risk factors can increase or decrease concussion risk. Diagnostic tools to help identify individuals with concussion include graded symptom checklists, the Standardized Assessment of Concussion, neuropsychological assessments, and the Balance Error Scoring System. Ongoing clinical symptoms, concussion history, and younger age identify those at risk for postconcussion impairments. Risk factors for recurrent concussion include history of multiple concussions, particularly within 10 days after initial concussion. Risk factors for chronic neurobehavioral impairment include concussion exposure and APOE e4 genotype. Data are insufficient to show that any intervention enhances recovery or diminishes long-term sequelae postconcussion. Practice recommendations are presented for preparticipation counseling, management of suspected concussion, and management of diagnosed concussion.

OBJECTIVE:This study prospectively examined neuropsychological functioning in 2300 collegiate football players from 10 National Collegiate Athletic Association Division A universities. The study was designed to determine the presence and duration of neuropsychological symptoms after mild head injury

Chlordane is a potent neurotoxin and animal carcinogen, yet the frequency and severity of injury due to exposure from inhalation or contact in the home has not been widely documented. Neuropsychological dysfunction and emotional distress were observed in 10 individuals exposed to chlordane pesticide after their homes were treated for termites. Cognitive deficits ranged from mild to moderate on tasks requiring speeded processing, problem solving, and delayed memory. Somatization, hysterical features, and depression dominated the clinical picture. Current results implicate the hazards associated with chlordane treatment of residential homes and the continued need for further studies.

Little data exist regarding the acute assessment of blast concussion and the course of recovery in the combat zone, as most research has examined service members long after they have returned home. This manuscript examined a case series of 377 service members seen for acute concussion evaluation following medical evacuation from the battlefield in Helmand Province, Afghanistan. Of these, 111 were assessed for concussion prior to their return to the continental USA for other severe physical injuries. Of the remainder, and when comparing those who returned to duty (RTD)/recovered from concussion in the combat zone and those who did not, data indicate that those who did not RTD were older and were more likely to endorse symptoms of combat stress. Quicker recovery times were associated with less severe headaches and fewer acute symptoms at the time of injury as well as the absence of combat stress reaction. Variables that were not associated with RTD and/or recovery were Military Acute Concussion Evaluation (MACE) cognitive scores and whether or not individuals suffered loss of consciousness. While MACE scores were not associated with recovery, they were deemed clinically useful as a part of a serial concussion evaluation if the initial MACE was given within 6 h of the blast. Implications for battlefield concussion assessment and management as well as future research directions are discussed. Language: en

Objective: Agitated behaviors are one of the most frequent reasons that patients with dementia are placed in long-term care settings. This study aims to validate the ability of a custom Body Sensor Network (BSN) to capture the presence of agitation against currently accepted subjective measures, the Cohen-Mansfield Agitation Inventory (CMAI) and the Aggressive Behavior Scale (ABS) and to discriminate between agitation and cognitive decline. Methods: Six patients identified as being at high risk for agitated behaviors were enrolled in this study. The devices were applied at three sites for three hours while behaviors were annotated simultaneously and subsequently repeated twice for each enrolled subject. Results: We found that the BSN was a valid measure of agitation based on construct validity testing and secondary validation using non-parametric ANOVAs. Discussion: The BSN shows promise from these pilot results. Further testing with a larger sample is needed to replicate these results.

Over the past forty years, a tremendous amount of information has been gained on the mechanisms and consequences of mild traumatic brain injuries. Using sports as a laboratory to study this phenomenon, a natural recovery curve emerged, along with standards for managing concussions and returning athletes back to play. Although advances have been made in this area, investigation into recovery and return to play continues. With the increase in combat-related traumatic brain injuries in the military setting, lessons learned from sports concussion research are being applied by the Department of Defense to the assessment of blast concussions and return to duty decision making. Concussion management and treatment for military personnel can be complicated by additional combat related stressors not present in the civilian environment. Cognitive behavioral therapy is one of the interventions that has been successful in treating symptoms of postconcussion syndrome. While we are beginning to have an understanding of the impact of multiple concussions and subconcussive blows in the sports world, much is still unknown about the impact of multiple blast injuries.

Assessment of gait and posture as symptoms has been the primary concern in the diagnosis and treatment of normal pressure hydrocephalus (NPH), a disease in which there is excessive accumulation of cerebrospinal fluid (CSF) in the brain. Diagnosis of NPH is usually initiated by a high volume lumbar puncture (HVLP) followed by the evaluation of clinical response to removal of CSF. In this paper, we analyze the gait movement of a patient using inertial body sensor nodes and capture features pre and post HVLP. This method provides a quantitative measure of gait assessment. The features extracted from a patient's gait are found to strongly correlate with the assessment recorded manually by the physician conducting the study.

Agitated behavior is one of the most frequent reasons that patients with dementia are placed in long-term care settings. These behaviors are indicators of distress and are associated with increased risk of injury to the patients and their caregivers. This study aims to explore the ability of a custom inertial wireless body sensor network (BSN) to objectively detect and quantify agitation, validating against currently accepted subjective clinical measures -- the Cohen-Mansfield Agitation Inventory (CMAI) and the Aggressive Behavior Scale (ABS) -- within the nursing home setting. The ultimate goal is to enable continuous, real-time monitoring of physical agitation in any location over an extended period. Continuous, longitudinal assessment facilitates timely response to agitation events in order to minimize patient distress and risk for injury, to more appropriately titrate pharmacotherapy, and to enable staff (or caregivers) to successfully intervene.Six patients identified as being at high risk for agitated behaviors were enrolled in this pilot study. Patients underwent a series of the above validated tests of memory and agitation. The BSN nodes were applied at three sites on body for three hours while behaviors were annotated simultaneously. This process was subsequently repeated twice for each enrolled subject. The BSN data was then processed using Teager energy analysis, which an earlier study suggested was a promising method for extracting jerky and repetitive movements from inertial data. Results based on construct validity testing for agitation (CMAI) and aggression (ABS) were promising and suggest that additional study with larger sample sizes is warranted.

We report on a 19-year-old male patient with chronic HBeAg-positive hepatitis B-infection and agranulocytosis as a severe side effect of pegylated interferon alpha therapy. Within the first six months of therapy the hepatitis B virus DNA became undetectable in parallel with a significant decrease of the HBsAg serum concentration. After a six-month course of therapy the patient was admitted to our emergency unit. He appeared significantly ill and reported that he had fever for two days, painful oral mucosa, throat pain and general fatigue and discomfort. A complete blood cell count was performed and revealed a complete agranulocytosis with no detectable neutrophilic granulocytes in the blood smear. Antiviral therapy was immediately stopped and he was admitted to our clinic where a supportive therapy and an empirical course of broadband antibiotics were initiated. A few days later an additional treatment with intravenous prednisolone was started. Within the next week the agranulocytosis resolved and the neutrophil count was completely restored. In parallel, the clinical status improved quickly. This case demonstrates the need for our awareness of agranulocytosis as a rare but severe and potentially life-threatening side effect of interferon alpha therapy.

Disability following head injury varies depending on injury mechanism, neuropathology, and other factors, including medical complications. Mild head injury (Glasgow Coma Scale score 13-15) has been shown to have considerable variability in outcome. Some persons experience rapid symptom resolution whereas others continue to evidence symptoms for an extended duration. A small, but clinically significant number of patients may be neuropsychologically and occupationally disabled at least up to 1 year postinjury. Methodological problems continue to plague mild head injury outcome studies. In contrast, moderate (Glasgow Coma Scale score 9-12) and severe head injury (Glasgow Coma Scale score 3-8) result in more consistent patterns of disability following injury. In general, patients who sustain moderate to severe head injury tend to experience persistent and extensive neuropsychological, psychiatric, and occupational impairment. The impact of rehabilitative interventions is variable and dependent on injury severity, intervention type, and outcome criteria.