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Background. Early Mobilization in Intensive Care Units (ICUs) enhances patients’ evolution, but its benefits and practical implementation have rarely been studied in neurological ICUs. To report on tolerance, feasibility and benefits of walking with a specific body-weight support (BWS) device for patients admitted to a neurological intensive care unit. Methods. Observational single-center one-year study. Inclusion criteria were adults with a neurological injury requiring mechanical ventilation. Exclusion criteria were early death or ICU transfer. After weaning from ventilation, patients were screened for indications of BWS walking using predefined criteria. Results. Patients’ conditions were mostly brain injuries: 32% subarachnoid hemorrhages, 42% focal strokes, 12% traumatic brain injuries. Out of 272 admissions, 136 patients were excluded, 78 were eligible, 33 performed BWS walking. Regarding non-eligible patients, 36 walked unsuspended upon ventilation weaning, 17 presented too severe impairments. Regarding the 45 eligible patients who did not receive BWS training, main reasons were workload and week-ends (31%), medical barriers (29%), early ICU discharge (22%). For the 33-patient study sample, 78 BWS sessions were performed. Pre-session, most patients had inadequate response to pain, orders, or simple orientation questions. Sitting without support was impossible for 74%. Most pre-post changes in hemodynamic, respiratory, and pain parameters were small. Eight sessions were interrupted; reasons were pain, fatigue or major imbalance (4), syncope (1), occurrence of stool (2), battery failure (1). All adverse events ended upon session interruption. Patients walked on median 17 meters. During 51% of sessions, patients showed a spontaneous smile. First BWS session occurred on median 3 days after ventilation weaning, and 11 days before patients were able to walk unsuspended. Conclusions. Verticalization and walking using a suspension device patients in neuroICU allows early gait training, despite challenging neurological impairments. It is safe and generally well tolerated. Trial registration. ClinicalTrials database (ID: NCT04300491)

The objective was to assess the relationships between neuropsychological impairments, functional outcome and life satisfaction in a longitudinal study of patients after a severe traumatic brain injury (TBI) (PariS-TBI study).Out of 243 survivors, 86 were evaluated 8 years post-injury. They did not significantly differ from patients lost-to-follow up except for the latter being more frequently students or unemployed before the injury.Outcome measures included the Glasgow Outcome Scale-Extended (GOS-E), a functional independence questionnaire, employment, mood, fatigue and satisfaction with life. Neuropsychological outcome was assessed by two ways: performance-based outcome measures, using neuropsychological tests and patient and relative-based measures.Neuropsychological measures were not significantly related to initial injury severity nor to gender, but were significantly related to age and education. After statistical correction for multiple comparisons, cognitive testing and cognitive questionnaires were significantly correlated with most outcome measures. By contrast, satisfaction with life was only related with patient-rated questionnaires. A regression analysis showed that the Trail-Making-Test-A was the best predictor of functional outcome, in addition to education duration.Cognitive measures, particularly slowed information processing speed, were significant indicators of functional outcome at a long-term post-injury, beyond and above demographics or injury severity measures.

International audience; OBJECTIVE:In traumatic brain injury (TBI), differences in health-care contexts have profound effects on care pathways. Objectives were to compare TBI pathways of care and practitioners' views on quality of care issues in two large European areas: Varsinais-Suomi, Finland and Ile-de-France, France.METHODS:Thematic analysis of semi-structured interviews was conducted with TBI practitioners (n = 10) from all stages of TBI care. Interviews addressed organization and financing of care, decision-making on care transitions, and perceived issues. The structure-process-outcome model of Donabedian was used to classify findings related to quality of care issues.RESULTS:Main differences in organization of care pathways for people with TBI were related to financing modalities, number of pathway alternatives, inpatient versus outpatient rehabilitation, and indirect versus direct referrals to rehabilitation. Similar categories of issues were raised in the two settings. Issues in structures involved availability of services, financial access, and heterogeneity of expertise. Issues in processes involved diagnosis and follow-up, training regarding cognitive impairments, decision-making for referrals, transition delays, and care pathways of very severely affected patients.CONCLUSIONS:These findings provide clues to address care pathways in further comparative studies. Determinants of care pathway quality could be classified as direct or indirect, binding or adaptive organizational factors.

International audience; Background: Severe traumatic brain injury (TBI) is a leading cause of complex and persistent disability. Yet, long-term change in global functioning and determinants of this change remain unclear. Objectives: This study aimed to assess change in global functioning in the long-term after severe TBI and factors associated with the change. Methods: This was a prospective observational study of an inception cohort of adults with severe TBI in the Paris area (PariS-TBI). Outcome was assessed at 1, 4 and 8 years post-injury. For the included participants (n = 257), change in global outcome between 4 and 8 years was evaluated with the Glasgow Outcome Scale Extended (GOSE) score, and its association with pre-injury, injury-related and post-injury variables was tested with univariate and multivariable analyses. Results: More than half of the 73 participants evaluated at both 4 and 8 years showed global improvement (of at least one point) in GOSE score and an improvement in mood, executive function, and subjective complaints. On univariate analysis, none of the pre-injury, injury or post-injury variables were associated with GOSE score change between 4 and 8 years, except for GOSE score at 4 years (rho = −0.24, P = 0.04). On multivariable analysis, probability of increased GOSE score was associated with more years of education (odds ratio 1.18 [95% confidence interval 1.02–1.37], P = 0.03). The change in GOSE score was significantly correlated with change in Hospital Anxiety Depression Scale score between 4 and 8 years (rho = −0.42, P < 0.001). Conclusions: Most participants with severe TBI in the present sample showed a late improvement (4 to 8 years post-injury) in global functioning. Of the socio-demographic and injury-related factors, only more years of education was associated with improvement in global functioning. Decreased anxiety and depression symptoms were associated with improved global functioning. Targeting interventions to enhance resilience may be the most effective in the long-term after severe TBI.

BACKGROUND Clinical evaluation of a pressure ulcer is based on quantitative and qualitative evaluation. In clinical practice, acetate tracing is the standard technique used to measure wound surface area; however, it is difficult to use in daily practice (because of material availability, data storage issues, and time needed to calculate the surface area). Planimetry techniques developed with mobile health (mHealth) apps can be used to overcome these difficulties. OBJECTIVE The goal of this study was to evaluate the metrological properties of a free-access mHealth app, called imitoMeasure, to assess pressure ulcers. METHODS This was a noninterventional, validation study. We included patients with spinal cord injury presenting with a pressure ulcer, regardless of its stage or location. We performed wound measurements with a ruler, and we performed acetate tracing using a transparent dressing with a wound measurement grid. Wound evaluation via the mHealth app was conducted twice by the main investigator and also by a coinvestigator to determine validity, intrarater reproducibility, and interrater reproducibility. Bland-Altman plots and intraclass correlation coefficients were used to compute the minimal detectable change percentage. RESULTS Overall, 61 different pressure ulcers were included. The validity, intrarater reproducibility, and interrater reproducibility of the mHealth app vs acetate tracing (considered the method of reference) were good, with intraclass correlation coefficients of 0.97 (95% CI 0.93-0.99), 0.99 (95% CI 0.98-0.99), and 0.98 (95% CI 0.96-0.99), respectively, and minimal detectable change percentages between 17% and 35%. CONCLUSIONS The imitoMeasure app had good validity and reproducibility. It could be an alternative to standard wound assessment methods. Further studies on larger and more diverse wounds are needed. CLINICALTRIAL ClinicalTrials.gov NCT04402398; http://clinicaltrials.gov/ct2/show/NCT04402398

Background Clinical evaluation of a pressure ulcer is based on quantitative and qualitative evaluation. In clinical practice, acetate tracing is the standard technique used to measure wound surface area; however, it is difficult to use in daily practice (because of material availability, data storage issues, and time needed to calculate the surface area). Planimetry techniques developed with mobile health (mHealth) apps can be used to overcome these difficulties. Objective The goal of this study was to evaluate the metrological properties of a free-access mHealth app, called imitoMeasure, to assess pressure ulcers. Methods This was a noninterventional, validation study. We included patients with spinal cord injury presenting with a pressure ulcer, regardless of its stage or location. We performed wound measurements with a ruler, and we performed acetate tracing using a transparent dressing with a wound measurement grid. Wound evaluation via the mHealth app was conducted twice by the main investigator and also by a coinvestigator to determine validity, intrarater reproducibility, and interrater reproducibility. Bland-Altman plots and intraclass correlation coefficients were used to compute the minimal detectable change percentage. Results Overall, 61 different pressure ulcers were included. The validity, intrarater reproducibility, and interrater reproducibility of the mHealth app vs acetate tracing (considered the method of reference) were good, with intraclass correlation coefficients of 0.97 (95% CI 0.93-0.99), 0.99 (95% CI 0.98-0.99), and 0.98 (95% CI 0.96-0.99), respectively, and minimal detectable change percentages between 17% and 35%. Conclusions The imitoMeasure app had good validity and reproducibility. It could be an alternative to standard wound assessment methods. Further studies on larger and more diverse wounds are needed. Trial Registration ClinicalTrials.gov NCT04402398; http://clinicaltrials.gov/ct2/show/NCT04402398

Objectives To explore late functional changes after a traumatic brain injury and their relation to patients' characteristics and reentry support. Design Prospective follow-up of an inception cohort of adults with severe traumatic brain injury recruited in 2005-2007 in the Parisian area, France. One and 4-year assessments were performed by trained neuropsychologists. One-to-4-year change in the Glasgow Outcome Scale-Extended defined 3 groups: "improvement," "stability," and "worsening." Relationships between these groups and patients' characteristics were analyzed. Results Among 504 recruited patients and 245 four-year survivors, 93 participated in both evaluations. Overall Glasgow Outcome Scale-Extended improved by 0.4. Forty percent of the sample improved, 44% were stable, and 16% worsened. Being in a more unfavorable group was related to preinjury alcohol abuse and to higher anxiety and depression at 4 years. Attendance to a specialized community reentry unit was related to higher chances of being in the "improvement" group in univariate analyses and after adjustment for age, time to follow command, preinjury alcohol and occupation, and mood disorders (adjusted odds ratio [OR] = 4.6 [1.1-20]). Conclusion Late functional changes were related to psychosocial variables and to reentry support. The effect of reentry support on late recovery needs to be confirmed by further investigations.

Background Stroke is a common and debilitating neurological disorder having a negative impact on quality of life. Objectives We aimed to compare differences in participation in work and leisure activities between patients with and without a self-reported stroke at the national level in France. Methods This study used cross-sectional data from the Disability Health Survey that was administered in people's homes (DHH) in 2008 and in institutions (DHI) in 2009. Stroke history and levels of participation in work and leisure activities were collected by interviews. The levels of participation in these activities were compared between participants with and without a history of stroke. Results Among the 33,785 interviewed participants, 1725 reported a history of stroke. After weighting, this represented a mean (SD) of 766,641 (36,650) people among 49 million adults living in France. After adjustment, as compared with people without stroke, those with stroke were less likely to work (odds ratio 0.19 [95% confidence interval 0.13–0.27]), use the telephone (0.21 [0.17–0.25]) and drive (0.25 [0.21–0.32]). In the age group 19–59 years, as compared with people without stroke, those with stroke less frequently worked (35.9% vs. 72.2%), drove (54.3% vs. 81.3%) and participated in sports (26.6% vs. 55.8%). Conclusions Overall, our study indicates that people with a history of stroke report more difficulties in participating in work and leisure activities than those without a history of stroke.

After a stroke, patients and their proxies require help in coping with various changes. The transition from hospital to home needs to be organized with the necessary adaptations and material or human aids. Ambulatory rehabilitation such as physiotherapy or speech therapy is frequently provided for several months, but is generally not required on the long term. Self-management programs, adapted sport and leisure activities are valuable. Patients' proxies and families need to be supported, and marital and sexual issues need to be addressed. Support programs exist to enhance leisure and social participation, and to facilitate outdoor mobility. When return to work is possible, patients need be counseled according to their wishes and capacities, and to be addressed to appropriate organizations.La vie après un accident vasculaire cérébral. De nombreux changements surviennent après un accident vasculaire cérébral, qui nécessitent un accompagnement du patient et de ses proches. Le retour à domicile doit être organisé, en adaptant le domicile, et en prévoyant les aides humaines et matérielles nécessaires. Après la sortie, la kinésithérapie voire l’orthophonie sont souvent prescrites pendant plusieurs mois, mais ne doivent généralement pas être maintenues au long cours. Ce sont les auto-exercices, les activités physiques adaptées et la reprise d’activités de loisir qui sont ensuite nécessaires. L’accompagnement doit soutenir les aidants familiaux et aborder les questions de couple et de sexualité. Les activités de loisir et sociales ainsi que les déplacements extérieurs peuvent être facilités par différentes structures. Quand cela est possible les patients doivent être conseillés dans leur projet professionnel et adressés si besoin aux organismes adéquats.

OBJECTIVES: To assess determinants of loss to follow-up (FU) at 2 time points of an inception traumatic brain injury (TBI) cohort. DESIGN AND PARTICIPANTS: The PariS-TBI study consecutively included 504 adults with severe TBI on the accident scene (76% male, mean age 42 years, mean Glasgow Coma Scale 5). No exclusion criteria were used. MAIN MEASURE: Loss to FU at 1 and 4 years was defined among survivors as having no outcome data other than survival status. RESULTS: Among 257 1-year survivors, 118 (47%) were lost to FU at 1 year and 98 (40%) at 4 years. Main reasons for loss to FU were impossibility to achieve contact (109 at 1 year, 52 at 4 years) and refusal to participate (respectively 5 and 24). At 1 year, individuals not working preinjury or with nonaccidental traumas were more often lost to FU in univariate and multivariable analyses. At 4 years, loss to FU was significantly associated with preinjury alcohol abuse and unemployment. Relationship with injury severity was not significant. CONCLUSIONS: Socially disadvantaged persons are underrepresented in TBI outcome research. It could result in overestimation of outcome and biased estimates of sociodemographic characteristics' effects. These persons, particularly unemployed individuals, require special attention in clinical practice. Language: en

Objectives Survivors of severe traumatic brain injury have a great variety of impairments and participation restrictions. Detailed descriptions of their long-term outcome are critical. We aimed to assess brain injury outcome for subjects with traumatic brain injury in terms of the International classification of functioning, disability and health. Materials and methods Four-year follow-up of an inception cohort of adults with severe traumatic brain injury by using face-to-face interviews with patients and proxies. Results Among 245 survivors at 4 years, 147 were evaluated (80% male, mean age: 32.5 ± 14.2 years at injury); 46 (32%) presented severe disability, 58 (40%) moderate disability, and 40 (28%) good recovery. Most frequent somatic problems were fatigue, headaches, other pain, and balance. One quarter of subjects had motor impairments. Rates of cognitive complaints ranged from 25 to 68%, the most frequent being memory, irritability, slowness and concentration. With the Hospital Anxiety and Depression Scale, 43% had anxiety and 25% depression. Overall, 79% were independent in daily living activities and 40 to 50% needed help for outdoor or organizational activities on the BICRO-39. Most had regular contacts with relatives or close friends but few contacts with colleagues or new acquaintances. Subjects spent little time in productive activities such as working, studying, looking after children or voluntary work. Quality of life on the QOLIBRI scale was associated with disability level (P Conclusion Management of late brain injury needs to focus on cognitive difficulties, particularly social skills, to enhance patient participation in life.

Background Knee flexion contractures occur frequently in non-ambulatory, aged persons and persons with central nervous system lesions, rendering positioning and nursing care difficult. There are often risks associated with surgical interventions. Objective To evaluate the effectiveness of percutaneous needle tenotomy to lengthen the knee flexor muscles and improve passive function. Methods This was a retrospective study of all patients who underwent percutaneous needle tenotomy between 2012 and 2014. Tenotomy was carried out in the semi-tendinosus, biceps femoris and gracillis muscles under local anesthesia. The procedure took no more than 40 minutes. Range of motion (ROM) was evaluated immediately post-operatively and 3 months later. Results Thirty-four needle tenotomies were carried out. Mean lack of knee extension was 94.2° (range 35–120°) pre-op, (range 15–90°; p

The aim of the study was to measure the prevalence of traumatic brain injury (TBI)-related disability and health status in the general population.The French National Survey, conducted in households and institutions, assessed 33,896 adults. Data included sequelae from TBI, impairments, current health conditions, and uses of health services. Analyses, adjusted for age and sex, compared subjects who declared sequelae from TBI (n = 479) with the remaining survey population (n = 33,287). Use of weighting factors ensured that results were representative of the national population.Prevalence of persistent sequelae from TBI in France was 704/100,000. Median time since injury was 14 yrs. For all Core Set items of the International Classification of Functioning, subjects with TBI reported more impairments than the control population: adjusted odds ratios from 1.7 (behavioral difficulties) to 8.6 (motor difficulties). Rates of cardiovascular, respiratory, musculoskeletal, digestive, urological, neurological, and psychiatric conditions were higher in the TBI population. Use of health services was greater, and women with TBI had higher rates of unmet health needs.Persistent sequelae from TBI significantly affect health in the general population. Planning of post-TBI care should address the chronic needs of these persons.

To determine the features of stroke-related HO in a large sample of patients and to assess if HO risk is increased by haemorrhagic stroke.A case control study (risk factor of a rare event using retrospective analysis).Sixty-one patients with stroke-81 troublesome HOs-were included, each was matched with four controls, i.e. 244 patients with no HO after stroke. Matching criteria were age (±3.5 years) and sex. Data recorded were time from stroke to surgery, ischaemic or haemorrhagic stroke and presence of HO risk factors.Mean age at time of stroke = 46.02 ± 11.4 years (15.9-76.3) for the case sub-group. Time from stroke to surgery = 23.4 ± 27.8 months (3.6-150.0). There was a significant relationship between haemorrhagic stroke and HO development (OR = 3.01; 95% CI = 1.14-7.98; p 0.05), but not for ischaemic stroke. This became non-significant when all matching and risk factors were included in the model (adjusted OR = 1.98; 95% CI = 0.60-6.54; p = 0.26).Haemorrhagic stroke appears to increase the risk of HO development. Further studies are required to determine if this risk factor is independent from other comorbid factors.

Objectives Life after severe burns is conditioned by the remaining sequelae. The pathophysiology and risk factors of Heterotopic Ossification (HO) after burns are still poorly understood. The aim of this study was to determine: 1) the incidence of HO after burns and 2) the risk factors associated with HO development, in a large retrospective study. Methods A case-control study of patients admitted to the burns intensive care unit of Percy Hospital, Paris, from the 1st January 2009 to the 31st December 2013 and then admitted to one of three centres specialised in the rehabilitation of patients with burns. Multivariate analysis was carried out to analyse the relationship between HO development and demographic and clinical data. Results 805 patients were included. 32 patients (4.0%) developed a total of 74 heterotopic ossifications, that is a little higher incidence than the incidence found in the literature. The epidemiological characteristics of the population studied was similar to the literature. HOs were mainly localized around the elbows, followed by the hips, shoulders and knees. Each case-patient was paired with 3 control-patients. There were significant associations between HO development and the length of stay in the burns intensive care unit, the extent and depth of the burns, the occurrence of pulmonary or cutaneous infections, use of curare and use of an air-fluidized bed. Conclusion In addition to recognized risk factors (duration of stay in the intensive care burns unit, extent and depth of burns, pulmonary and cutaneous infections), the use of curare and the use of a fluidized bed (with the duration of use) were significantly associated with HO formation.

To describe employment outcome four years after a severe traumatic brain injury by the assessment of individual patients' preinjury sociodemographic data, injury-related and postinjury factors.A prospective, multicenter inception cohort of 133 adult patients in the Paris area (France) who had received a severe traumatic brain injury were followed up postinjury at one and four years. Sociodemographic data, factors related to injury severity and one-year functional and cognitive outcomes were prospectively collected.The main outcome measure was employment status. Potential predictors of employment status were assessed by univariate and multivariate analysis.At the four-year follow-up, 38% of patients were in paid employment. The following factors were independent predictors of unemployment: being unemployed or studying before traumatic brain injury, traumatic brain injury severity (i.e., a lower Glasgow Coma Scale score upon admission and a longer stay in intensive care) and a lower one-year Glasgow Outcome Scale-Extended score.This study confirmed the low rate of long-term employment amongst patients after a severe traumatic brain injury. The results illustrated the multiple determinants of employment outcome and suggested that students who had received a traumatic brain injury were particularly likely to be unemployed, thus we propose that they may require specific support to help them find work. Implications for rehabilitation Traumatic brain injury is a leading cause of persistent disablity and can associate cognitive, emotional, physical and sensory impairments, which often result in quality-of-life reduction and job loss. Predictors of post-traumatic brain injury unemployment and job loss remains unclear in the particular population of severe traumatic brain injury patients. The present study highlights the post-traumatic brain injury student population require a close follow-up and vocational rehabilitation. The study suggests that return to work post-severe traumatic brain injury is frequently unstable and workers often experience difficulties that caregivers have to consider.

Objective To study the results and complications of percutaneous needle tenotomy for superficial retracted tendons in patients with brain damage. Design Prospective observational study. Setting University hospital. Participants Patients with severe brain damage (N=38; mean age, 60.7y; age range, 24–93y; 21 women) requiring surgical management of contractures and eligible for percutaneous needle tenotomy were enrolled between February 2015 and February 2016. Interventions The percutaneous needle tenotomy gesture was performed by a physical medicine and rehabilitation physician trained by an orthopedic surgeon, under local or locoregional anesthesia. Treated tendons varied among patients. Main Outcome Measures All patients were evaluated at 1, 3, and 6 months to assess surgical outcomes (joint range of motion [ROM], pain, and functional improvement) while screening for complications. Results Improvements in ROM (37/38) and contractures-related pain (12/12) were satisfactory. Functional results were satisfactory (Goal Attainment Scale score ≥0) for most patients (37/38): nursing (n=12), putting shoes on (n=8), getting in bed or sitting on a chair (n=6), verticalization (n=7), transfers and gait (n=8), and grip (n=2). Five patients had complications related to the surgical gesture: cast-related complications (n=2), hand hematoma (n=2), and cutaneous necrosis of the Achilles tendon in a patient with previous obliterative arteriopathy of the lower limbs (n=1). Conclusions Percutaneous needle tenotomy yields good results in the management of selected superficial muscle and tendon contractures. The complications rate is very low, and this treatment can be an alternative to conventional surgery in frail patients with neurologic diseases.

After a serious head trauma, the return home constitutes a key moment in the patient's reintegration. It is prepared by a multi-disciplinary team throughout the rehabilitation and re-adaptation process, taking into account the patient's prognosis for recovery.

International audience; After a serious head trauma, the return home constitutes a key moment in the patient's reintegration. It is prepared by a multi-disciplinary team throughout the rehabilitation and re-adaptation process, taking into account the patient's prognosis for recovery.

International audience; Human immunodeficiency virus (HIV)-associated ectatic cerebral vasculitis (HIV-AECV) is a rare form of vasculitis with diffuse fusiform aneurysms. Its pathophysiology remains poorly understood. Although extensively described in children, it is still incompletely studied in adults. Our objective was to present five adult cases with emphasis on imaging findings and long-term evolution. From 2006 to 2014, we included 5 HIV-infected patients presenting with fusiform cerebral aneurysms. Vessels abnormalities were assessed with brain computed tomography (CT) angiography, magnetic resonance angiography (MRA) and/or digital subtraction angiography (DSA). All patients had MR assessment of the brain. Clinical and biological data were analyzed. Fusiform aneurysms of carotid terminations extending to middle and anterior cerebral arteries were bilateral in three patients and unilateral in one. More distal fusiform aneurysms were observed in four patients and saccular aneurysms in two patients, two patients suffered from ischemic lesions while none experienced hemorrhage. Unlike recent reviews, our study underlines the low hemorrhagic potential of HIV-AECV and long-term follow-up suggests a monophasic evolution under antiretroviral medication.

International audience; Traumatic brain injury (TBI) can lead to cognitive, behavioural and social impairments. The relationship between criminality and a history of TBI has been addressed on several occasions.Objective: The objective of this review was to present an update on current knowledge concerning the existence of a history of TBI in prison populations.Methods: PubMed and PsycINFO databases were searched for relevant papers, using the PRISMA guidelines. We selected papers describing TBI prevalence among incarcerated individuals and some that also discussed the validity of such studies.Results:,Thirty-three papers were selected. The majority of the papers were on prison populations in Australia (3/33), Europe (5/33) and the USA (22/33). The selected studies found prevalence rates of the history of TBI ranging from 9.7% and 100%, with an average of 46% (calculated on a total population of 9342). However, the level of evidence provided by the literature was poor according to the French national health authority scale. The majority of the prisoners were males with an average age of 37. In most of the papers (25/33), prevalence was evaluated using a questionnaire. The influence of TBI severity on criminality could not be analysed because of a lack of data in the majority of papers. Twelve papers mentioned that several comorbidities (mental health problems, use of alcohol…) were frequently found among prisoners with a history of TBI. Two papers established the validity of the use of questionnaires to screen for a history of TBI.Conclusion: These results confirmed the high prevalence of a history of TBI in prison populations. However, they do not allow conclusions to be drawn about a possible link between criminality and TBI. Specific surveys need to be performed to study this issue. The authors suggest ways of improving the screening and healthcare made available to these patients.

Objective: To evaluate the patient’s awareness of his or her difficulties in the chronic phase of severe traumatic brain injury (TBI) and to determine the factors related to poor awareness. Design/Setting/Subjects: This study was part of a larger prospective inception cohort study of patients with severe TBI in the Parisian region (PariS-TBI study). Intervention/Main measures: Evaluation was carried out at four years and included the Brain Injury Complaint Questionnaire (BICoQ) completed by the patient and his or her relative as well as the evaluation of impairments, disability and quality of life. Results: A total of 90 patient-relative pairs were included. Lack of awareness was measured using the unawareness index that corresponded to the number of discordant results between the patient and relative in the direction of under evaluation of difficulties by the patient. The only significant relationship found with lack of awareness was the subjective burden perceived by the relative (Zarit Burden Inventory) ( r = 0.5; P < 0.00001). There was no significant relationship between lack of awareness and injury severity, pre-injury socio-demographic data, cognitive impairments, mood disorders, functional independence (Barthel index), global disability (Glasgow Outcome Scale), return to work at four years or quality of life (Quality Of Life after Brain Injury scale (QOLIBRI)). Conclusion: Lack of awareness four years post severe TBI was not related to the severity of the initial trauma, sociodemographic data, the severity of impairments, limitations of activity and participation, or the patient’s quality of life. However, poor awareness did significantly influence the weight of the burden perceived by the relative.

To describe the characteristics of neurogenic heterotopic ossification (NHO) based on clinical tests, electroneuromyography (ENMG) and CT in a database of patients with lesions of the central nervous system who required sciatic nerve neurolysis along with posterior hip NHO resection, and to determine the respective roles of ENMG and CT in the management of posterior hip NHOs in patients who are unable to communicate or express pain.The consistency of the ENMG results with clinical findings, CT results and macroscopic signs of lesions was retrospectively assessed after sciatic nerve neurolysis and ablation of 55 posterior hip NHOs.Sciatic nerve neurolysis was necessary in 55 cases (47.4%; 55 out of 116). CT showed contact of the NHO with the nerve in all cases: 5 in contact with no deflection, 3 in contact with deflection, 21 moulded into a gutter and 26 entrapped in the NHO. There were clinical signs of sciatic nerve lesion in 21.8% of cases (12 out of 55). ENMG showed signs of sciatic nerve lesions in only 55.6% (10 out of 18), only 4 of whom presented with clinical signs of a nerve lesion. No significant relationship was found between clinical symptoms and ENMG findings of sciatic nerve compression (n = 13, p = 0.77).Nerve compression by NHO is likely an underdiagnosed condition, particularly in patients who are unable to communicate. Diagnosis of sciatic compression by NHO should be based on regular clinical examinations and CT. ENMG is not sufficiently sensitive to be used alone for surgical decision-making.

To assess predictors and indicators of disability and quality-of-life 4 years after severe traumatic brain injury (TBI), using structural equation modelling (SEM).The PariS-TBI study is a longitudinal multi-centre inception cohort study of 504 patients with severe TBI. Among 245 survivors, 147 patients were evaluated upon 4-year follow-up, and 85 completed the full assessment. Two outcome measures were analysed separately using SEM: the Glasgow Outcome Scale-extended (GOS-E), to measure disability, and the QOLIBRI, to assess quality-of-life. Four groups of variables were entered in the model: demographics; injury severity; mood and cognitive impairments; somatic impairments.The GOS-E was directly significantly related to mood and cognition, injury severity, and somatic impairments. Age and education had an indirect effect, mediated by mood/cognition or somatic deficiencies. In contrast, the only direct predictor of QOLIBRI was mood and cognition. Age and somatic impairments had an indirect influence on the QOLIBRI.Although this study should be considered as explorative, it suggests that disability and quality-of-life were directly influenced by different factors. While disability appeared to result from an interaction of a wide range of factors, quality-of-life was solely directly related to psycho-cognitive factors.

Background. After a severe traumatic brain injury (TBI), some patients are discharged home without rehabilitation, although rehabilitation is assumed to improve outcome. Objective. To assess factors that predict referral to rehabilitation following acute care. This study is part of a larger inception cohort study assessing the care network in the Parisian area (France). Methods. Between July 2005 and April 2007, 504 adults with severe TBI (Glasgow Coma Scale score ≤8) were prospectively recruited by mobile emergency services. This study included 254 acute care survivors (80% male, median age 32 years). Data regarding demographics, injury severity, and acute care pathway were collected. The first analysis compared patients referred to a rehabilitation facility with patients discharged to a living place. The second analysis compared patients referred to a specialized neurorehabilitation (NR) facility with patients referred to nonspecialized rehabilitation. Univariate and multivariate statistics were computed. Results. In all, 162 patients (64%) were referred to rehabilitation, 115 (45%) of which were referred to NR and 47 (19%) to nonspecialized rehabilitation. The following factors were significantly predictive of nonreferral to rehabilitation: living alone, a lower income professional category, pretraumatic alcohol abuse, lower TBI severity, and transfer through a nonspecialized medical ward before discharge. Patients referred to specialized NR were significantly younger and from a higher income professional category. Conclusions. These results raise concern regarding care pathways because many patients were discharged to living places, probably without adequate assessment and management of rehabilitation needs. Injury severity and social characteristics influenced discharge destination.

Objective Sleep apnea is a frequent issue for the general population, with a prevalence between 2 and 4%. It is 2 to 5 times more frequent for the spinal cord-injured population. The night ventilation by positive pressure is the reference treatment but the compliance is still an issue. Its determinants are well studied in the general population, but we have limited data for the spinal cord-injured patients. The goal of this study is to elaborate a comprehensive model of compliance with ventilatory assistance using positive pressure for spinal cord-injured patients affected by sleep apnea. Material/Patients and methods Qualitative, prospective, monocentric study based on semi-directed interview, which are based on Bandura social cognitive theory. Each interview is recorded and transcribed. Data are analysed by the working group according to the grounded theory: codification, categorisation and liking. Results We included 15 patients which allows to generate 90 codes. This code's categorisation is in process and highlights the fact that spinal cord-injured patients face the same compliance determinants than the general population (factors related to material, provider, medical team, patient belief) but also factors specific to the handicap situation of the spinal cord-injured patient in term of constraints, autonomy and priority of care. Discussion/Conclusion The model of compliance generated by this study will lead the practitioner in setting up the ventilatory assistance and its integration in the day-to-day functioning for a spinal cord-injured person.

Introduction/Background The variety of consequences of traumatic brain injuries (TBI) constitutes a challenge in defining priorities of care planning. Our aim was to assess care utilization and unmet care needs in a homogeneous well-described sample of patients with long-term TBI. Material and method The Paris-TBI inception cohort recruited adults with severe TBI (initial GCS Results Mean age was 43 years, mean Glasgow Outcome Score-Extended (GOSE) was 6 (moderate disability). Care utilization was important, with 20% having physiotherapy, 10% speech therapy, 2% occupational therapy, 6% psychotherapy. In the past year, 7% had been hospitalized; mean number of visits to general practitioners was 4.2. For everyday activities, 6% had professional help, 67% had help from a proxy. Most care needs were cited as unmet by 10 to 30% of the sample. Unmet needs for information on TBI to patients, to proxies, and for coordination of services were each cited by more than 50%. Unmet need for psychological help was cited by 46%. Mainly expressed barriers to care access were lack of information (52%), and waiting times (27%). Mean number of unmet needs per patient was 8 (min–max: 3–12). Number of unmet needs was not significantly related with age and gender. It was significantly associated with GOSE (rho = −0.5, P Conclusion Such results can help address the needs of the brain injury population. A priority seems to be to improve the information offered to patients and proxies.

Introduction/Background Traumatic Brain Injury (TBI) is a leading cause of acquired persistent disabilities. Sequalae increase with TBI severity. As young adults are particularly exposed, TBI represent an important health and economic burden. However, long-term outcome is poorly described in scientific literature. Material and method Prospective observational study of an inception cohort of adult patients with severe traumatic brain injury in the Parisian area (Paris-TBI). Outcome description assessed with face-to-face interview 8 years after TBI. Results Five hundred and four patients were included between 2005 and 2007, 257 were discharged alive from acute care. At 8-year follow-up, 261 of initial 504 were deceased, 128 patients were lost to follow-up, 22 refused to participate, 86 were finally evaluated. Mean age was 41.9 (SD 13.6), 79% were male, median initial Glasgow Coma Scale Score (GOS) was 6. Age, sex, initial severity did not differ between evaluated patients and lost to follow-up who were more frequently students or unemployed. Detailed information on impairments, functional status, activities were obtained. 5% were institutionalized. 11% suffered seizure since TBI. According to GOS-Extended scale score, 30% remained severely disabled, 41% moderately disabled, 29% had a good recovery. The most frequent somatic disorders concern balance (47.5%), motricity (31%), headaches (36%) and were less frequent than cognitive complaints (Memory 71%, Slowness 68%, Concentration 67%). On Hospital Anxiety and Depression scale, 16% had a score > 10 for anxiety and 18% for depression. At 8 years, 12% worked temporarily after TBI 4, 45% had a job. Of those 37%, declared a salary loss since TBI. Among those who did not returned to work, 89% declared that was because of TBI consequences. Conclusion These results from an inception cohort highlight that adult patients frequently suffer cognitive and somatic disorders after severe TBI. Long after the TBI, these impairments still interfere with social integration and participation.

To assess brain injury services utilization and their determinants using Andersen's model.Prospective follow-up of the PariS-TBI inception cohort. Out of 504 adults with severe traumatic brain injury (TBI), 245 survived and 147 received a 4-year outcome assessment (mean age 33 years, 80% men). Provision rates of medical, rehabilitation, social and re-entry services and their relations to patients' characteristics were assessed.Following acute care discharge, 78% of patients received physiotherapy, 61% speech/cognitive therapy, 50% occupational therapy, 41% psychological assistance, 63% specialized medical follow-up, 21% community re-entry assistance. Health-related need factors, in terms of TBI severity, were the main predictors of services. Provision of each therapy was significantly associated with corresponding speech, motor and psychological impairments. However, care provision did not depend on cognitive impairments and cognitive therapy was related to pre-disposing and geographical factors. Community re-entry assistance was provided to younger and more independent patients.These quantitative findings illustrate strengths and weaknesses of late brain injury care provision in urban France and highlight the need to improve treatment of cognitive impairments.

The Dysexecutive Questionnaire (DEX; Wilson, Pettigrew, & Teasdale, 1998 ) has been designed to assess executive dysfunctions in daily life. However, its relationships with cognitive testing, mood, and the ability to fulfil daily life demands, have not yet been systematically addressed. The objective of this study was to address these issues in a prospective four-year follow-up study of patients with severe traumatic brain injury (TBI) (PariS-TBI study). One hundred and forty seven patients were included. The DEX (self-version) showed a good internal consistency. The total DEX score was significantly inversely correlated with years of education, but did not significantly correlate with any initial injury severity measure. The DEX was significantly and positively related to cognitive deficits, as assessed with the Neurobehavioral Rating Scale-Revised (NRS-R); with mood disorders, as assessed with the Hospital Anxiety and Depression Scale (HADS); with dependency in elementary and extended activities of daily living; and with non-return to work. In multivariate analyses, cognitive and mood impairments were significantly and independently related to the total DEX score. These results suggest that the DEX is a multidetermined sensitive questionnaire to detect everyday life difficulties in patients with severe TBI at a chronic stage.

Objective Traumatic brain injury (TBI) is not only an event causing long-term sequelae. It is also a chronic condition, with life-long changes in health status, impairments and socio-psychological situation. Patients need a prolonged care, which is challenging to plan. Objectives were to explore self-expressed needs of services of individuals with chronic TBI, whether needs were met, and barriers to receiving services. Material/patients and methods In Turku area, South-West Finland, 65 patients (80% male, mean age 39 years) who had suffered a TBI requiring a hospital stay more than four years previously were contacted by telephone. Assessments included demographics, current disability (GOSE questionnaire), and current health services received. Patients completed a TBI Patients Needs Questionnaire, which consisted of 28 items relating to unmet needs, and an 8-item questionnaire regarding barriers to care access. Results One the GOSE, 17% of patients had severe disability, 38% moderate disability, 45% good recovery. Physiotherapy was received by 23%, speech therapy by 5%, occupational therapy by 8%. Fourteen patients (22%) reported no needs, 51 patients reported 1 to 22 needs each. The two unmet needs expressed by over half the sample were information on TBI for patients, and for proxies. A need for rehabilitation of motor and of cognitive impairments was expressed by more than 30%. Five other domains were expressed by more than 20%, other needs were expressed by 0 to 10%. Main perceived barriers were the lack of information on services (65%) and the lack of services (39%). Geographic or transport difficulties were rarely reported. Discussion – conclusion In this population of patients with TBI of mixed severity, most services needs were met for 60% to 80% of the sample. Main unmet needs and barriers to care regarded information on the pathology and on the available services, which should be a priority target to help patients in this area. Comparison with results of a similar ongoing study (PariS-TBI) addressing care needs and barriers in chronic TBI in the Parisian area will identify needs which appear TBI-specific and/or specific to the care context.

Objective: Prospective assessment of informal caregiver (IC) burden 4 years after the traumatic brain injury of a relative.Setting: Longitudinal cohort study (metropolitan Paris, France).Participants: Home dwelling adults (N = 98) with initially severe traumatic brain injury and their primary ICs.Main Outcome Measures: Informal caregiver objective burden (Resource Utilization in Dementia measuring Informal Care Time [ICT]), subjective burden (Zarit Burden Inventory), monetary self-valuation of ICT (Willingness-to-pay, Willingness-to-accept).Results: Informal caregivers were women (81%) assisting men (80%) of mean age of 37 years. Fifty-five ICs reported no objective burden (ICT = 0) and no/low subjective burden (average Zarit Burden Inventory = 12.1). Forty-three ICs reported a major objective burden (average ICT = 5.6 h/d) and a moderate/severe subjective burden (average Zarit Burden Inventory = 30.3). In multivariate analyses, higher objective burden was associated with poorer Glasgow Outcome Scale-Extended scores, with more severe cognitive disorders (Neurobehavioral Rating Scale-revised) and with no coresidency status; higher subjective burden was associated with poorer Glasgow Outcome Scale-Extended scores, more Neurobehavioral Rating Scale-revised disorders, drug-alcohol abuse, and involvement in litigation. Economic valuation showed that on average, ICs did not value their ICT as free and preferred to pay a mean Willingness-to-pay = [Euro sign]17 per hour to be replaced instead of being paid for providing care themselves (Willingness-to-accept = [Euro sign]12).Conclusion: Four years after a severe traumatic brain injury, 44% of ICs experienced a heavy multidimensional burden.

CO27-002-f Pertes de vue d’une cohorte de patients traumatises crâniens et contexte social. L’etude PariS-TBI C. Jourdan a,∗, E. Bayen b, S. Barhami a, I. Ghout c, E. Darnoux c, S. Azerad c, P. Pradat-Diehl b, A. Ruet a, C. Vallat-Azouvi a, J.J. Weiss d, P. Aegerter c, P. Azouvi e a Assistance publique–Hopitaux de Paris, hopital Raymond-Poincare, Garches, France b Assistance publique–Hopitaux de Paris, hopital Pitie-Salpetriere, Paris, France c Unite de recherche clinique, hopital Ambroise-Pare, Assistance publique–Hopitaux de Paris, Paris, France d Centre ressources francilien du traumatisme crânien, Paris, France e Universite de Versailles – Saint-Quentin-en-Yvelines, France ∗Auteur correspondant.

International audience; BACKGROUND: Between 7% and 15% of patients are dissatisfied after total hip arthroplasty (THA). To assess predictors and postoperative determinants of satisfaction and expectation fulfilment one year after (THA). METHODS: Before THA surgery, 132 patients from three tertiary care centres and their surgeons were interviewed to assess their expectations using the Hospital for Special Surgery Total Hip Replacement Expectations Survey (THR survey). One year after surgery, patients (n = 123) were contacted by phone to complete a questionnaire on expectation fulfilment (THR survey), satisfaction, functional outcome (Womac), and health-related quality of life (SF 12). Univariate and multivariate analyses were performed. RESULTS: Preoperative predictors of satisfaction were a good mental wellbeing (adjusted OR 1.09 [1.02; 1.16], p = 0.01) and optimistic surgeons expectations (1.07 [1.01; 1.14], p = 0.02). The main postoperative determinant of satisfaction was the fulfilment of patient's expectations (1.08 [1.04; 1.12], p