ST. LOUIS, MO (Ivanhoe Newswire) - It's the number one cause of death and disability in children, killing more kids than cancer or any other disease. Every year, 475,000 children under age 14 suffer traumatic brain injuries. Now, new discoveries are giving kids a better shot at survival.
A horrific car accident changed Joe Detwiler's life in an instant, the impact caused severe brain injury.
"He just looked so still and unresponsive. You want to just hug him and tell him you love him," Mike Detwiler, Joe's Dad, told Ivanhoe.
The teen spent two months in a medically induced coma and two more in the hospital relearning everything.
"That's actually brain injury, the tissue looks dark because it's damaged," Jose A. Pineda, MD, MScan, an assistant Professor at Washington University School of Medicine, explained.
Doctor Jose Pineda hopes to help kids like Joe, survive traumatic brain injuries and improve their recovery. He's pioneering research in kids, looking at trauma to the mitochondria. The power plant that energizes cells in the brain.
"We confirmed what we had suspected and that is that, indeed the mitochondria of children with brain injuries is failing, and it's been failing for many many weeks," Dr. Pineda said.
Now, they're exploring a way to stimulate the mitochondria in kids with TBI.
"We would administer a medication that will travel to the brain to the injured brain, go directly to the mitochondria and help it heal," Dr. Pineda said.
Clinical trials are going on right now to test that kind of medication in adults. The doctor tells us they're promising. In an unrelated study a similar therapeutic approach in adults with TBI improved function at 30 days after the injury and reduced mortality by more than 60%.
As for Joe, he's made an amazing recovery and believes his doctors made all the difference.
"I can't even put into words how thankful I am," Joe said.
Since his accident, Joe has graduated high school and is getting ready to further his education. Meanwhile, several drugs are being developed by researchers around the world to stimulate the mitochondria in TBI patients.
BACKGROUND: According to the Centers for Disease Control and Prevention, 50,000 people in the U.S die each year from TBI and 85,000 people suffer long term disabilities. In the U.S more than 5.3 million people live with disabilities caused by TBI. There are many different kinds of treatment for TBI patients such as: the initial treatment that stabilizes an individual immediately following a traumatic brain injury; Rehabilitative Care Center Treatment to help restore patient to daily life; Acute Treatment of Traumatic Brain Injury is aimed a minimizing secondary injury and life support; and surgical treatment that may be used to prevent secondary injury by helping to maintain blood flow and oxygen to the brain and minimize swelling and pressure. (www.traumaticbraininjury.com)
CAUSES: There are many causes of TBI. The top three are car accident, firearms and falls. Young adults and the elderly are the groups at higher risks of TBI. The mechanisms that are the highest cause of brain injury are: open head injury, closed head injury, deceleration injuries, chemical/toxic, hypoxia, tumors, infections and stroke. An open head injury results from something such as a bullet wound in which there is penetration of the skull. A closed head injury results from something such as a slip and fall or motor vehicle accident where the effects tend to be broad. Deceleration occurs when the brain is slammed back and forth in the skull because of its gelatinous consistency; causing even the nerve cells to stretch and compress where if it stretches enough the nerve cells can tear. Certain chemicals and toxins can also damage neurons, such as insecticides, lead poisoning and solvents. Hypoxia is lack of oxygen and can be caused by respiratory failure, heart attacks, drops in blood pressure; this can cause severe cognitive and memory deficits. (www.traumaticbraininjury.com)
EFFECTS: TBI is classified into two categories: mild and severe. A brain injury can be classified as mild if loss of consciousness and/or confusion and disorientation is shorter than 30 minutes. While MRI and CAT scans are normal the individual has cognitive problems such as headache, difficulty thinking, memory problems, attention deficits, mood swings and frustration.
Severe brain injury is associated with loss of consciousness for more than 30 minutes and memory loss after the injury or penetrating skull injury longer than 24 hours. The deficits range from impairment of higher level cognitive functions to comatose states. Survivors may have limited function of arms or legs, abnormal speech or language, loss of thinking ability or emotional problems. The range of injuries and degree of recovery is very variable and varies on an individual basis. (www.traumaticbraininjury.com)
Dr. Jose Pineda, Pediatrician, Director of Neurocritical Care, St. Louis Children's Hospital, Washington University, talks about a new approach to teach kids with traumatic brain injury.
Tell me about traumatic brain injury in kids, how difficult is it to treat and how deadly can it be?
Dr. Pineda: Traumatic brain injury is the number one cause of death and disability in children. Every day it kills more children than cancer or any other disease. As a matter of fact TBI kills more children than all other top ten diseases put together. So it's a real problem. Not only is it very common, but also the brain is very complex. We don't even understand how it functions fully. So when it's injured it's very difficult to treat it. We have made a lot of progress in the past few years but we have a lot of challenges.
How much have you been able to improve the survival rates here for kids with brain injuries?
Dr. Pineda: We are very excited we started this quest about five years ago. I was recruited to St. Louis to tackle this new challenge and say okay, every kid is doing better with heart disease, with cancer and all that — let's do something about brain injury. I took on that quest, and we have observed over the past five years a seventy percent decrease in mortality in children with severe traumatic brain injury. We also observed an improvement in outcome on those children who survived. And that's very important with brain injury. The fear always is you do something that decreases the number of children who die but increases the number of children who survive in bad shape. The good news is as it has happened in the past with previous leaps in improving recovery children go from, "I was going to die" to "I do great." They skip the middle and that is exactly what we have seen. So we have seen a seventy percent decrease in mortality matched to an improvement in the outcome of survivors. To give you an idea, and this is scientific, it will take us time to explain it in a way that we can demonstrate scientifically what we are saying. It's important to be able to say, for example, that since 2008 every child with severe traumatic brain injury treated here has gone home except for one child. And it didn't used to be like that many of them had to go to extended care facilities, and that's disappearing too. So in summary, yes, we have seen a seventy percent decrease in mortality with children with severe traumatic brain injury in the past five years with the implementation of the neurocritical care program here at St. Louis Children's Hospital. And not only that, that seventy percent decrease in mortality is linked to improvement in function in those children who survived. The vast majority of them are now going home.
How has the team approach changed things?
Dr. Pineda: People ask us how did you do that, people from other hospitals, parents, everybody asks, "how do you accomplish that"? It's not that we have a new medicine that we could inject. We grabbed what we already had but applied it very effectively and very efficiently through the permission of a multidisciplinary team. Successful medicine in 2011 is measured not only by how good you are — everybody is good, everybody has resources — you distinguish yourself in 2011 by your ability to work together as a team. The more you can do that, the more you can progress in medicine in 2011. So that's what has made the difference. We have a team of neurosurgeons, critical care doctors, nurses, therapists, respiratory therapists, even child life. We partner with our EMS colleagues in the ambulance. We talk about the cases, and we try to help each other. The ER is part of the team, then the ICU and then rehab. So even though it's called a neurocritical problem, the ICU is just one link in that chain of care, and you cannot drop the ball at any single step. So we are there in the ER working together, we're in the ICU working together, we see how they're doing in the rehab unit and make sure that everything is optimized. So the team approach has made a big difference.
What is mitochondria as it is applied to the brain and to traumatic brain injury?
Dr. Pineda: I would like to add one thing about the teamwork. Something important that the father of one of the former patients told me a few years ago is that when you're dealing with a very complex problem like brain injury, eighty five percent of what you're supposed to do you already know you're supposed to do, so as a team you just do it. You do it quickly so that the patient gets that, and you're not going in circles with any of that. There is this fifteen percent that is truly unique to each patient. Every patient is different, and that fifteen percent is what the team has to concentrate on, where the discussions have to be. Not the eighty five percent of care that should be streamlined. That has also made a big difference — the ability to not worry about the obvious things but think about what is unique about Charlie, just to make up a name, or why is Charlie behaving this way? How can we change what we do to optimize his care and his outcome?
What have you discovered about mitochondria in the brain with a brain injury and explain what mitochondria is.
Dr. Pineda: The mitochondria is the energy hog in the cell, not only in the brain but in any cell in the body. It is especially important in brain cells because the brain is constantly using energy for two things: one, to stay alive like any other cell in the body, but also to perform the very complex tasks that the brain is always performing. You're consuming tremendous amounts of energy in your brain even when you're under general anesthesia. So this hog has to be very efficient. And it's different than just a simple battery or a power generator — it's more like a nuclear plant. So it's very powerful. It gives you all the energy you want, but if something goes wrong and it starts leaking, it's deadly. When the mitochondria fails, it starts sending messages to the cell that it's time to die. So trauma triggers messengers to toxic substances that will damage the mitochondria. And not only the mechanical injury, there is chemical injury to the brain after an accident, a car accident, for example. The mitochondria fails, the brain has no energy to perform, and you are unconscious. These messengers start leaking and the also start dying. So when we have the best outcomes that we can have in 2011 we're very happy about that. This is still not enough.
You have developed some imaging?
Dr. Pineda: The first step to improving that the next step toward improved recovery will be to understand what's going on. Ideally we would like to grab mitochondria from the brain of children with brain injury put it in a test tube, see if it is working and if not, understand why and fix it. They do that with rats these days because they can take the brain out. Obviously I'm not going to touch my patient's brain, but these days, with MRI for example, we can do chemistry and test the mitochondria without touching the brain, without putting it in a test tube. We did some of that over the past few years, and we confirmed what we had suspected, and that is indeed the mitochondria of children with brain injury is failing. And it's failing for many, many weeks. So I would say that is good news because that opens the door for us to, in the near future, test new treatments and improve survival even more and make the recovery for survivors less painful, less prolonged. You know we're talking about months. It takes these children sometimes four weeks to just wake up. We want to speed that up, and we want them to get even closer to where they were before brain injury. Nobody is the same after brain injury, but the closer we can get them the better.
So now you're looking at drugs that might be able to reverse this process, tell me about that.
Dr. Pineda: Yes, talking about teamwork. So now we go from the team that we assemble at a single ICU or a hospital to take care of children to a team of international investigators that is taking on the task of A, understanding brain injury better and B, selecting the most promising therapy to be tested. Every time you do that you're committing millions of dollars and at least five years of work. So it's a very delicate decision, but we have three candidates right now that we're discussing seriously, and we hope to be testing one of them at least in the next couple of years.
So what might drugs be able to do in the future?
Dr. Pineda: What they will do as opposed to what we do now, which is basically supporting the brain with intensive care and letting it heal, this approach will be different because we will administer a medication that will travel to the brain and go directly to the mitochondria and help it heal. That's what is different. We anticipate that should result in the first few days in less brain swelling, less neurocritical intensive care and long-term faster recovery. So it's basically like saying before if you had cancer, we could just do surgery and take the tumor out and say "good luck with the leftover cancer or the metastases." Now they give chemotherapy which goes to the tumor and kills it, that's the difference. Now we are supporting the care of the brain with intensive care that is excellent. Ninety seven percent of children who come here with brain injury survive, but it's still not a brain-directed therapy. We want something that is like chemotherapy and treats the disease itself, in this case mitochondria failure.
How excited are you in what you're seeing in terms of development and what you've been able to discover here?
Dr. Pineda: I'm very excited, and I'm even more excited about the success of many of my colleagues because everybody is working really, really hard. I always tell everybody it would be the biggest frustration for me and for many if ten years from now we're doing the same thing that we do today for children with brain injury. That will be a huge disappointment. So what can we do differently is to come up with a pharmacological treatment that will stabilize the mitochondria or some other key component of an injury and takes us to the next level.
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