Good morning everyone.
I apologize for
being a male here at the women's executive breakfast.
>> [LAUGH] >> Right up front, and
I would have to say I've kind of lived through a woman's journey
just because my wife and I were residents together.
We were medical students together.
She became a psychiatrist, she's on faculty here.
But we moved to the Hopkins area 13 years ago because she had
been the first State Inspector General for
all the mental health hospitals in Virginia.
It was a Governor's Cabinet-level position for her.
She then became a presidential appointee, and now she's
president-elect to the American Psychiatric Association.
So, she is an executive leader and
it's a pleasure to have her as my partner.
And being a psychiatrist, she talks a lot, so she talks
a lot about her journey and so we share a lot of that together.
So I'm a pediatrician and a pediatric cardiologist, and
I'm gonna talk a little about concussion,
which seems like a really weird topic for a pediatrician and
cardiologist to talk about.
But how this kind of ties in at the end kind of talks about some
of our research that we're doing,
that I hope that you'll find informative.
So what's a concussion?
So a concussion is when someone has a fall or
jolt to the head where they have a change in mental status,
and that could be a loss of consciousness.
It could be amnesia that happens.
It could be what people say that they see stars after
they've had a hit.
You don't really have to lose consciousness to be able to have
a concussion, but it, very frequent.
So the official definition, if you're trying to look at
patients for whether they really had a concussion or
not, is you have to have a loss of consciousness for
less than 30 minutes, or that you have to have amnesia for
less than 24 hours, which seems to me a very broad definition.
And it's quite an impact to think about loosing
consciousness for a half hour.
There's a lot of symptoms that are associated with concussion.
People often have nausea, vomiting, they can be irritable,
they can have memory loss, fatigue, lots of non-specific
things, but often very quite new to people in this category.
And I apologize I'm going to have some notes because I'm not
used to talking without slides.
I'm a nerd scientist and we always kind of do this.
So I know I'm gonna forget stuff if I don't look
down at something every now and then.
So these issues that people have with a concussion,
they usually resolve.
They resolve in usually 80% of people, but it takes a while.
Typically, these symptoms people have of headaches and
dizziness and memory loss,
those take up to three months to resolve in most people.
So this is a long process that people go through to recover.
And it takes most people more than a month,
sometimes up to three months before they can return to work
after a concussion because this is, again,
kind of a slow healing process.
What happens to the brain is that the brain, either
because of the way it twists depending on what's involved for
the impact, or the brain kind of moving back and
forth within the skull itself, really creates kind of a tearing
of the nerve fibers that connect to different cells called axons.
And so, these are what interconnect, and I apologize,
since there's a real neuroscientist over here,
for this terrible description of this.
But they're the connections between brain cells which make
the brain work, and so this kind of compression stretching of
the brain within inside the skull tears this apart.
And so, this is part of the main injury that happens with
concussion.
The other thing, if there's enough impact within the skull
you can develop these hemorrhages, these small
bleeds like a bruise on the surface of the brain itself.
And so, those create a lot of secondary injury that takes
place in the brain.
And so, this is part of the big, long healing process that has to
take place because there's a lot of injury that can happen there.
The memory aspect of
this problem is a huge deficit for people.
It takes,
usually some of this starts to resolve in two to three weeks,
but often still takes months to be able to resolve.
And it's a huge issue for
people who are usually very high functioning.
People who have longer persistence of symptoms
are often folks who themselves already have some deficits.
People who already have depression,
people who are drug abusers or have alcohol problems,
it takes much longer to be able to resolve from a concussion.
So there's been a lot of the same information about
people who've had strokes, people who recover from strokes.
The higher functioning they are, then the faster they recover and
the better they recover.
So there's a lot about what you do in your health that makes it
really an important aspect of that.
The demographics of concussion are really
pretty fascinating to look at.
In the latest data from the Center for
Disease Control in 2010, so just in emergency room visits
there were 2.5 million visits in the US for head injury, of which
most of these, more than 80%, were just mild concussion.
So it's a very big issue.
And of the demographic to look at,
it's more common in women than men.
And part of that, I think,
is because there's been a continuing increase in sports
related concussion.
And part of that may be that there's more of
it occurring, but
it's also because there's more recognition of it as well, too.
But it's a huge issue.
It happens much more commonly in collegiate sports than high
school sports, if it's sports related, but a very big and
common problem.
So in the, [COUGH] excuse me, in the cost-wise for this,
in kind of the lifetime cost in 2009 dollars to look at this, it
cost the US $221 billion related to head injury for people.
So this is not only a big number kind of problem,
but it's also a very huge cost problem as well, too.
As a pediatrician,
we look at this big numbers about the incidence of people
coming to the emergency room from head injury, the thing that
resonates with me about this is half of these are children.
So if you cut the numbers in half,
then 1.2 million ED visits are for children with head injury.
And if you look at all of these, the demographic about it,
who has head injury of all ages to look at, the biggest category
are children less than 5 and children 14 to 19 years of age.
So, 5 is pretty accidental, but
14 to 19 really has to be sports related for the most part.
So this is a big impact.
So where we kind of come into this,
is we've been interested in my lab for a while and being able
to look for things that we can measure in blood that
can be clinical tests to help us with the care of patients.
And one of the big groups we've been interested in is how can we
kind of develop a test that would help kind of
tell when a person has had a brain injury, and then help
kinda predict more about what their outcome's gonna be.
Because it's pretty clear from the beginning that we can't
really tell who's gonna have significant problems long term,
who's gonna recover fast, who's gonna recover slow.
And we have to be able to make some decisions for when people
can go back to work, when an athlete can go back and play.
Those become really important,
emotionally charged kind of issues.
The athlete wants to get back to the field.
When you listen to some of the interviews from some of
the retired Ravens about would they want a test to be able to
tell them about they're having a brain injury when they play,
they said absolutely not because they want to go back and play.
So with athletes,
it's the same kind of issue that they really don't want to know
about this because they want to be able to play.
So part of the way this also interfaces is kind of how,
when you hit the emergency room, how the doctor there decides
kind of what you have and how bad it is.
And decision making in the emergency room,
the emergency room doctors are what I call binary, they really
kinda look at a patient and try to decide does this patient have
something I can treat them with and they can go home, or
do they need to be admitted to the hospital.
So when patients come in with a concussion into the emergency
room, they're trying to use all of their clinical measures, and
there's really no test other than kind of clinical measures
to help decide this and say, okay, this is a child, or
this is a young adult.
Or this is Alan,
you shouldn't have been on that ladder with a chainsaw,
I told you to get off of that.
>> [LAUGH] >> To try to decide about,
what category does this person fall into?
And the best way that they have to decide is to say, okay,
the person that needs to get to the hospital either has a skull
fracture, they had a big enough hit that they broke part of
the skull and/or are they at risk or not of being able to
have kind of bleeding between the brain and
the skull with that called a hematoma.
Those who are people who are called the walking dead,
who come to the emergency room after an impact and seem like
they're perfectly fine, and then they're dead five hours later
because of this insidious process that takes place.
And what happens is is that, so
this CT Scan ends up being the best way to describe that
because they can easily tell if they've had a skull fracture.
They can look to see if there's a blood collection around
the outside of the brain.
But the issue is,
is that everybody doesn't really need that, right?
If 85% of the people coming into the emergency room really just
have a mild concussion and they should go home, trying to
separate who is in what category becomes really important.
So, basically, of the 2.5 million people who come into
the emergency rooms, 70% of them get a CT scan.
And of the people who get a CT scan,
less than 10% of those are positive.
So it tells us that our clinical skill in being able to
separate who's in what category is really very poor.
And so, if you think about this, so this basically 1.7 million CT
scans that are done when it's not necessary.
So, and if you think about that half of these patients coming to
the emergency room are children, then there's 700,000
CT scans that are done on children that aren't necessary.
So huge cost, radiation exposure, radiation is coming
down as far as these studies go, but it's enormous.
So part of what we've been trying to understand is,
could a blood test looking at
proteins that leak from the brain with injury,
would they be useful in being able to kinda separate this out?
So, the first idea of how a blood test for
brain injury would work is that you'd say, okay, can we
do a blood test and say this is a person who is low risk, and so
this is a person with concussion, they don't need any
of these kind of imaging, they can go home, or this is someone
who seems to be at higher risk, they go get the CT scan done.
Even if you have a lousy test that only helps about 10%,
because of the numbers involved with this,
10% means you've just taken 17,000 CT scans off the board.
So, that's a huge cost and
a huge radiation exposure in of itself.
So that's one of the ways we're thinking about how these brain
injury biomarker tests, as a blood test, could be utilized in
the emergency room to kind of help move this along.
It also would be helpful in being able to understand who has
severe injury.
Who are the people who we know are gonna have deficits and
will take a long time to recover?
And even more importantly, can we really tell who's recovering?
Because it's really difficult to understand that it takes fairly
sophisticated neuropsychiatric testing
to be able to kinda tease out all these different things.
And, again,
it can be complicated in people who already have
some deficits that make this much more difficult to sort out.
So it's really useful to have an objective measure you can repeat
often, cheaply and easily, to be able to do that.
You don't want to be doing a $5,000 MRI scan on
everybody all along to try to sort these things out.
And so, in the emergency room,
if you're in a tiny little emergency room someplace else
in the far reaches of Maryland or out west,
you might not have a CT scanner and you might not have an MRI.
So, you certainly wouldn't have an MRI.
And so, the imaging become really important in sort of how
it fits into this.
The CT scans are great for being able to tell if you have a skull
fracture, and they're really great to tell if you've got
a worse injury and you're having bleeding around the brain.
Clearly, most people don't need that, but
they're not really good about seeing exactly what
kind of injury happened to the brain.
They can't really see whether these connections between
neurons are torn.
You might be able to see hemorrhages a little bit, but
that's not even very clear.
MRIs, this magnetic resonance imaging in the brain is
beautiful studies for being able to look at the brain, the fibers
of how the nerves connect to one another is really spectacular.
But you can't do that everywhere.
You can do it downtown at our hospital very readily, and
the imaging is incredibly sophisticated as well as
the people who interpret it.
But that's not everywhere.
And so, you need to be able to take this to the field side
to be able to say this athlete really had an injury and
they need to stay off.
You need to be able to take it to the ambulance to try
to intervene on people early if you need to.
So you need more and faster and maybe even more
complex means to be able to try to do this because it's
the only way you're gonna be able to try to move it forward.
And at the moment we have a large trial going on in
Baltimore at the Bayview in the downtown campus
to enroll adult patients with traumatic brain injury to
be able to look at them and see how these tests perform.
So we're hoping to be able to really learn how useful it is
at being able to discriminate patients at
these different ages, and then find out that we can finally
move this towards the clinic to be able to help people.
We're also trying to use this,
getting back to the pediatric side, to think about how these
same different factors can be used to measure in blood
looking at premature infants because they have
a very high incidence of brain injury shortly after birth.
And so we're trying to be able to adapt this
same markers that we can measure in blood and
try to define these children who have risk,
beginning to have injuries so we can find new ways to intervene.
These babies that are weighing two pounds that are in
the nursery and they're gonna be there for
three months, they're exposed to a lot.
They're born early,
there's a lot that's necessary to take care of them.
And their risk of having not a normal IQ, cerebral palsy,
those kind of things after this premature birth are not small.
Maybe as high as 20% in some of those categories.
So, in a lot of the different things about the people who
are at risk of brain injury, we know they're at risk,
we know it can happen.
But we can't really tell when it's happening a lot.
So being able to have fast, easy, reproducible,
objective measures that we can do often and frequently,
even in babies that weigh two pounds or an adult that comes in
an emergency room, end up having a lot of value.
So thank you very much.