I'd like to call Professor Oman to the stage, who joins us from Finland. Thank you very much. I suppose the weather's a little bit warmer here than it was when you left, just a bit. Welcome. Thank you. Good morning, Chairman, ladies and gentlemen. We have to know that our head injuries, 80% are mild. So this is a little bit different presentation than before. If you look at the annual numbers of publications in mild traumatic brain injury, we can see that until year 2011, it was quite low. That's why it wasn't said that disease, it didn't exist. But nowadays, it has gone up, maybe because of the lawyers that were meant here before and maybe other reasons. And you have to remember that if you have a severe head injury patient that's dead, then he is dead and he doesn't take any money anymore. But those patients who are mild or moderate head injuries many times must give clear help and clearance. If you look at post-concussion syndrome in six months after mild head injury, about 14% of patients have that. And even return to work is 95% within three to six months. So many people go back to work after mild head injury, even though they have still symptoms. So we can say that neuropsych recovery is about 90 days. The content of the mild head injury is a timeline and there is an injury. And of course, at the end is the outcome. What are the predictors of the outcome? We have to think about time of pre-trauma, the peritrauma, and the post-trauma. So if we look at the mild traumatic brain injury itself, we can see that the operational diagnostic criteria are heterogeneity between studies. There is a large variation. There are over 40 ways to say which is mild head injury. But still we go and look at this patient with GASCO coma score, which is very, very five-point scale and neuroimaging. And moreover, the terminology is very mixed. We talk about mild traumatic brain injury versus concussion versus head injury. Head injury, you can hit your head in the like or somebody hits your head with a fist and that's not traumatic brain injury. And that's why the literature is so complicated. Well, if we go back to the content, we have to think about the outcome. And examples of different outcome dimensions are like in severe head injury, but they are not so hard to measure because it's a question of life and death in severe head injury. But still there are a lot of measures measuring a patient's daily living skills, symptoms, physical function, and cognition, and everything is like a wheel combined together. But what we do, we look at the GASCO outcome score or the extended outcome score, SF16 or slash 36 or DRS. We don't do this dignified outcome measures because it's too expensive and people don't know how to do it. Again, back to the predictors. What happened? I don't go through this picture, as you can understand. But this is by Professor Iverson, that's part of our study group. And there are over 50 variables that affect the patient's outcome, or at least he has and his group has found it. So what a mess. But how about prognostic models? This is a two-year-old review by his group, and everybody can read that sentence there. Actually there is no prognostic model that you could say what will the patient's outcome be after mild or even moderate head injury. So how easy it would be to go straight, not via the labyrinth, straight from the mild TBI to the outcome like this, but that's not possible. The following slides try to simplify and mainstream the complex field of the outcome prediction of MTBI. Don't take them for granted. So we have the pre-trauma. What are the predictors? Poor outcome, sorry, female gender, age, the older the patient, the poorer the outcome. Maybe the upper E, epsilon four, lower IQ, lower education, poorer mental health, maybe affective disorders, lower resilience, and of course, poorer physical health. Then the peritraumatic contents. We have operational diagnostic criteria for mild TBI, and we have all these. How long is the loss of consciousness? Usually it's 30 minutes. How long is the PTA? What's the Glasgow Coma score? What kind of lesions are in the head CT, and what we do. No, no prognostic, they are not prognostic. So this is a little bit complicated field. And then MRI. There are some contradictional results. For example, contusions seen in MRI and microhemorrhages seen in MRI, they can be predictive. Not based by a markers, there was a very good presentation about that. No test routinely recommended S100B may possibly be prognostic. But poorer injuries usually depend on extracranial injuries, early post-injury anxiety, higher symptom burden at acute presentation. And what is very strange is that the patient is not drunk at the moment of the injury. But it seems like that. And last but not least, post-trauma. We have a road to recovery. Is there a sign that something is wrong? It's a prolonged recovery. Patient has sleeping problems, depression, post-traumatic syndrome disorder, fatigue, cognitive defects, and pain. So it's quite large scale that the patient can have. And still, he or she is living and trying to survive in everyday life. Conclusion, the MTBI literature is enormous and growing. However, it's heterogeneous and difficult to interpret. So Charles Simons said, it's not only the kind of injury that matters, but the kind of head. And I added, and body. So everybody who is working with head injury, severe or mild, has not put this kind of sign outside his hospital to get patients. Thank you very much. Thank you. Questions for Professor Ullmann? One of the problems with mild TBI that we're wrestling with currently is the question of does a mild TBI lead to long-term sequelae such as CTE? Is there a threshold? Maybe you could tolerate one mild TBI, maybe two, maybe not. And I think your talk just added layers of complexity to that argument. I think it was very well explained. I think there might be one ray of hope. There was a paper published from the Boston Group. The first author was Taggied this year. And it was done in mice. And they actually used a mouse model of mild TBI in unanesthetized mice, which I think is a real coup, if you'll pardon the pun, because it's very difficult to get that sort of research through your IRB, your animal committee. But I have rarely, if ever, treated a mild or other TBI patient that was anesthetized at the time that they got their TBI. So I think they're to be congratulated for that. But what they actually found in this study is that there didn't seem to be a correlation between the severity of the immediate impact symptoms and whether or not their animals went on to develop some of the hallmarks of CTE. Could you comment on that? Yes. We are, we don't use mice. We use hockey players. And we have a Finnish hockey team, all hockey players. And we have a special program. And that cost a lot. And we have not seen, but we have some kind of thought that if patient has more than one head injury, that he is not maybe unconscious, but comatose, a little bit comatose or something. And he will be out in the field for a week or two weeks. And then he will get the repeated head injury that will be much worse. Yeah, the second injury syndrome is very, very important. Other questions from the audience or comments? Okay, thank you, Professor.

mild traumatic brain injury

MTBI

outcomes

predictors of outcome

prognostic model