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Title: Chapter 1 Overview of Brain Injury by Cathy FickerTerill, M.S., Karen Flippo, M.R.A., Terri Antoinet


1
Chapter 1 Overview of Brain Injury by Cathy
Ficker-Terill, M.S., Karen Flippo, M.R.A., Terri
Antoinette, N.G.S.A., R.N.C. and Debra
Braunling-McMorrow, Ph.D.
2
Learning objectives
  • Describe the incidence, prevalence and
    epidemiology of brain injury
  • Distinguish between traumatic brain injury and
    acquired brain injury
  • Describe the systems of care available in the
    rehabilitation continuum
  • Demonstrate several of the funding issues for the
    support of persons with brain injury
  • Explain the Traumatic Brain Injury Act of 1996
    and its impact on services and funding for
    persons with brain injury.

3
Introduction
  • Traumatic brain injury (TBI) has been called the
    silent epidemic.

Chapter 1 Overview of Brain Injury
4
Prevalence
  • 18.8 million- Depressive disorders
  • 6.2. - 7.5 million- Mental retardation
  • 5.3 million - TBI
  • 4.7 million Stroke
  • 4 million - Alzheimers disease
  • 2.3 million - Epilepsy
  • 500,000 - Cerebral palsy

Chapter 1 Overview of Brain Injury
5
TBI is a largely unrecognized major public health
problem!
  • An estimated 10 million Americans are affected by
    stroke and TBI . . .
  • which makes brain injury the second most
    prevalent injury and disability in the United
    States.

Chapter 1 Overview of Brain Injury
6
Definition of TBI
  • TBI is an insult to the brain, not of a
    degenerative or congenital nature but caused by
    an external physical force, that may produce a
    diminished or altered state of consciousness,
    which results in an impairment of cognitive
    abilities or physical functioning. It can also
    result in the disturbance of behavioral or
    emotional functioning. These impairments may be
    either temporary or permanent and cause partial
    or total functional disability or psychosocial
    maladjustment.
  • National Head Injury Foundation (1996)

Chapter 1 Overview of Brain Injury
7
Causes of TBI
  • Motor vehicle crashes (44-50)
  • Falls (20-26)
  • Gunshot wounds (1 cause of fatalities)
  • Sports injuries
  • Workplace injuries
  • Shaken baby syndrome
  • Child abuse
  • Domestic violence
  • Military actions
  • Other

Chapter 1 Overview of Brain Injury
8
TBI Facts
  • 56 of adults with brain injuries tested positive
    for blood alcohol.
  • Each year, 2-4 million women are physically
    abused by an intimate. The head, face and neck
    are the most frequent sites of injury.

Chapter 1 Overview of Brain Injury
9
Acquired Brain Injury (ABI)
  • An ABI is an injury to the brain that has
    occurred after birth and is not hereditary,
    congenital or degenerative. The injury commonly
    results in a change in neuronal activity, which
    affects the physical integrity, the metabolic
    activity, or the functional ability of the cell.
    The term does not refer to brain injuries induced
    by birth trauma. Includes TBI and injuries caused
    by an internal insult to the brain.
  • Brain Injury Association of America (1997)

Chapter 1 Overview of Brain Injury
10
Causes of ABI
  • TBI
  • Tumor
  • Blood clot
  • Stroke
  • Seizure
  • Toxic exposure (e.g., substance abuse, ingestion
    of lead, inhalation of volatile agents)
  • Infections (encephalitis, meningitis)
  • Metabolic disorders (insulin shock, diabetic
    coma, liver and kidney disease)
  • Neurotoxic poisoning
  • Lack of oxygen to the brain (airway obstruction,
    strangulation, cardiopulmonary arrest, carbon
    monoxide poisoning, drowning)

Chapter 1 Overview of Brain Injury
11
ABI cont.
  • Acquired brain injury may result in mild,
    moderate, or severe impairments in one or more
    areas including
  • Cognition (i.e. speech-language communication
    memory, attention and concentration, reasoning,
    and abstract thinking)
  • Physical functions (i.e. ambulating, seeing,
    hearing, balancing)
  • Psychosocial behavior (i.e., social skills, anger
    management, impulsivity)

Chapter 1 Overview of Brain Injury
12
Understanding the Definitions
  • While it is important to understand the different
    definitions of brain injury, the term brain
    injury is used throughout this manual to refer to
    acquired brain injury.
  • When reference is specifically made to injury
    caused by trauma due to external physical force,
    the term traumatic brain injury (TBI) is used
  • (Much of the research has been done with persons
    with TBI).

Chapter 1 Overview of Brain Injury
13
Epidemiology of Traumatic Brain Injury
  • Every 21 seconds, one person in the United States
    sustains a traumatic brain injury.
  • 1.5 million Americans survive traumatic brain
    injuries each year.
  • More than 50,000 people die every year as a
    result of traumatic brain injury.
  • 1/3 of all injury related deaths are due to
    traumatic brain injury.
  • 230,000 people are hospitalized each year with
    traumatic brain injury.

Chapter 1 Overview of Brain Injury
14
Epidemiology of Traumatic Brain Injury
  • 80,000-90,000 Americans experience the onset of a
    long-term disability following traumatic brain
    injury each year.
  • After one traumatic brain injury, the risk for a
    second injury is three times greater after the
    second injury, the risk for a third injury is
    eight times greater.
  • 2/3 of firearm-related traumatic brain injuries
    are classified as suicidal in intent.
  • 91 of firearm-related TBIs result in death.

Chapter 1 Overview of Brain Injury
15
Injury Severity
  • Injuries are classified according to mild,
    moderate and severe injuries.
  • 80 are mild
  • 10-30 are moderate
  • 5- 25 are severe
  • Concussion mild TBI that often goes undiagnosed
    as such

Chapter 1 Overview of Brain Injury
16
Gender
  • Males sustain nearly two to three times as many
    brain injuries as females.
  • Firearms are the leading cause of TBI related
    death for men ages 15-84.
  • Motor vehicle crashes are the leading cause of
    TBI related death for women 15-74.
  • Falls are the leading cause of death from TBI for
    women over 75 years of age and for men over 85
    years of age.

Chapter 1 Overview of Brain Injury
17
Race and Age
  • Race
  • Studies report conflicting findings regarding the
    relationship between race and the incidence of
    TBI.
  • Age
  • Highest in the 15-24 age group.
  • But, some state registries have reported highest
    rates in the over 75 age group, followed by the
    15-24 year age group.

Chapter 1 Overview of Brain Injury
18
Systems of Care
  • Hospital-Based Services
  • Acute Hospital Care
  • Acute Rehabilitation
  • Post-Hospital Services
  • Skilled Nursing Facility (Sub-acute)
  • Post-Acute Rehabilitation
  • Outpatient Services
  • Supported Living

Chapter 1 Overview of Brain Injury
19
Home and community based services may include
  • Case management Homemaker service
  • Home health aide services Personal care
  • Adult day health Habilitation services
  • Respite care
  • Day treatment or other partial hospitalization
    services, psychosocial rehabilitation services,
    clinic services for individuals with chronic
    mental illness
  • Expanded habilitation services (i.e.,
    prevocational services to prepare an individual
    for paid or unpaid employment)
  • Other emergency response systems, assistive
    technology, etc.

Chapter 1 Overview of Brain Injury
20
Access to Services
  • Those most likely to have difficulty accessing
    services are individuals
  • with cognitive impairment but who lack physical
    disabilities
  • without an effective advocate
  • with problematic or unmanageable behaviors
  • Without treatment, individuals with problematic
    or unmanageable behaviors are the most likely to
    become homeless, institutionalized in a mental
    facility, or imprisoned.
  • Government Accounting Office (GAO)

Chapter 1 Overview of Brain Injury
21
Costs of Traumatic Brain Injury
  • Traumatic brain injuries cost more than 48.3
    billion annually.
  • Hospitalization accounts for 31.7 billion.
  • Fatal brain injuries cost the nation 16.6
    billion each year.
  • The costs are often due to the resultant
    life-long disability.

Chapter 1 Overview of Brain Injury
22
Funding
  • Approximately 5 of individuals with severe
    brain injuries have adequate funding for
    long-term treatment.
  • BIAA

Chapter 1 Overview of Brain Injury
23
Funding
  • Whatever the funding source, it is essential
    that
  • advocacy is provided
  • available funding is appropriately and cost
    effectively managed.

Chapter 1 Overview of Brain Injury
24
Private Funding
  • Indemnity Insurance
  • Insurer assumed the responsibility of paying
    medical benefits for services performed and
    covered under the policy in return for premium
    payments
  • Managed Care
  • Health Maintenance Organizations (HMOs)
  • Preferred Provider Organizations (PPOs)
  • gate-keeping
  • elective contracting with providers
  • quality controls
  • risk-sharing

Chapter 1 Overview of Brain Injury
25
Public Funding
  • Medicaid provides health care for more than 40
    million people throughout the US
  • low-income families
  • people who are blind
  • people age 65 and older
  • people who have disabilities

Chapter 1 Overview of Brain Injury
26
Public Funding
  • State Home and Community-Based Services Waivers
    (HCBS)
  • A state with Centers for Medicare and Medicaid
    approval can waive one or more of the
    requirements of eligibility for funding and
    provision of services.
  • Increases accessibility to services.
  • Encourages the development of new approaches for
    health care delivery to meet the special needs of
    particular areas or groups of people (e.g.,
    persons with brain injury).

Chapter 1 Overview of Brain Injury
27
GAO Report
  • The 1997 GAO report on Traumatic Brain Injury
    determined that Medicaid and Home and Community
    Based Waiver programs covered an estimated 2,478
    individuals and spent 118 million.
  • By comparison in the same year, waivers covered
    an estimated 236,000 individuals with mental
    retardation/developmental disabilities and spent
    approximately 5.8 billion!

Chapter 1 Overview of Brain Injury
28
Advocacy
  • Traumatic brain injury represents a public health
    problem of great magnitude.
  • During the 1970s, improvements occurred in
    emergency medical services and acute care
    specialized models of brain injury rehabilitation
    were initiated.

Chapter 1 Overview of Brain Injury
29
Advocacy Brain Injury Association of America
  • In 1980, a group of family members of persons
    with traumatic brain injuries founded the
    National Head Injury Foundation, now BIAA.
  • The organization has grown into a national
    organization, including 42 chartered state
    affiliates.

Chapter 1 Overview of Brain Injury
30
Significant Legislature Legal Decisions
  • The TBI Act (1996)
  • The Olmstead Decision (1999)

Chapter 1 Overview of Brain Injury
31
Traumatic Brain Injury Act (1996)
  • Purpose
  • To expand efforts to identify methods of
    preventing traumatic brain injury
  • Expand biomedical research efforts or minimize
    the severity of dysfunction as a result of such
    an injury
  • To improve the delivery and quality of services
    through State demonstration projects.

Chapter 1 Overview of Brain Injury
32
Traumatic Brain Injury Act (1996)
  • TBI Act authorized
  • The Centers for Disease Control and Prevention
    (CDC) to establish projects to prevent and reduce
    the incidence of traumatic brain injury
  • The National Institutes of Health to award grants
    to conduct basic and applied research on
    developing new methods for more effective
    diagnosis, therapies, and a continuum of care.

Chapter 1 Overview of Brain Injury
33
"The Olmstead Decision"
  • It requires states to administer their services,
    programs, and activities "in the most integrated
    setting appropriate to the needs of qualified
    individuals with disabilities.
  • The ADA and the Olmstead decision apply to all
    qualified individuals with disabilities
    regardless of age.
  • The decision has resulted in several federal and
    state initiatives that will make living in the
    community a reality for more people with
    disabilities.

Chapter 1 Overview of Brain Injury
34
National Accreditation State Licensure
  • National accreditation organizations have
    established set standards for rehabilitation
    programs.
  • JCAHO Joint Commission on the Accreditation of
    Healthcare Organizations
  • CARF Rehabilitation Accreditation Commission
  • A number of states have required licenses for
    programs serving persons with brain injury.
  • The goal of accreditation standards and licensure
    is to ensure that the organization has the
    capacity to meet the needs of individuals with
    disabilities.

Chapter 1 Overview of Brain Injury
35
Research
  • A traumatic brain injury can happen to a child or
    adult of any age, race, gender, religion or
    socioeconomic status.
  • It is important to quantify the problem by
    conducting surveillance.
  • Surveillance is the ongoing and systematic
    collection, analysis and interpretation of data
    used to describe and monitor a health event.

Chapter 1 Overview of Brain Injury
36
Research
  • Traumatic Brain Injury (TBI) Model Systems of
    Care (TBIMS) (1987)
  • Funding provided by US Department of Education's
    National Institute on Disability and
    Rehabilitation Research (NIDRR), which maintains
    the TBI Model Systems National Data Base
  • To develop a model system of care for persons
    with traumatic brain injury, emphasizing
    continuity and comprehensiveness of care
  • To maintain a standardized national database for
    innovative analyses of TBI treatment and
    outcomes.
  • Each center provides a coordinated system of
    emergency care, acute neurotrauma management,
    comprehensive inpatient rehabilitation and
    long-term interdisciplinary follow-up services.

Chapter 1 Overview of Brain Injury
37
The Health Resources and Services Administration
(HRSA)
  • Provides grants to states to carry out
    demonstration programs to implement systems that
    ensure statewide access to comprehensive and
    coordinated TBI services.
  • States who receive grants must implement the
    following components
  • Statewide TBI advisory board
  • Staff responsible for TBI activities
  • Statewide needs assessment to address the full
    spectrum of services
  • Statewide action plan to develop a comprehensive,
    community-based system of care (HRSA 1999).

Chapter 1 Overview of Brain Injury
38
NIH Research
  • The National Institutes of Health conducted
    research on the development of new methods and
    modalities for
  • more effective diagnosis
  • measurement of degree of injury
  • post-injury monitoring
  • assessment of care models for brain injury
    recovery and long term care.

Chapter 1 Overview of Brain Injury
39
Conclusion
  • TBI is a silent epidemic that is a major public
    health problem
  • TBI can affect any of us at any time
  • Through legislation and research, we can develop
    appropriate and effective services to meet the
    unique needs of individuals who have experienced
    a brain injury

Chapter 1 Overview of Brain Injury
40
Chapter 2 Philosophy of Rehabilitation Al
Condeluci, Ph.D. and Marty McMorrow, M.S.
41
Learning objectives
  • Distinguish between historical and contemporary
    rehabilitation philosophies
  • Describe the philosophical basis of the helping
    role in rehabilitation

Chapter 2 Philosophy of Rehabilitation
42
Different Approaches
  • Needs to be corrected mentality
  • Vs.
  • Positive Approach

Chapter 2 Philosophy of Rehabilitation
43
Cultural Devaluation
  • Historical devaluation of people, particularly
    people with disabilities, who are different in
    some way.
  • People are often . . .
  • Labeled, stereotyped, segregated
  • Thought to be a problem or to pose some kind of
    threat to those in authority
  • Identified by their label or their difference
  • Perceived to be a cost to society, in material or
    economic ways

Chapter 2 Philosophy of Rehabilitation
44
Cultural Devaluation
  • In the U.S., the climate for inclusion and full
    community participation for people with
    disabilities is still remarkably inconsistent.
  • People with disabilities
  • continue to be labeled at the drop of a hat
  • are still readily institutionalized
  • continue to be viewed as a problem for society
  • are seen as an economic burden
  • People with disabilities are caught in this web
    of cultural devaluation!

Chapter 2 Philosophy of Rehabilitation
45
The Medical Model
  • The condition is the problem
  • Core of the problem is with the person
  • The professional is the expert
  • The problem should be treated, healed, fixed

Chapter 2 Philosophy of Rehabilitation
46
The Medical Model, cont.
  • Most options for control are held by the expert
    or other representatives of the paradigm
  • The patient is exempt from any real
    responsibility, except to cooperate.
  • Most aspects of the ailment are treated in
    separate and distinct facilities designed for the
    ailment.
  • Serious problems arise when its components
    continue to be used after sickness or medical
    stability has been addressed.

Chapter 2 Philosophy of Rehabilitation
47
Goal of Brain Injury Rehabilitation
  • To establish medical stability
  • Not to eliminate sickness, but to return people
    to their communities
  • To help the individual adapt to the expectations
    of the community
  • To help the community accept and respect the
    differences that people with disabilities may
    have

Chapter 2 Philosophy of Rehabilitation
48
Interdependence, Inclusion, Self-Determination
  • Interdependence
  • Implies a connection or a relationship between
    two or more entities
  • Is about relating in ways that promote mutual
    acceptance and respect
  • Encourages acceptance and empowerment for all

Chapter 2 Philosophy of Rehabilitation
49
Interdependent Paradigm
  • The Problem Limited or non-existent
    supports for differences
  • Core of the Problem In the system or
    community
  • Actions of the Paradigm To create supports and
    empower
  • Power Person The person with the
    disability
  • Goal of the Paradigm Develop mutually
    desired relationships

Chapter 2 Philosophy of Rehabilitation
50
Comparison of Paradigms
  • Interdependence Medical
  • Focuses on capacities Focuses on deficiencies
  • Stresses relationships Stresses congregation
  • Driven by the person/disability Driven
    by the expert/professional
  • Promotes micro/macro change Promotes
    that the person can be fixed

Chapter 2 Philosophy of Rehabilitation
51
Inclusion
  • Inclusion the individual is incorporated and
    welcomed into the community, regardless of their
    disability.
  • Inclusion brings people to the community
    regardless of their differences
  • It does not try to change or alter differences
    against the person's will or capacity.
  • It does not try to create forced similarity.
  • It suggests that people join in as they are.
  • It respects differences, honors diversity, and
    invites full community participation.
  • It is a term that implies welcome to all!

Chapter 2 Philosophy of Rehabilitation
52
Self-Determination
  • Builds on the principles of informed consent,
    right to refuse, and consumer empowerment
    (individual freedom).
  • People with disabilities have rights and
    authority over how, where, and with whom they
    live.
  • People can and should advocate for their needs.
  • In the recent Olmstead decision, the Courts
    ruled
  • people with disabilities have the right to equal,
    community based options
  • states must make these options available.

Chapter 2 Philosophy of Rehabilitation
53
4 Critical Components of Self-Determination
  • Freedom to plan a life with supports rather than
    purchase or be referred to a particular program.
  • Authority to control a certain sum of dollars to
    purchase
  • preferred supports.
  • Support Use of resources to arrange formal and
    informal supports to live within the community.
  • Responsibility Can and should have a role within
    the community through competitive employment,
    organizational affiliations, and accountability
    for spending public dollars in life-enhancing
    ways.

Chapter 2 Philosophy of Rehabilitation
54
Promoting Self-Determination in the Human
Services
  • Transfer financial control to the consumer
    through individual budgets
  • Use person centered planning to identify,
    organize, and communicate choices
  • Promote cooperation and collaboration
  • Increase community awareness through
    communication and information sharing

Chapter 2 Philosophy of Rehabilitation
55
Promoting Self-Determination in the Human
Services
  • Institute change through legislature and advocacy
  • Develop leadership skills among people with
    disabilities
  • Gather and analyze data to evaluate and improve
    quality of services

Chapter 2 Philosophy of Rehabilitation
56
Basis of Interaction within Rehabilitation
  • Rehabilitation involves complex techniques,
    procedures, or approaches by a diverse group of
    people
  • It involves the creation, adaptation, and use of
    various community services and supports.

Chapter 2 Philosophy of Rehabilitation
57
Basis of Interaction within Rehabilitation
  • There is a very delicate balance between
    assisting someone by encouraging inclusion or
    self-determination and interacting in a way that
    inadvertently contributes to devaluation, social
    isolation and increased dependency
  • The best guide to determining what to do in a
    given situation still may be to consider how you
    or any individual would prefer to be treated in
    similar circumstances.

Chapter 2 Philosophy of Rehabilitation
58
Interacting with Empathy
  • A day in rehabilitation is remarkably different
    than anything ever experienced before.
  • Participants are poked and prodded, evaluated and
    observed.
  • Having empathy will improve our interactions
  • However, to impact interactions in a noticeable,
    consistent, and effective way, we must understand
    mutual reinforcement and reciprocity

Chapter 2 Philosophy of Rehabilitation
59
Mutual Reinforcement and Reciprocity
  • Mutual reinforcement an exchange of reinforcers
    or desired events between two or more people.
  • Behavioral research suggests that
  • human behaviors often develop and continue
    because of their desirable effects for the
    individual who performs them
  • people probably have a tendency to treat others
    as they are treated
  • self reports of interactional satisfaction (e.g.,
    friendship, love, joy) appear related to the
    concept of mutual reinforcement

Chapter 2 Philosophy of Rehabilitation
60
Mutual Reinforcement Reciprocity, Cont.
  • Lasting relationships involve a regular exchange
    of reinforcers or desired events
  • When an exchange of reinforcers develops into a
    consistent pattern, it can be called a positive
    reciprocal relationship or positive reciprocity.

Chapter 2 Philosophy of Rehabilitation
61
Mutual Reinforcement Reciprocity, Cont.
  • Ongoing exchange of unwanted events between
    people is referred to as a negative reciprocal
    relationship or negative reciprocity.
  • Striving toward the development of mutually
    reinforcing relationships, or positive
    reciprocity, may help the person achieve greater
    success in rehabilitation and in life.

Chapter 2 Philosophy of Rehabilitation
62
Promoting Mutually Reinforcing Interactions
  • What is not wanted in interactions between
    persons in rehabilitation includes
  • insensitivity to differences
  • particularly those that are unlikely to change
  • the creation or prolonging of negatively
    reciprocal interactions
  • e.g., overly corrective, disempowering, or
    unnecessarily restrictive comments or actions

Chapter 2 Philosophy of Rehabilitation
63
Promoting Mutually Reinforcing Interactions
  • Active treatment interaction
  • An interaction that is intended to result in
    greater independence, autonomy, empowerment, or
    inclusion for one of those people
  • The term is intended to imply directed action,
    teaching, and a certain degree of risk taking.

Chapter 2 Philosophy of Rehabilitation
64
PEARL
  • Positive being upbeat, enthusiastic, requesting
    rather than demanding, actively prompting and
    encouraging participation.
  • Early being proactive when difficult or
    troubling situations arise, intervening early to
    facilitate problem solving, and interrupting or
    redirecting behavioral consequences that could
    lead to more serious problems.
  • All acting these ways all the time, with all
    participants, and in all daily situations.
  • Reinforce consistently recognizing,
    acknowledging, and socially reinforcing
    participant accomplishments.
  • Look looking for situations or opportunities to
    facilitate independence, autonomy, empowerment,
    or inclusion.

Chapter 2 Philosophy of Rehabilitation
65
No Blame!
  • Each individual is predisposed to act in
    particular ways in particular situations.
  • Predispositions include all the medical,
    cognitive, physical, biochemical, and
    environmental factors that influence actions in a
    given situation.
  • If people are predisposed to behave in certain
    ways in certain situations, then holding them at
    fault or blame for unwanted actions does not make
    good sense.

Chapter 2 Philosophy of Rehabilitation
66
Can vs. Cant
  • Encourage inclusion
  • Think that the person can vs. cant do something
  • Consider what is possible (instead of what might
    possibly happen) and the potential benefit of
    doing rather than preventing
  • Find ways to support a persons interests, rather
    than ignoring them or constantly refusing
    requests
  • This approach increases mutually desired actions

Chapter 2 Philosophy of Rehabilitation
67
Outcome, Partnerships and Agreements
  • Rehabilitation involves partnerships between many
    different people to accomplish the various goals.
  • An outcome oriented model is designed to identify
    areas of agreement between people that are
    related to the goals
  • The most important partnership is that with the
    person who has sustained the injury.
  • These partnerships must be established very
    rapidly after the injury and must be maintained
    at every point in the process.

Chapter 2 Philosophy of Rehabilitation
68
Conclusion
  • Avoid promoting a rehabilitation culture that
    devalues persons who behave differently.
  • The ultimate goal of brain injury rehabilitation
    is to return people as fully as possible to their
    communities.
  • Remember the interdependent paradigm, the
    principles of inclusion, and self-determination.

Chapter 2 Philosophy of Rehabilitation
69
Conclusion
  • Consider Mutual Reinforcement and Reciprocity
    when interacting with individuals with brain
    injuries.
  • Active treatment with PEARL, No Blame, and Can
    vs. Cant are interactional styles that
    facilitate outcome goals, partnerships, and
    agreement within the rehabilitation process.

Chapter 2 Philosophy of Rehabilitation
70
Chapter 3 Understanding the Brain and Brain
Injury by Ronald C. Savage, Ed.D.
71
Learning objectives
  • Identify basic brain structures and functions
  • Describe brain-behavior relationships
  • Understand the functional impact of a brain injury

Chapter 3 Understanding the Brain and Brain
Injury
72
Introduction
  • The brain is the main organ of learning.
  • It makes it possible for us to think,
    communicate, act, behave, move about, and create.

Chapter 3 Understanding the Brain and Brain
Injury
73
Anatomy of the Brain
  • The brain . . .
  • Is a soft organ, like the consistency of gelatin
  • Weighs less than 1 lb. at birth and grows to
    about 3 ½ lbs.
  • Sits inside a rough and bony skull and is bathed
    in a cerebrospinal fluid (CSF)
  • Receives oxygen and glucose through a
    sophisticated system of blood vessels that carry
    blood to and from the heart

Chapter 3 Understanding the Brain and Brain
Injury
74
Anatomy of the Brain, cont.
  • Three membranes or meninges cover the brain
  • The outer dura mater or hard matter, which is
    like a heavy plastic covering.
  • The arachnoid, which is like a spiderweb that
    bridges the brain's many wrinkles and folds.
  • The pia mater or tender matter, which molds
    around every tiny crook and crevice on the
    brain's surface.
  • Between the pia mater and the arachnoid, there is
    145cc of cerebrospinal fluid.

Chapter 3 Understanding the Brain and Brain
Injury
75
Anatomy of the Brain, cont.
  • There are four ventricles which make, store, and
    circulate cerebrospinal fluid.
  • It helps cushion the brain and protect brain
    tissue when swelling occurs.

Chapter 3 Understanding the Brain and Brain
Injury
76
Neurons
  • Neurons the billions and billions of tiny brain
    cells making up the nervous system
  • Glial ("glue") non-communicating cells support
    and nourish the neurons.
  • Three main parts of the neuron cell body, axon,
    dendrites

Chapter 3 Understanding the Brain and Brain
Injury
77
CELL BODY
Synapses
AXON
Dendrites
Nucleus
Myelin sheath
AXON
Synaptic terminals
Chapter 3 Understanding the Brain and Brain
Injury
78
Neurons
  • The neurons communicate with each other via a
    unique electro-chemical process.
  • Neurotransmitters receive and transmit
    information in a relay of electrical impulses
  • Neurochemical transmitters leap the synaptic
    gaps.
  • After a person sustains a brain injury, many of
    the neuron pathways may be torn apart or
    stretched so that information processing is no
    longer possible.

Chapter 3 Understanding the Brain and Brain
Injury
79
Brain Geography
  • Brain stem
  • Located at the top of the spinal column and it
    relays information in and out of the brain.
  • Diencephalon
  • The thalamus, hypothalamus and other structures,
    located centimeters above the midbrain. The
    diencephalon is a master relay center for
    forwarding information, sensations, and movement.
  • Limbic system
  • Middle section of the brain, sitting on top of
    the brain stem. The limbic system is involved in
    emotions and basic feelings.

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The Brain Stem
  • Top of the spine and the central nervous system
  • The brainstem is made up of three integral areas
  • medulla pons midbrain
  • Contains many of the centers for the senses of
    hearing, touch, taste, and balance

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The Brain Stem, Cont.
  • Medulla
  • The first area in the lower part of the brain
    stem.
  • The medulla is about one inch of brain tissue
    that is vital to life and death.
  • It contains reflex centers which control many
    involuntary functions such as breathing, heart
    rate, blood pressure, swallowing, vomiting, and
    sneezing.

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The Brain Stem, Cont.
  • Pons (just above the medulla)
  • Essential for facial movements, facial sensation,
    hearing, and coordinating eye movements
  • Enables the "thinking" part of the brain (cortex)
    to work with the "movement" (cerebellum) part of
    the brain.
  • Midbrain
  • The smallest part of the brainstem
  • Functions for seeing, hearing, alertness, and
    arousal

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The Brain Stem
  • There are nerve fibers and nuclei called the
    reticular activating system (RAS).
  • Modulates or changes arousal, alertness,
    concentration, and basic biological rhythms.
  • The RAS can be depressed to a point where a
    person dies because all main body functions are
    shut down permanently.

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The Brain Stem
  • Injury to the brain stems can cause . . .
  • attention and concentration problems
  • difficulty with memory storage and retrieval
  • weakened mental stamina
  • decreased sensory information
  • difficulty in reacting to stress
  • difficulty with excessive or not enough emotional
    responses
  • disorders in eating/drinking, sleeping, and
    sexual functioning

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Diencephalon
  • Includes hypothalamus, thalamus and other
    structures.
  • Hypothalamus controls hunger, thirst, sexual
    response, endocrine levels (hormones),
    temperature regulation, and many complex
    responses like anger, fatigue, memory, and
    calmness.

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Thalamus
  • Thalamus sits on the very top of the brain stem,
    just beneath the cortex
  • Acts as a major relay station for incoming and
    outgoing sensory information.

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The Limbic System
  • The middle part of the brain
  • Situated above, around, and interconnected with
    the diencephalon
  • Houses basic elemental drives, emotions, and
    survival instincts
  • Injury or disruption to the limbic system can
    produce problems with basic emotional
    perceptions, feelings and responses to the world
    and oneself

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The Limbic System
  • Injury is often associated with injury to the
    cerebral cortex
  • The two major structures usually associated with
    the limbic system include the hippocampus and the
    amygdala.

Hippocampus
Amygdala
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Hippocampus
  • A pairedorgan, one on each side of the brain,
    that is situated within the temporal lobes.
  • Associated with memory functioning
  • Injury can cause difficulty with short term
    memory and organizing and retrieving previously
    stored memories

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Amygdala
  • A "fight - flight" structure that is closely tied
    with emotional memories and reactions.
  • The amygdala is where the stimulus is evaluated
    for emotional content.
  • The hippocampus and amygdala are directly tied
    with the olfactory fibers (smell). Smell or taste
    seem to be the most powerful stimulants for
    recollection

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Basal Ganglia
  • Manages physical movements by relaying
    information from the cerebral cortex to the
    brainstem and cerebellum.
  • Helps maintain physical equilibrium.
  • Injury affects voluntary motor nerves
  • Results in slowness and loss of movement
    (akinesia), muscular rigidity, and tremors which
    can be localized or diffuse.

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  • Cerebellum
  • Located in the lower back section of the brain,
    the cerebellum coordinates, modulates, and stores
    all body movement.
  • Cerebral Cortex
  • Two hemispheres dedicated to the highest levels
    of thinking, moving, and acting. The right and
    left hemispheres are divided into four lobes
    frontal, parietal, temporal and occipital.

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The Cerebellum
  • Wedged between the brainstem and the cerebral
    cortex is and hitched to the back of the head.
  • About 1/8 of the brain's mass
  • Monitors impulses from the motor and sensory
    centers (brainstem, basal ganglia, motor/sensory
    cortex) to help control direction, rate, force
    and steadiness of a persons movements.
  • Responsible for coordinating muscle tone,
    posture, or eye/hand movements

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Injury to The Cerebellum
  • Injury can produce problems with coordination,
    fine motor movements, equilibrium (balance) and
    ones sense of where the body is in space.

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Injury to The Cerebellum
  • A person with a damaged cerebellum may look
    "drunk" when they walk.
  • A person may not even be able to walk a marked
    straight line or sit without support.
  • Eye-hand coordination may be disabled
  • A person may not be able to reach out and pick up
    a glass of water.
  • A person's movement may become awkward trying to
    brush one's teeth results in a blow to the face.

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The Cerebral Cortex
  • Cerebral cortex the most complicated structural
    component of the brain
  • Made up of the right hemisphere and left
    hemisphere
  • The cortex is full of wrinkles and folds.
  • If you took out and flattened the cortex, it
    would be the size of a pillowcase.

Right Hemisphere
Left Hemisphere
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The Cerebral Cortex
  • The two hemispheres of the brain have unique ways
    of processing information.
  • The right hemisphere is more holistic,
    visualspatial, and intuitive.
  • The left hemisphere is more linear,
    verbalanalytic, and logical.
  • The cerebral hemispheres control opposites sides
    of the body.
  • Each hemisphere has four lobes (frontal,
    parietal, temporal and occipital).

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The Cerebral Cortex, Cont.
  • Left hemisphere
  • Processes information in a logical and linear
    manner
  • Controls speaking, reading, writing, doing
    calculations
  • Right hemisphere
  • Responds to information in a more holistic and
    spatial sense (shapes, faces, music, art)
  • The cerebral hemispheres communicate to each
    other a thousand times a second through the
    corpus callosum (the 4 inch long, pencil thick
    band of complex nerve fibers).

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Lobes of the Brain
  • Frontal
  • Parietal
  • Temporal
  • Occipital

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Parietal lobe
Frontal lobe
Occipital lobe
Temporal lobe
Cerebellum
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Lobes of the Brain
  • The lobes are interconnected by complex neural
    fibers, which relay impulses and information to
    and from the cortex.
  • Each lobe has a right and left side.
  • The lobes are interconnected by complex neural
    fibers, which relay impulses and information to
    and from the cortex.

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Frontal Lobes
  • Vulnerable to injury since they sit just inside
    the front of the skull near a rough bony area
  • Have extensive connections with many brain
    regions, especially with the parietal lobe and
    the limbic system (emotions).
  • Includes the motor strip
  • Sends signals to the muscles of the body, telling
    them what to do

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Frontal Lobe, Cont.
  • Prefrontal cortex located at the very front part
    of the frontal lobes
  • Regulates emotional responses, motivation,
    executive functions, working memory
  • Responsible for teaching a person to learn from
    consequences

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Frontal Lobe Injury
  • Injury damages an individual's ability to . . .
  • synthesize signals from the environment
  • assign priorities
  • make decisions
  • initiate actions
  • attend to tasks
  • control emotions
  • behave and interact socially
  • make plans

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Frontal Lobe Injury in Children
  • Prefrontal lobe injuries in young children
    sometimes go unnoticed
  • Parents and teachers typically function as their
    frontal lobesthey organize, plan, and direct
    their childrens lives.
  • As the child gets older and enters early
    adolescence, they are expected to be more
    independent and learn to manage themselves over
    time.
  • In the child with a brain injury, the capability
    for more independent frontal lobe functioning has
    been diminished.

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Parietal Lobe
  • Situated behind the frontal lobes
  • Includes the primary sensory cortex which is
    posterior to the motor strip.
  • The first part of the brain to consciously
    register physical sensations.
  • Regulates responses to touch, heat, cold, pain,
    and body awareness

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Parietal Lobe
  • When one side of the lobe is injured, they may
    not recognize that anything is wrong with
    movement on the other side of the body.
  • Even more complex functions like attention can be
    affected by damage to the parietal lobes.

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Occipital Lobe
  • Located in the lower back part of the brain
  • The primary visual center of the brain
  • Involves the visual cortex
  • connected to the eyes by optic nerves
  • optic nerves carrying signals meet at a
    "crossing" called the optic chiasm
  • The left optic track carries signals from the
    rightside field of vision, and the right optic
    track takes signals from the left so that both
    sides of the brain "see" the same thing.
  • Most of what a person "sees" derives its meaning
    from prior learning and symbolic representations.

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Temporal Lobes
  • Rest on both sides of the brain
  • The centers for language, hearing, and, with
    their connections to the hippocampus, help in the
    longterm storage of permanent memories.

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Temporal Lobes
  • Brocca's area located in the lower portion of
    the motor cortex in the left frontaltemporal
    lobe
  • Controls muscles of the face and mouth and
    enables the production of speech
  • Wernicke's area located left temporalparietal
    lobe
  • Governs a persons understanding of speech

Brocas Area
Wernickes Area
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When the Brain is Injured
  • After a sudden jolt or bang, the brain . . .
  • Bounces around in the skull
  • Blood vessels and delicate nerve tissues often
    rips, tears, and stretches
  • Major bleeding can occur when the brain rubs
    against the inside of the skull, which is ragged
    with sharp bony ridges
  • Swells with blood and fluid

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When the Brain is Injured, cont.
  • After a sudden jolt or bang, the brain . . .
  • Swells with blood and fluid
  • Becomes compressed due to tremendous pressure
  • Can be deprived oxygen and create an additional
    or secondary brain injury
  • Increased pressure can result in
  • hematomas
  • hydrocephalus

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When the Brain is Injured, Cont.
  • A brain injury is often the result of two
    injuries
  • the primary injury caused by the initial blow
    or insult to the brain
  • the secondary injury caused by the swelling,
    bleeding, compression and contusions (bruises) to
    the brain.

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Other Brain Injuries
  • Coup-contracoup the brain moves side-to-side
    or back-to-back as from injury to one side of the
    brain
  • Axonal injuries (DAI) are damaged nerve cells
    throughout the brain that are stretched and
    break.
  • Hyoxia decreased oxygen to the brain resulting
    from severe blood loss
  • Anoxia complete loss of oxygen causing brain
    cells (neurons) to die.
  • Other causes drowning, heart attack,
    suffocation, smoke inhalation, asthma attack, and
    strangulation

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Brain Injury Severity
  • Glasgow Coma Score (GSC)
  • Measures Eye Response Verbal Response Motor
    Response Total Score
  • Scores range between 3 and 15
  • The lower the score, the more severe is the brain
    injury

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Brain Injury Severity
  • Severity of brain injury is described in multiple
    ways.
  • The most common are
  • mild
  • moderate
  • severe

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Severity of Brain Injuries, Cont.
  • Mild brain injury
  • Loss of consciousness for less than 30 minutes
    (possibly no loss of consciousness)
  • Glasgow Coma Scale of 13-15
  • Posttraumatic amnesia for less than 24 hours
  • Temporary or permanently altered mental or
    neurological state

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Severity of Brain Injuries, Cont.
  • Postconcussion symptoms that or may not persist
    include
  • headache changes in personality
  • dizziness memory problems
  • vomiting depression
  • sleep disturbance difficulty problem solving
  • irritability diminished attention span

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Brain Injury Severity
  • Moderate brain injury
  • coma more than 20-30 min., but less than 24 hrs.
  • Glasgow Coma Scale of 9-12
  • possible skull fractures with bruising bleeding
  • signs on EEG, CAT or MRI scans
  • some long term problems in one or more areas of
    life (i.e., home, work, community)

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Brain Injury Severity
  • Severe brain injury
  • coma longer than 24 hours, often lasting days or
    weeks
  • Glasgow Coma Scale of 8 or less
  • bruising, bleeding in brain
  • signs on EEG, CAT or MRI scans
  • long term impairments in one or more areas of
    life (i.e., home, work, community)

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Many professionals and family members feel that
the severity of the actual injury and the
severity of the problems or consequences do not
necessarily match the strict definitions of mild,
moderate and severe.
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Conclusion
  • Individuals with brain injuries often have
    difficulty with new learning while exhibiting a
    good memory for information learned previous to
    the injury.
  • Virtually every behavior depends on the
    interconnectedness of the brain.
  • Because of the interconnectedness of the brain
    and behavior functions, even an injury that is
    relatively mild in severity or small in size may
    lead to many distressing symptoms.

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Chapter 4 Health, Medications and Medical
Management Issues by Terri Antoinette M.H.S.A.,
R.N.C.,C.R.R.N.,C.B.I.S.C.E., C.L.N.C. David
Strauss, PhD. Tina M Trudel Ph.D., C.B.I.S.-C.E.
124
Learning Objectives
  • Demonstrate knowledge of the most commonly
    prescribed medications used after brain injury.
  • Identify and report signs and symptoms of illness
    that require the attention of medically trained
    personnel.
  • Understand the effects of alcohol and substance
    abuse in brain injury.
  • Identify aspects of aging with brain injury.

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Introduction
  • The brain is a complex and vulnerable organ.
  • Injury can result in a multitude of physical and
    psychological impairments and medical
    complications.
  • Once a person has been deemed medically stable
    by the acute care hospital staff, transfer to
    either medically based or community based
    rehabilitation programs, or even to home, may
    occur.
  • Direct care staff often first identify possible
    conditions and complications that effect a
    persons medical stability.

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The Goal of Rehabilitation
  • The goal of rehabilitation is to help people
    regain the most independent level of functioning
    possible.
  • Treatment must be individualized in accordance
    with each persons unique needs.
  • The first step in assisting the person is a
    thorough review and assessment of factors which
    have impacted upon the whole person.
  • Well documented information on the health status
    of the individual when admitted is important.
  • It is a baseline for comparison when health
    status changes.

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Initial Assessment
  • Review past medical history including
  • how the injury happened
  • time elapsed since injury
  • age at onset of injury
  • physical or mental health problems prior to the
    injury
  • history of loss of consciousness or brain injury
    prior to this injury
  • major hospitalizations and surgery
  • right handed or left handed
  • sleep habits

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Initial Assessment, Cont.
  • Review historical information including
  • developmental / psychosocial / behavioral history
  • family support systems
  • educational history including evidence of
    learning disability
  • work history/socioeconomic status
  • military service
  • marital history
  • legal record
  • substance abuse
  • cultural, religious, and language background
  • sexual preference
  • recent life stressors (i.e. deaths, family,
    marital, financial, academic, vocational, etc.)
  • nature and extent of financial resources

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Initial Assessment, cont.
  • Review information about the accident/injury
    including
  • area of the brain injured
  • severity of injury
  • etiology of the injury (i.e. traumatic, anoxic)
  • complications/ coexisting medical conditions
  • acute medical/rehabilitative treatment including
    medical conditions/complications
  • the presence of multiple injuries

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Initial Assessment, cont.
  • Review of evaluations including
  • medical, psychiatric, nursing, neuropsychological,
    neuropsychiatric, physical therapy, occupational
    therapy, speech language therapy, social and
    vocational history.
  • Review of current medications, dosages and side
    effects
  • Make information available to direct care staff
  • Any questions should be addressed to the
    physician in charge of the person's treatment.

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Medical Management of Brain Injury
  • The medical management of brain injury is complex
    and can be a lifelong challenge

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Cardiovascular and Respiratory System
  • Cardiovascular
  • May be caused by direct trauma to the heart
    itself, complications from trauma, or damage to
    parts of the brain that control the functioning
    of the heart
  • Monitor heart rate (normal adult 60-90
    beats/minute)
  • Monitor blood pressure (optimal 120/80 mm Hg)
  • Observe for side effects of antihypertensive meds
    (dizziness, lightheadedness especially after
    standing)
  • Respiratory
  • Complications include infection, airway
    obstruction, trauma to the larynx, trachea, chest
    and lungs, risk of aspiration pneumonia
  • Monitor breathing rate ( normal adult 12-20
    breaths per minute)

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Musculoskeletal System
  • Observe for muscle and skeletal complications and
    peripheral nerve injuries
  • Spasticity (an involuntary increase in muscle
    tone-tension)
  • Contractures - (flexion and fixation of a joint
    due to a wasting away and abnormal shortening of
    muscle fibers and loss of skin elasticity)
  • Heterotopic ossification (HO) abnormal growth of
    bone in soft tissues or around joints.

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Integumentary System
  • Skin lacerations and abrasions
  • Acne and profuse sweating may appear or be
    worsened by a brain injury
  • Pressure ulcers are the most frequent
    complication of chronic illness and physical
    disability.
  • Bony prominences such as hips, coccyx, heels,
    elbows, shoulder blades and the back of the head
    are common sites
  • Persons using wheelchairs must be closely
    observed for pressure ulcers of the ischium (the
    back lower portions of the hip bones).
  • Staff members must frequently examine skin,
    report any skin abnormalities, use proper
    transfer techniques, frequently reposition, and
    provide adequate nutrition and hydration.

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Gastrointestinal System
  • Injury to the brain directly affects a persons
    nutritional needs.
  • A persons metabolism may increase after brain
    injury which causes the body to need increased
    energy and calories.
  • Problems such as poor hand to eye coordination,
    difficulty swallowing, diminished attention and
    impaired cognition can further compromise a
    persons nutritional intake.

Chapter 4 Health, Medications and Medical
Management Issues
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