Supported employment for persons with traumatic brain injury: a preliminary investigation of long-term follow-up costs and program efficiency

OBJECTIVE: To investigate the long-term follow-up costs of supported employment as well as the wage and employment characteristics for individuals with moderate to severe traumatic brain injury (TBI) who participated in supported employment services over a 14-year time period. DESIGN: Longitudinal design with prospectively collected data. SETTING: A university-based supported employment program that uses the individual placement model of supported employment. PARTICIPANTS: Fifty-nine individuals with moderate to severe TBI who were consecutively referred for supported employment services. The sample was restricted to individuals who were placed into a least 1 supported employment position during the study period. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Data were collected on clients placed into at least 1 competitive supported employment position from 1985 to 1999. Analyses were performed to examine the costs of supported employment, employment characteristics (eg, wages, length of employment), and benefit-cost ratios of supported employment for individuals with TBI. RESULTS: The average length of employment for the current sample was 42.58 months. Average gross earnings were US dollars 26,129.74 for individuals during their entire duration of employment. Billing charges accrued for employment services averaged US dollars 10,349.37. Individuals with TBI earned an average of US dollars 17,515 more than the costs associated with their supported employment. CONCLUSIONS: Our investigation provides additional support for the conclusion that supported employment is cost effective for individuals with disabilities, including individuals with TBI, and that the costs of supported employment decrease over time.     

The impact of burn injury: a preliminary investigation.

Thirty-eight individuals who had been previously hospitalized for burn injuries were interviewed about the problems that they had experienced as a result of their injuries, their rehabilitation goals, and factors that they believed had influenced either the rate or extent of their recovery. The problems that were most frequently mentioned by participants were compared with problem areas that are covered by the Burn-Specific Health scale, which is a standardized measure designed to assess the impact of burn injury. Our findings suggest that although many problem areas are well covered by the Burn-Specific Health scale, other areas are covered less well. Thus more work is needed to refine the scale to capture more fully the wide variety of problems that are experienced by survivors of burn injuries. In general, patients' rehabilitation goals reflected the types of problems they experienced. Support from health care providers was the most frequently mentioned facilitator to recovery, which emphasizes the importance of the patient-provider relationship.     

成年创伤性脑损伤病人呼吸暂停：初级研究

目的：明确成年创伤性脑损伤病人与睡眠相关的呼吸暂停。设计：对病人在脑损伤后进行了回顾性,观察性,连续性康复。环境：四所医学院的住院康复中心和亚急性康复中心。参加者：包括成年脑损伤和在脑损伤后3个月内的病人（n=28）内进行综合院内康复和Rancho Los Amigos 量表分数≥3的病人。干预：利用随身携带的6通道监测系统研究整个夜晚的睡眠。主要的结果测量：呼吸暂停指数（每小时呼吸暂停的次数和低通气次数）。结果：10个RDL分数≥5和3个RDL分数≥10的病人出现呼吸暂停。所测得的呼吸暂停率明显高于预计值。未发现呼吸暂停的发…     

Sleep apnea in adults with traumatic brain injury: a preliminary investigation

OBJECTIVE: To determine the occurrence and nature of sleep-related breathing disorders in adults with traumatic brain injury (TBI). DESIGN: Prospective, observational, consecutive sample enrollment of subjects admitted for rehabilitation after TBI. SETTING: Inpatient rehabilitation and subacute rehabilitation units of a tertiary care university medical system. PARTICIPANTS: Subjects (n = 28) included adults with TBI and a Rancho Los Amigos Scale level of 3 or greater who were less than 3 months postinjury and admitted for comprehensive inpatient rehabilitation. INTERVENTIONS: Overnight sleep study using portable 6-channel monitoring system. MAIN OUTCOME MEASURE: Respiratory disturbance index (RDI), which is the number of apneic and hypopneic episodes per hour of sleep. RESULTS: Evidence of sleep apnea was found in 10 of 28 (36%) subjects as measured by a RDI level of 5 or greater and in 3 of 28 (11%) subjects as measured by a RDI level of 10 or greater. This rate of sleep apnea is significantly (p =.002) higher than would be predicted based on population norms. No correlation was found between the occurrence of significant sleep apnea and measures of TBI severity or other demographic variables. Sleep-related breathing disorders were primarily central though obstructive apneas were also noted. CONCLUSION: In this preliminary investigation, sleep-related breathing disorders as defined by a respiratory disturbance index of 5 or greater appears to be common in adult subjects with TBI.     

Early intervention in severe head injury: long-term benefits of a formalized program.

With traumatic brain injuries numbering more than two million per year, health professionals are faced with the challenges of restoring and maximizing quality of life. This study quantifies the benefits of a formalized head injury program, including the concept of trauma rehabilitation, defined as early, aggressive rehabilitation during acute hospitalization. Thirty-eight severely head injured patients received treatment at the same rehabilitation facility. Twenty-one of these patients received acute care services at ten different hospitals without formalized traumatic brain injury programs, and 17 received services at a hospital with a formalized early intervention program. Comparison of outcome data for the two programs revealed that patients in the formalized program had comas and rehabilitation stays approximately one third the length of patients in nonformalized programs (18.9 vs 53.8 days and 106.5 vs 239.5 days, respectively). Mean cognitive levels at discharge from the acute hospitals (5.6 vs 4.0) and the rehabilitation facility (7.4 vs 6.7) were significantly higher for the formalized program, and they facilitated a significantly higher percentage of discharges to home vs extended care facility (94% vs 57%).     

Partnering for injury prevention: evaluation of a curriculum-based intervention program among elementary school children

A randomized pretest and posttest comparative design was used to evaluate the outcome of implementing Think First for Kids (TFFK), an injury prevention program for children grades 1, 2, and 3, among intervention and controls schools. The study showed that children often lack basic knowledge regarding safety and do not recognize behaviors considered high risk for injury. By using multivariate analysis, the intervention children had a significantly greater increase in knowledge about the brain and spinal cord and safe behaviors to prevent traumatic injury, and a decrease in self-reported, high-risk behaviors (p < .001) when compared with control subjects, adjusting for the covariates gender, socioeconomic status, and race/ethnicity. African American and Hispanic children, although displaying the lowest test scores at baseline, had the largest absolute improvement in posttest scores. The TFKK prevention program addresses the leading causes of trauma among children including sports, motor vehicle crashes, falls, drowning, and pedestrian injuries.     

Auditory processing in spinal cord injury: a preliminary investigation from a sensory deprivation perspective

Research on sensory deprivation suggests that the loss of somatosensory input to the central nervous system may have an impact on cortical reactivity and subsequent cognitive task efficiency. Individuals with spinal cord injury have a permanent loss of such input to varying degrees. However, there have been few investigations of cognitive processing in spinal cord injury. In this study, six outpatients with quadriplegia and 12 able-bodied controls were administered a dichotic listening task while auditory evoked response data and auditory threshold data were recorded. There were no differences between groups in terms of auditory threshold or auditory evoked responses. However, the outpatient quadriplegic group was more successful than the able-bodied controls in performing the dichotic listening task at one but not all levels of complexity. Results suggest that differences in cognitive processing ability between spinal cord injured and able-bodied individuals may reflect higher level motivational attention-concentration differences rather than more basic auditory and neurophysiologic processing differences.     

Cerebral contusion: a prototype for head injury

Cerebral contusions occur as a result of traumatic head injury. These lesions may consist of tissue necrosis, hemorrhage, and edema. The patient with a cerebral contusion is at risk to develop increased ICP and brain tissue displacement that may cause a rapid deterioration in his clinical condition.     

Factors associated with avoidable interhospital transfers for children with a minor head injury

IntroductionChildren with minor head injuries (MHI) are routinely transferred to a pediatric trauma center for definitive care. Unwarranted transfers result in minimal benefit to the patient and add substantially to healthcare costs. The purpose of this study is to explore the factors associated with avoidable interhospital transfers of children with MHI.MethodsWe conducted a retrospective cohort study of children <18 years of age transferred to our pediatric emergency department (PED) for MHI between January 2013 and December 2018. Patients transferred for non-accidental trauma, and those with a history of coagulopathies, underlying neurological conditions, intraventricular shunts and developmental delay were excluded. Transfers were categorized as avoidable if none of the following interventions were required at our PED: procedural sedation, anticonvulsant initiation, subspecialty consultation, intensive care unit admission or hospital admission for ≥2 nights, intubation or operative intervention. We collected demographics, injury mechanism, neuroimaging results, interventions performed and PED disposition. Binary logistic regression was conducted to provide adjusted associations between patient characteristics and the risk of avoidable interhospital transfers.ResultsWe analyzed 1078 transfers for MHI, of which 450 (42%) transfers were classified as avoidable. Children in the avoidable transfer group tended to be younger, less likely to have experienced loss of consciousness, and more likely to belong to the the group at lowest risk for a clinically important traumatic brain injury (ciTBI). Our multivariable model determined that children less than 2 years of age (OR = 1.75; 95% CI = 1.3–2.37), low-risk group for ciTBI (OR = 1.66; 95% CI = 1.22–0.1), and a positive head CT at the transferring hospital (OR = 0.06; 95% CI = 0.02–0.1) were all significantly associated with avoidable transfers.ConclusionThere is a high rate of avoidable transfers in children with MHI. Focused interventions targeting risk factors associated with avoidable transfers may reduce unwarranted interhospital transfers.     

Penetrating head injury in children: a case report and review of the literature

Head trauma is exceedingly common in children, but rarely presents as a penetrating injury to the skull. Most of the recommendations on evaluation, management, and follow-up of such injuries are based on the adult literature. We report a case of penetrating head injury from a tapered metal object in a 4-year old child.