Correlation analysis of disease type, course, seriousness and age when treating craniocerebral injuries with hyperbaric oxygen

FormAugust１９９５toDecember１９９８,６１casesofcraniocerebralinjuriesweretreatedwithHBOandsatisfactoryresultswereobtained,itisreportedasfollowing．１Subjectandmethod１．１Subject４６malecasesand１５femalecases,theywerefrom３to７７yearsincluding９casesof３to２０years,３casesof２１to４０yearsand１９casesofover４０years．AccordingtotheGlasgowcomascoring,therewere１０casesofslighttypes（scoring１３～１５）,１５casesofmiddlecases（scoring９～１２）and３６casesofseverecases（scoring３～８）…     

Awareness of behavioral, cognitive, and physical deficits in acute traumatic brain injury

OBJECTIVE: To compare awareness of deficit in 3 domains of function (physical, cognitive, behavioral/emotional) in acute traumatic brain injury (TBI), controlling for severity of impairment in the different domains. DESIGN: Inception cohort. SETTING: Three inpatient rehabilitation programs. PARTICIPANTS: People with acute TBI (N=161), tested as soon as feasible after posttraumatic amnesia. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Awareness Questionnaire (AQ) completed by the person with TBI and the treating neuropsychologist; and self- and clinician-rating scores calculated in the 3 domains. RESULTS: For participants who were rated by clinicians as more impaired in at least 1 domain (ie, scored lower on the AQ), self-ratings differed significantly from one another in all 3 domains, with behavioral self-ratings highest, physical self-ratings lowest, and cognitive self-ratings intermediate. In subgroups of participants rated at the same level by clinicians in all 3 domains, physical self-ratings were also lowest, that is, more consonant with clinician ratings. Participants tended to rate themselves as relatively unchanged in cognitive and behavioral domains regardless of the level of clinician ratings on these factors. CONCLUSIONS: Patterns of discrepant awareness of deficit in different functional areas seen in postacute TBI also appear to be present acutely and are not entirely related to differential severity of deficit. We discuss several possible reasons for discrepant awareness of deficit, including differences in internal and external feedback, cultural and psychologic factors, and different levels of ambiguity inherent in causal explanations for different types of problems.     

Racial Differences in Employment Outcome After Traumatic Brain Injury at 1, 2, and 5 Years Postinjury

Gary KW, Arango-Lasprilla JC, Ketchum JM, Kreutzer JS, Copolillo A, Novack TA, Jha A. Racial differences in employment outcome after traumatic brain injury at 1, 2, and 5 years postinjury.

Objectives

To examine racial differences in competitive employment outcomes at 1, 2, and 5 years after traumatic brain injury (TBI) and to determine whether changes in not competitive employment rates over time differ between blacks and whites with TBI after adjusting for demographic and injury characteristics.

Design

Retrospective cohort study.

Setting

Sixteen TBI Model System Centers.

Participants

Blacks (n=615) and whites (n=1407) with moderate to severe TBI.

Interventions

Not applicable.

Main Outcome Measure

Employment status dichotomized as competitively employed versus not competitively employed.

Results

After adjusting for demographic and injury characteristics, repeated-measures logistic regression indicated that (1) the odds of not being competitively employed were significantly greater for blacks than whites regardless of the follow-up year (all P<.001); (2) the odds of not being competitively employed declined significantly over time for each race (P≤.004); and (3) changes over time in the odds of not being competitively employed versus being competitively employed were not different between blacks and whites (P=.070). In addition, age, discharge FIM and Disability Rating Scale, length of stay in acute and rehabilitation, preinjury employment, sex, education, marital status, and cause of injury were significant predictors of employment status postinjury.

Conclusions

Short- and long-term employment is not favorable for people with TBI regardless of race; however, blacks fare worse in employment outcomes compared with whites. Rehabilitation professionals should work to improve return to work for all persons with TBI, with special emphasis on addressing specific needs of blacks.     

Acquired brain injury, visual attention, and the useful field of view test: A pilot study

OBJECTIVE: To compare the findings of the Useful Field of View (UFOV) test with those of conventional neuropsychologic tests to determine the utility of the UFOV test as a measure of attention in a population with brain injury. DESIGN: Cohort study. SETTING: Freestanding rehabilitation hospital. PARTICIPANTS: Fifteen inpatients with severe brain injury. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: UFOV test, FIM\T instrument, length of stay (LOS), and standard neuropsychologic testing. RESULTS: The UFOV subtest UF2 correlated strongly with the other 2 subtests, UF1 and UF3. The UF2 subtest correlated most strongly with paper and pencil tests of visual attention. The UF2 predicted 52% of the FIM change and 60% of the LOS variance, second only to admission FIM score, which predicted 75% and 80% of FIM change and LOS variance, respectively. CONCLUSIONS: Among the patients in our study, the UFOV test can be used to determine the visual divided attention of patients with acquired brain injury. The results also showed that the UFOV test correlated with LOS and FIM change in patients with acquired brain injury recovering in a rehabilitation facility. Because the UFOV test is much more quickly administered and scored than other measures of attention and divided attention, these results suggest that the UFOV test may provide an easy means to measure a critical variable in the population with head injury.     

Association of antidepressant medication therapy with inpatient rehabilitation outcomes for stroke, traumatic brain injury, or traumatic spinal cord injury

Weeks DL, Greer CL, Bray BS, Schwartz CR, White JR Jr. Association of antidepressant medication therapy with inpatient rehabilitation outcomes for stroke, traumatic brain injury, or traumatic spinal cord injury.

Objective

To study whether outcomes in patients who have undergone inpatient rehabilitation for stroke, traumatic brain injury (TBI), or traumatic spinal cord injury (TSCI) differ based on antidepressant medication (ADM) use.

Design

Retrospective cohort study of 867 electronic medical records of patients receiving inpatient rehabilitation for stroke, TBI, or TSCI. Four cohorts were formed within each rehabilitation condition: patients with no history of ADM use and no indication of history of depression; patients with no history of ADM use but with a secondary diagnostic code for a depressive illness; patients with a history of ADM use prior to and during inpatient rehabilitation; and patients who began ADM therapy in inpatient rehabilitation.

Setting

Freestanding inpatient rehabilitation facility (IRF).

Participants

Patients diagnosed with stroke (n=625), TBI (n=175), and TSCI (n=67).

Interventions

Not applicable.

Main Outcome Measures

FIM, rehabilitation length of stay (LOS), deviation between actual LOS and expected LOS, and functional gain per day.

Results

In each impairment condition, patients initiating ADM therapy in inpatient rehabilitation had longer LOS than patients in the same impairment condition on ADM at IRF admission, and had significantly longer LOS than patients with no history of ADM use and no diagnosis of depression (P<.05). LOS for patients initiating ADM therapy as inpatients even exceeded LOS for patients without ADM history, but who had a diagnosis for a depressive disorder. Deviation in LOS was significantly larger in the stroke and TBI groups initiating ADM in IRF than their counterparts with no history of ADM use, illustrating that the group initiating ADM therapy in rehabilitation significantly exceeded expected LOS. Increased LOS did not translate into functional gains, and in fact, functional gain per day was lower in the group initiating ADM therapy in IRF.

Conclusions

Explanations for unexpectedly long LOS in patients initiating ADM in inpatient rehabilitation focus on the potential for ADM to inhibit therapy-driven remodeling of the nervous system when initiated close in time to nervous system injury, or the possibility that untreated sequelae (eg, depressive symptoms or fatigue) were limiting progress in therapy, which triggered ADM treatment.     

Poster 24: Relationship of independent living status, vocational outcome status, and satisfaction with life after traumatic brain injury

Objective: To determine whether independent living status or vocational outcome status predicts satisfaction with life for patients after moderate to severe traumatic brain injury (TBI). Design: Prospective cohort study. Setting: Acute care, rehabilitation hospital. Participants: 26 men and 23 women with moderate to severe TBI. Interventions: Not applicable. Main Outcome Measures: Satisfaction with Life Scale (SWLS), Vocational Outcome Scale (VOS), and Independent Living Scale (ILS) collected at hospital discharge and at 1- and 2-year follow-up. Results: Discharge SWLS predicted 1-year SWLS score (n=49; r=.51, P<.001); 1-year SWLS score predicted SWLS score at 2 years (n=28, r=.60, P<.001). Discharge ILS and VOS scores did not predict SWLS score at 1 year. 1-year SWLS score correlated mildly (r=.39, P<.01) with 1-year VOS and with 1-year ILS (r=.38, P<.01) scores. 78% indicated positive life satisfaction (SWLS score, >19) at discharge and 61% at 1 year. Of those satisfied at discharge, 79% remained satisfied at 1 year. Of those dissatisfied at discharge, 82% remained dissatisfied at 1 year. Conclusions: SWLS score appears relatively stable over time. Life satisfaction may be less dependent on vocational and independent living status than on longstanding personality or social factors.     

Aging, gender, and spinal cord injury

OBJECTIVE: To identify differences in the aging experiences of men and women with spinal cord injury (SCI). DESIGN: This study is part of a longitudinal international study of aging and SCI. SETTING: Five centers in England, Canada, and the United States. Three were spinal cord rehabilitation facilities (Stoke-Mandeville Hospital, Southport Hospital, Craig Hospital) and 2 were community agencies (Ontario and Manitoba divisions of the Canadian Paraplegic Association). PARTICIPANTS: A matched sample of 67 men and 67 women with SCI for at least 20 years. The 2 groups were matched on age, country of origin, and duration of disability. Participants had an average age of 57 years and an average disability duration of almost 33 years. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Two measures were taken by interview: demographic form and current status interview. Five others were self-administered and returned by mail: the Perceived Stress Scale, Craig Handicap Assessment and Reporting Technique, Index of Psychological Well-Being, Current Problem Questionnaire, and Life Satisfaction Index. RESULTS: Although both sexes rated their quality of life about equally, women characterized their aging experience as "accelerated," while men characterized it as "complicated." Women reported more effects of pain, fatigue, and skin problems and more transportation problems. Men experienced more health problems, more diabetes, and more adaptive equipment changes. Older men and women with SCI spent their time differently, consistent with traditional gender roles. CONCLUSIONS: These results underline the need for gender-specific consideration of aging experiences associated with SCI and further emphasize the need for primary and preventive care to promote health and well-being as people with SCI survive into old age.     

Race, employment, and spinal cord injury

OBJECTIVES: To examine issues of employment and race for persons with spinal cord injury (SCI), by assessing the type of work that was being done before and after injury and by placing this in the context of patterns for the general population. DESIGN: Retrospective, cross-sectional analysis. SETTING: Centers funded as part of the federally sponsored Model Spinal Cord Injury Systems (MSCIS) Project. PARTICIPANTS: Two samples: 5925 African Americans and whites with SCI who are part of the MSCIS and a subset of 577 people with SCI. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Demographic information, occupational status, employment rate, job census codes, Craig Hospital Assessment and Reporting Technique-Short Form, and Satisfaction With Life Scale. RESULTS: Racial disparities were found in employment rates before injury and at 1, 5, 10, 15, and 20 years after SCI. Differences were also found in the types of jobs that were held before SCI with patterns for participants similar to those of African Americans and whites in the general population. No differences were found in the types of jobs held by African Americans and whites with SCI at 1 year after injury. After injury, African Americans had lower economic self-sufficiency scores, regardless of employment status, and lower social integration scores among those who were not employed. CONCLUSIONS: Racial disparities found in employment patterns among persons with SCI mirrored patterns among the general population.     

Health status, community integration, and economic risk factors for mortality after spinal cord injury

OBJECTIVE: To examine the association of health, community integration, and economic status with subsequent mortality and life expectancy among persons with spinal cord injury. DESIGN: Cohort study. SETTING: Model Spinal Cord Injury Systems (MSCIS) hospitals. PARTICIPANTS: A total of 5947 persons injured since 1973 who were enrolled in the National Spinal Cord Injury Database and who were still alive and received an annual evaluation from November 1995 through March 2002. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURE: Mortality was determined by routine follow-up supplemented by information from the Social Security Death Index. A logistic regression model based on the full set of predictor variables was developed to estimate the chance of dying in any given year. RESULTS: After adjusting for demographic characteristics and injury severity, health status indicators, measures of community integration, and economic status indicators all had relatively small but statistically significant effects (20%-70% increases) on the likelihood of dying during the next year. Inclusion of these factors may result in higher life expectancy estimates under highly favorable conditions. CONCLUSIONS: Whereas previous reports of the MSCIS data have identified the life expectancies associated with a particular set of demographic (eg, age, gender) and injury-related characteristics (level and completeness of injury; ventilator dependence), the current analysis suggests that consideration of health, economic, and psychosocial factors may make computations of life expectancy more accurate.     

Characteristics of a Mild Head Injury Subgroup With Extreme, Persisting Distress on the Rivermead Postconcussion Symptoms Questionnaire

Kirsch NL, de Leon MB, Maio RF, Millis SR, Tan-Schriner CU, Frederiksen S. Characteristics of a mild head injury subgroup with extreme, persisting distress on the Rivermead Postconcussion Symptoms Questionnaire.

Objective

To examine baseline variables and identify characteristics of participants with extremely high reports of symptoms (ie, outliers) 12 months after mild head injury (MHI).

Design

A prospective cohort study of MHI with and without loss of consciousness (LOC) and/or posttraumatic amnesia (PTA) recruited from and interviewed at the emergency department (ED), with a follow-up telephone interview at 12 months.

Setting

Level II community hospital ED.

Participants

Participants (n=58) with MHI and LOC less than or equal to 30 minutes and/or PTA less than 24 hours and participants (n=173) with MHI but no PTA/LOC. Inclusion criteria: age greater than or equal to 18 years, less than or equal to 24 hours after injury, Glasgow Coma Scale score greater than or equal to 13, and discharge from the ED. Fourteen (6%) participants had extremely high scores on the Rivermead Postconcussion Symptoms Questionnaire (RPQ).

Main Outcome Measures

RPQ and questions on health services use and litigation.

Results

Characterizing the outlier cases are prior head injury, preinjury disability, history of substance use, unemployment, and elevated somatic symptoms at the ED. At 12 months, outliers had higher use of health services and litigation.

Conclusions

The existence of a subgroup with a distinctive pattern of baseline characteristics in combination with elevated somatic symptoms at the time of presentation to the ED suggests that further taxonomic distinctions may be warranted for the MHI population, each requiring appropriately targeted interventions for addressing symptomatic complaints.     

Risk of stroke, heart attack, and diabetes complications among veterans with spinal cord injury

Banerjea R, Sambamoorthi U, Weaver F, Maney M, Pogach LM, Findley T. Risk of stroke, heart attack, and diabetes complications among veterans with spinal cord injury.

Objectives

To compare the rates of diabetes and macrovascular conditions in veterans with spinal cord injury (SCI) and to examine variations by patient-level demographic, socioeconomic, access, and health status factors.

Design

A retrospective analysis. Diabetes status was classified by merging with diabetes epidemiology cohort using a validated algorithm. Chi-square tests and logistic regressions used to compare rates in macro- and microvascular conditions in veterans with and without diabetes.

Setting

Veteran Health Administration clinic users in fiscal year (FY) 1999 to FY 2001.

Participants

SCI patients (N=8769) with diabetes (n=1333), in FY 2000, identified through the SCI registry.

Interventions

Not applicable.

Main Outcome Measures

Macrovascular and microvascular conditions in the next year (February 2001). Derived from International Statistical Classification of Diseases, 9th Revision, Clinical Modification, codes in the patient treatment files.

Results

Overall, 15% of SCI veterans were identified with diabetes but this was an underestimate due to high mortality (8%). Among SCI veterans with diabetes, 49% had at least one macrovascular condition and 54% had microvascular conditions compared with 24% and 25% of those without diabetes (P<.001).

Conclusions

Our study highlights the highly significant relationship between diabetes and macro- and microvascular conditions in veterans with SCI. Neurologic deficit combined with increased insulin resistance has a greater macrovascular impact on SCI veterans than on those who do not have diabetes. Increasing age and physical comorbidities compound the problem.     

Influence of Race/Ethnicity on Divorce/Separation 1, 2, and 5 Years Post Spinal Cord Injury

Arango-Lasprilla JC, Ketchum JM, Francis K, Premuda P, Stejskal T, Kreutzer J. Influence of race/ethnicity on divorce/separation 1, 2, and 5 years post spinal cord injury.

Objectives

(1) To compare the proportions of divorce/separation between races/ethnicities at 1, 2, and 5 years post spinal cord injury (SCI); (2) to examine changes in proportions of divorce/separation over time within each race/ethnicity group; and (3) to compare the changes in proportions of divorce/separation over time between races/ethnicities.

Design

Retrospective study.

Setting

Model Spinal Cord Injury Systems.

Participants

A sample of participants married preinjury (N=1528; 1108 whites, 258 blacks, 162 Hispanics) was selected from the National Spinal Cord Injury Statistical Center database from 1988 to 1998.

Interventions

Not applicable.

Main Outcome Measures

Proportion of separation/divorce at 1, 2, and 5 years postinjury for each race/ethnic group.

Results

At all postinjury years (1, 2, 5y), blacks had significantly greater odds of divorce/separation versus staying married than Hispanics. In addition, whites had significantly greater odds of divorce/separation versus staying married compared with Hispanics at 1 and 2 years postinjury. People with SCI of all races/ethnicities showed significantly greater increases in the odds of divorce/separation versus staying married over time (1–2, 2–5, 1–5y postinjury). Although there was evidence that the races/ethnicities were significantly different at each postinjury year, and that each race/ethnicity showed significant increases in the proportion of divorce/separation over time, there was no indication that the increases in the divorce/separation over time were significantly different among the race/ethnic groups.

Conclusions

Family therapists and rehabilitation professionals should work together to reduce the separation and divorce rates in all subjects with SCI, with special attention paid to meeting the specific needs of those with minority backgrounds.     

The Incidence and Burden of Ladder, Structure, and Scaffolding Falls

Objectives: The national morbidity and mortality associated with falls from a height is incompletely described. The authors estimated the rates of injury, hospitalization, and mortality due to these falls for subgroups of the U.S. population. Methods: Administrative databases (1995–2000) provided national samples of patients treated for injuries following a fall from a height (ICD‐9‐CM E‐codes E881.0, E881.1, or E882). Inpatient data are from the Nationwide Inpatient Sample, and emergency department data are from the National Hospital Ambulatory Medical Care Survey. Results: A total of 347,484 (95% confidence interval = 308,417 to 386,551) emergency department presentations occur annually for injuries following a fall. Hospitalized patients older than 75 years of age had a 3.3% case fatality, and 42% were discharged to a skilled nursing facility. For patients older than 55 years of age, 86% of falls were not work related. Conclusions: Ladder and structure falls by elders are a substantial emergency department problem warranting thorough clinical evaluation and injury prevention efforts.