Social skills treatment for people with severe, chronic acquired brain injuries: a multicenter trial

McDonald S, Tate R, Togher L, Bornhofen C, Long E, Gertler P, Bowen R. Social skills treatment for people with severe, chronic acquired brain injuries: a multicenter trial.

Objective

To determine whether social skills deficits including unskilled, inappropriate behavior, problems reading social cues (social perception), and mood disturbances (such as depression and anxiety) could be remediated after severe traumatic brain injuries.

Design

Randomized controlled trial comparing a social skills program with social activity alone or with waitlist control. Several participants were reassigned after randomization.

Setting

Hospital outpatient and community facilities.

Participants

Fifty-one outpatients from 3 brain injury units in Sydney, Australia, with severe, chronic acquired brain injuries were recruited. A total of 39 people (13 in skills training, 13 in social activity, 13 in waitlist) completed all phases of the study.

Intervention

Twelve-week social skills treatment program encompassing weekly 3-hour group sessions focused on shaping social behavior and remediating social perception and 1-hour individual sessions to address psychologic issues with mood, self-esteem, etc.

Main Outcome Measures

Primary outcomes were: (1) social behavior during encounters with a confederate as rated on the Behaviorally Referenced Rating System of Intermediary Social Skills−Revised (BRISS-R), (2) social perception as measured by The Awareness of Social Inference Test, and (3) depression and anxiety as measured by the Depression, Anxiety and Stress Scale. Secondary outcomes were: relative report on social behavior and participation using: the Katz Adjustment Scale−R1; the Social Performance Survey Schedule; the La Trobe Communication Questionnaire; and the Sydney Psychosocial Reintegration Scale (both relative and self-report).

Results

Repeated-measures analysis of variance indicated that social activity alone did not lead to improved performance relative to waitlist (placebo effect) on any outcome variable. On the other hand, the skills training group improved differentially on the Partner Directed Behavior Scale of the BRISS-R, specifically the self-centered behavior and partner involvement behavior subscales. No treatment effects were found for the remaining primary outcomes (social perception, emotional adjustment) or for secondary outcome variables (relative and self-report measures of social function).

Conclusions

This study suggested that treatment effects after social skills training in people with severe, chronic brain injuries are modest and are limited to direct measures of social behavior.     

Recognition of disgust is selectively preserved in Alzheimer's disease

The neural substrates that subserve decoding of different emotional expressions are subject to different rates of degeneration and atrophy in Alzheimer's disease (AD), and there is therefore reason to anticipate that a differentiated profile of affect recognition impairment may emerge. However, it remains unclear whether AD differentially affects the recognition of specific emotions. Further, there is only limited research focused on whether affect recognition deficits in AD generalize to more ecologically valid stimuli. In the present study, relatively mild AD participants (n = 24), older controls (n = 30) and younger controls (n = 30) were administered measures of affect recognition. Significant AD deficits were observed relative to both the younger and older control groups on a measure that involved labeling of static images of facial affect. AD deficits on this measure were observed in relation to all emotions assessed (anger, sadness, happiness, surprise and fear), with the exception of disgust, which was preserved even relative to the younger adult group. The relative preservation of disgust could not be attributed to biases in the choice of labels made, and it is suggested instead that this finding might reflect the relative sparing of the basal ganglia in AD. No significant AD effect was observed for the more ecologically valid measure that involved dynamic displays of facial expressions, in conjunction with paralinguistic and body movement cues, although a trend for greater AD difficulty was observed.     

Inequitable provision of optimal services for patients with chronic heart failure: a national geo-mapping study

OBJECTIVE: To compare the location and accessibility of current Australian chronic heart failure (CHF) management programs and general practice services with the probable distribution of the population with CHF. DESIGN AND SETTING: Data on the prevalence and distribution of the CHF population throughout Australia, and the locations of CHF management programs and general practice services from 1 January 2004 to 31 December 2005 were analysed using geographic information systems (GIS) technology. OUTCOME MEASURES: Distance of populations with CHF to CHF management programs and general practice services. RESULTS: The highest prevalence of CHF (20.3-79.8 per 1000 population) occurred in areas with high concentrations of people over 65 years of age and in areas with higher proportions of Indigenous people. Five thousand CHF patients (8%) discharged from hospital in 2004-2005 were managed in one of the 62 identified CHF management programs. There were no CHF management programs in the Northern Territory or Tasmania. Only four CHF management programs were located outside major cities, with a total case load of 80 patients (0.7%). The mean distance from any Australian population centre to the nearest CHF management program was 332 km (median, 163 km; range, 0.15-3246 km). In rural areas, where the burden of CHF management falls upon general practitioners, the mean distance to general practice services was 37 km (median, 20 km; range, 0-656 km). CONCLUSION: There is an inequity in the provision of CHF management programs to rural Australians.     

Development of spontaneous intracranial hypotension concurrent with grade IV mobilization of the cervical and thoracic spine: a case report

Donovan JS, Kerber CW, Donovan WH, Marshall LF. Development of spontaneous intracranial hypotension concurrent with grade IV mobilization of the cervical and thoracic spine: a case report.Spontaneous intracranial hypotension (SIH) has been clinically defined as the development of severe orthostatic headaches caused by an acute cerebrospinal fluid (CSF) leak. Typically, intracranial hypotension occurs as a complication of lumbar puncture, but recent reports have identified cases caused by minor trauma. We report a case of SIH secondary to a dural tear caused by a cervical and thoracic spine mobilization. A 32-year-old woman with SIH presented with severe positional headaches with associated hearing loss and C6-8 nerve root distribution weakness. CSF opening pressure was less than 5cmH₂O and showed no abnormalities in white blood cell count. Cranial, cervical, and thoracic magnetic resonance imaging revealed epidural and subdural collections of CSF with associated meningeal enhancement. Repeated computed tomography myelograms localized the leak to multiple levels of the lower cervical and upper thoracic spine. A conservative management approach of bedrest and increased caffeine intake had no effect on the dural tear. The headache, hearing loss, and arm symptoms resolved completely after 2 epidural blood patches were performed. Practitioners performing manual therapy should be aware of this rare, yet potential complication of spinal mobilizations and manipulations.     

Efficacy and Safety of 5 Anesthetics in Adult Zebrafish (Danio rerio)

Although the safety and efficacy of tricaine methanesulfonate (MS222) for anesthesia of fish are well established, other anesthetics used less commonly in fish have been less extensively evaluated. Therefore, we compared gradual cooling, lidocaine hydrochloride (300, 325, and 350 mg/L), metomidate hydrochloride (2, 4, 6, 8, and 10 mg/L), and isoflurane (0.5 mL/L) with MS222 (150 mg/L) for anesthesia of adult zebrafish. The efficacy and safety of each agent was evaluated by observing loss of equilibrium, slowing of opercular movement, response to tail-fin pinch, recovery time, and anesthesia-associated mortality rates. At 15 min after anesthetic recovery, we used a novel-tank test to evaluate whether anesthetic exposure influenced short-term anxiety-like behavior. Behavioral parameters measured included latency to enter and number of transitions to the upper half of the tank, number of erratic movements, and number of freezing bouts. Behavior after anesthesia was unaltered regardless of the anesthetic used. Efficacy and safety differed among the anesthetics evaluated. Gradual cooling was useful for short procedures requiring immobilization only, but all instrumentation and surfaces that come in contact with fish must be maintained at approximately 10 °C. MS222 and lidocaine hydrochloride at 325 mg/L were effective as anesthetic agents for surgical procedures in adult zebrafish, but isoflurane and high-dose lidocaine hydrochloride were unsuitable as sole anesthetic agents due to high (30%) mortality rates. Although MS222 remains the best choice for generating a surgical plane of anesthesia, metomidate hydrochloride and gradual cooling were useful for sedation and immobilization for nonpainful procedures.Abbreviation: MS222, tricaine methanesulfonateSeveral publications review anesthesia in fish.^1,16,20 Buffered tricaine methanesulfonate (MS222) is the anesthetic typically used to provide surgical level anesthesia in zebrafish (Danio rerio),^8,15 and most researchers use MS222 at a concentration of 164 mg/L.^15,25,26 However, reported side effects of MS222 that are dependent on dose and exposure duration include respiratory acidosis, cardiac depression, cardiac failure, and death.^10,19,21,24 MS222 increases blood glucose, plasma cortisol, lactate, and blood chemistry values in zebrafish and other species.^1,6,23,24 Because of these and other undesirable side effects of MS222, other anesthetics have been used to anesthetize adult zebrafish.^{1,5,6,10,15,19,21,24}The use of several less common anesthetic agents has been described in ornamental fish, including zebrafish.¹⁶ Lidocaine hydrochloride is a local anesthetic that has previously been used for anesthesia in medaka (Oryzias latipes),^17,23 in which it produced a surgical plane of anesthesia. Metomidate hydrochloride is an imidazole-based nonbarbiturate hypnotic that is used to sedate fish for handling and to reduce the trauma and stress associated with transportation.^{1,2,4,5,12,14,16,22} Isoflurane is a hydrocarbon that can be used as an anesthetic immersion bath.^16,23 Alone, isoflurane provides variable anesthesia and analgesia in fish, but when combined with MS222, it has been reported to produce a surgical plane of anesthesia for more than 20 min in zebrafish.^10,16 Gradual cooling has been shown to be useful for short-term procedures, such as intraperitoneal injections in adult zebrafish.^6,13,15Little information is available regarding the suitability of these agents as anesthetics for invasive surgical procedures in the zebrafish. Therefore, we investigated the effects of lidocaine hydrochloride, metomidate hydrochloride, isoflurane, and gradual cooling on zebrafish because the anesthetic solutions require only a simple one-step preparation and because these agents potentially could provide a longer duration of surgical anesthesia than does MS222, with shorter induction and recovery times. This study is the first to compare multiple uncommon anesthetic agents in the adult zebrafish. We hypothesized that lidocaine hydrochloride, metomidate hydrochloride, and gradual cooling would be as efficacious as MS222 in providing surgical level anesthesia, but isoflurane alone would be ineffective, given that previous literature suggests this agent may be beneficial only in combination with MS222.⁹In addition, we performed anxiety-like behavior tests to determine the effects of these anesthetic agents on the behavior of adult zebrafish. We sought to determine whether anesthesia-related behavioral effects in zebrafish are similar between anesthetic agents, and we hypothesized that anxiety-like behavior would be altered in fish recovering from isoflurane anesthesia, similar to what is seen in mice.⁸