Amma A. Agyemang

Consent to organ donation: a review

Successful transplant medicine hinges on consent to deceased organ donation. Yet rates of consent remain suboptimal. To increase the availability of transplantable organs, several policy strategies along with a rich body of evidence aimed at identifying best practices for obtaining consent have accumulated. This review describes past and current policies and practices, presents evidence illustrating the impact of these policies and practices on consent, and summarizes future directions and recommendations for the field. Key findings include evidence that although past policies such as required request have been unsuccessful, the recent policy, first-person authorization, shows promise. Additionally, practices such as decoupling and detailed discussions of brain death are unwarranted. On the other hand, the Organ Donation Breakthrough Collaboration was successful. We also underscore the impact of alternative procedures such as donation after cardiac death. Last, effective communication that is delivered by trained, caring requesters at the appropriate time, in a supportive environment, and allows sufficient time for families to make an informed decision, optimizes the request process. Organ procurement organizations adoption of such request practices, implementation of evidence-based policies regarding donation after cardiac death, and further investigations of the medical basis for dual brain death examinations are recommended.

Oncologists’ assessments of lung cancer patient and family disagreements regarding treatment decision making

BACKGROUNDnDisagreements between cancer patients and their caregivers about treatment and care can affect the patients physical and mental well-being. Therefore it is important to understand if oncologists can accurately identify the presence of patient-caregiver decisional conflict. This study examined assessments made by lung cancer patients, their caregivers, and their oncologists regarding patient-caregiver disagreements concerning treatment and care decisions.nnnPARTICIPANTS AND METHODSnWe assessed the extent to which the patient, caregiver, and oncologist reported disagreement between the patient and the family member regarding treatment decisions in 134 patient-caregiver-oncologist triads. Descriptive statistics were used to explore rates of concordance amongst all possible combinations of raters. Loglinear models were tested for 3-way agreement.nnnRESULTSnMost patient-caregiver pairs, 82.1% (n = 110), reported agreement concerning presence or absence of decisional conflict. Oncologists were more successful in detecting absence of conflict than the presence of conflict. When the caregiver and the oncologist agreed, it was regarding the absence of conflict (64.9%), rather than the presence of conflict. In 10.6% (n = 15) of cases, oncologists reported that conflictual relationships negatively impacted their ability to provide patient care.nnnCONCLUSIONSnRecent models of cancer patient care promote including the caregiver fully in the process while respecting the primacy of the patients perspective. However, these models assume that the oncologist will recognize when disagreements exist and be able to assist in conflict resolution. The degree to which the oncologist identified that conflict exists and implications for their ability to provide patient care when familial disagreements existed are discussed.

Quality of depression treatment in Black Americans with major depression and comorbid medical illness

OBJECTIVEnThe objective was to evaluate how comorbid type 2 diabetes (T2DM) and hypertension (HT) influence depression treatment and to assess whether these effects operate differently in a nationally representative community-based sample of Black Americans.nnnMETHODSnData came from the National Survey of American Life (N=3673), and analysis is limited to respondents who met lifetime criteria for major depression (MD) (N=402). Depression care was defined according to American Psychiatric Association (APA) guidelines and included psychotherapy, pharmacotherapy and satisfaction with services. Logistic regression was used to examine the effects of T2DM and HT on quality of depression care.nnnRESULTSnOnly 19.2% of Black Americans with MD alone, 7.8% with comorbid T2DM and 22.3% with comorbid HT reported APA-guideline-concordant psychotherapy or antidepressant treatment. Compared to respondents with MD alone, respondents with MD+T2DM/HT were no more or less likely to receive depression care. Respondents with MD+HT+T2DM were more likely to report any guideline-concordant care (odds ratio=3.32; 95% confidence interval, 1.07-10.31).nnnCONCLUSIONSnAlthough individuals with MD and comorbid T2DM+HT were more likely to receive depression care, guideline-concordant depression care is low among Black Americans, including those with comorbid medical conditions.

Masculinity and Race-Related Factors as Barriers to Health Help-Seeking Among African American Men.

Mens tendency to delay health help-seeking is largely attributed to masculinity, but findings scarcely focus on African American men who face additional race-related, help-seeking barriers. Building principally on reactance theory, we test a hypothesized model situating racial discrimination, masculinity norms salience (MNS), everyday racism (ERD), racial identity, sense of control (SOC), and depressive symptomatology as key barriers to African American mens health help-seeking. A total of 458 African American men were recruited primarily from US barbershops in the Western and Southern regions. The primary outcome was Barriers to Help-Seeking Scale (BHSS) scores. The hypothesized model was investigated with confirmatory factor and path analysis with tests for measurement invariance. Our model fit was excellent CFI = 0.99; TLI = 1.00; RMSEA = 0.00, and 90% CI [0.00, 0.07] and operated equivalently across different age, income, and education strata. Frequent ERD and higher MNS contributed to higher BHHS scores. The relationship between ERD exposure and BHHS scores was partially mediated by diminished SOC and greater depressive symptomatology. Interventions aimed at addressing African American mens health help-seeking should not only address masculinity norms but also threats to sense of control, and negative psychological sequelae induced by everyday racism.

The top 100 cited neurorehabilitation papers

BACKGROUNDnNeurorehabilitation covers a large range of disorders, assessment approaches and treatment methods. There have been previous citation analyses of rehabilitation and of its subfields. However, there has never been a comprehensive citation analysis in neurorehabilitation.nnnOBJECTIVEnThe present study reports findings from a citation analysis of the top 100 most cited neurorehabilitation papers to describe the research trends in the field.nnnMETHODSnA de-novo keyword search of papers indexed in the Web of Science Core Collection database yielded 52,581 papers. A candidate pool of the 200 most-cited papers published between 2005 and 2016 was reviewed by the clinician authors. The papers in the top 100 deemed to be irrelevant were discarded and replaced by the most highly-cited articles in the second tier deemed to be clinically relevant.nnnRESULTSnThe most frequently cited neurorehablitation papers appeared in Stroke, Movement Disorders, and Neurology. Papers tended to focus on treatments, especially for stroke. Authorship trends suggest that top cited papers result from group endeavors, with 90% of the papers involving a collaboration among 3 or more authors.nnnCONCLUSIONnTreatment studies, often focused on stroke, appear to have the highest impact in the field of neurorehabilitation.

Chronic Effects of Neurotrauma Consortium: a combined comparative analysis of six studiesIntroduction to Special edition of Brain Injury

Concussions, or mild traumatic brain injuries (mTBI), are the most common, potentially clinically debilitating, neurological injury associated with military combat, sports, vehicular accidents and domestic trauma (1). Awareness efforts surrounding the identification and management of concussions have existed for decades, but, given the recent Gulf Wars and concerns regarding repeated concussions in sports, there has been increasing attention focused on them. Research efforts to systematically and conclusively categorize and understand the diagnosis, short-term management and late effects of mTBIs remain nascent. There are a number of studies (2) supporting the incidence of concussive injuries from the Afghanistan (Operation Enduring Freedom [OEF]), Iraq (Operation Iraqi Freedom [OIF]) and subsequent worldwide War on Terror (Operation New Dawn [OND]) wars. The incidence of concussions from these conflicts ranges from 6% to 20% among all U.S. Service members (SMs) (3,4). Approximately 40% ofOEF–OIF–ONDconcussedVeterans seeking care at Veterans Affairs Medical Centers (VAMCs), which represents nearly 8% of all those deployed in these conflicts, report persistent neurosensory (headache, hearing, tinnitus, vision), somatic (balance, coordination, sleep), cognitive (executive function, memory) and behavioural symptoms (irritability, anxiety) (5). Additionally, secondary co-morbidities thatmay be associated with the traumatic episode but are not directly physically related to the actual brain trauma, such as post-traumatic stress disorder (PTSD), depression, substance abuse or low back or joint pain, may be seen in more than three-quarters of these Veterans with combat-associated concussions, adding to the diagnostic and management complexity (5). In 2013, as a response to theNational ResearchAction Plan (6), the Departments of Veterans Affairs and Defense jointly-funded the Chronic Effects of Neurotrauma Consortium (CENC) (www. cenc.rti.org) (7). Consisting of more than 50 leading clinical, translational, epidemiologic and basic scientists from more than 30 academic universities, 15 VAMCs and 12 military treatment facilities (see Figure 1), CENC is a nationwide consortium focused on identifying and characterizing the anatomic, molecular and physiological mechanisms of combat-associated mTBI, evaluating how co-morbidities are associated with and exacerbated by combat-associated mTBI and studying treatment and rehabilitation strategies for the shortand long-term effects of combat-associated mTBI. To date, CENC has initiated 10 major clinical, animal and epidemiologic studies that are supported by five centralized, research and administrative infrastructure cores. This report examines the findings to date of the six clinical projects, describes the growing cohort of Veterans and SMs and identifies emerging cross-study similarities and differences. Whereas this report provides a cross-sectional, broad stroke comparison of six of the CENC clinical studies, this special issue also contains 14 other papers that present more nuanced findings on individual CENC studies. There are a number of papers reporting on various aspects of a smaller sample of the currently 1450+ participants enrolled in CENC’s longitudinal study. These include the association of mTBI with pain, functional brain connectivity and cortical thickness, balance performance, Department of Veterans Affairs (VA) -defined service-connected disability and with the biomarker tau, as well as a description of its highly successful recruitment strategies and the factor structure of the battery of neuropsychological assessments used in the sample. Other papers in this issue describe findings on the longitudinal changes in neuroimaging and neuropsychiatric status of postdeployment Veterans, sensory dysfunction in the context of TBI and the association of mTBI with ventricular volume changes and characterize those individuals receiving opioid therapy for chronic pain. Of additional interest, there are also two papers describing advances in mTBI methodology, including an assessment of quantitative magnetic resonance imaging metrics in the brain through the use of a novel phantom and a description of a novel white matter imaging technique. Finally, there is a paper evaluating the impact of age on acute post-TBI neuropathology findings using CENC’s standardized mouse model for repetitive mTBI.

Recruiting for a multicentre DoD and VA longitudinal study: lessons learned

ABSTRACT Primary Objective: The primary objective of the study is to identify and delineate effective recruitment practises in a large, multi-site, longitudinal, observational study employing both military service members and Veterans. Setting: Four Chronic Effects of Neurotrauma Consortium sites. Design: A descriptive study. Results: Overall and cohort-specific recruitment increased with the addition of focused recruitment strategies and a military/Veteran-centric recruitment director. Conclusion: Use of site-specific strategies aligned with local Institutional Review Board procedures and emphasizing awareness of service member organizational allegiances was the key to effective recruiting. Adding a recruitment director with background similar to study participants coincided with significantly improved overall participant numbers and specific subpopulations of research subjects, thus adding to the value of the study.

Understanding the impact of mild traumatic brain injury on veteran service-connected disability: results from Chronic Effects of Neurotrauma Consortium

ABSTRACT Objectives: Disability evaluation is complex. The association between mild traumatic brain injury (mTBI) history and VA service-connected disability (SCD) ratings can have implications for disability processes in the civilian population. We examined the association of VA SCD ratings with lifetime mTBI exposure in three models: any mTBI, total mTBI number, and blast-related mTBI. Methods: Participants were 492 Operation Enduring Freedom/Operation Iraqi Freedom/Operation New Dawn veterans from four US VA Medical Centers enrolled in the Chronic Effects of Neurotrauma Consortium study between January 2015 and August 2016. Analyses entailed standard covariate-adjusted linear regression models, accounting for demographic, military, and health-related confounders and covariates. Results: Unadjusted and adjusted results indicated lifetime mTBI was significantly associated with increased SCD, with the largest effect observed for blast-related mTBI. Every unit increase in mTBI was associated with an increase in 3.6 points of percent SCD. However, hazardous alcohol use was associated with lower SCD. Conclusions: mTBI, especially blast related, is associated with higher VA SCD ratings, with each additional mTBI increasing percent SCD. The association of hazardous alcohol use with SCD should be investigated as it may impact veteran health services access and health outcomes. These findings have implications for civilian disability processes.

Is balance performance reduced after mild traumatic brain injury?: Interim analysis from chronic effects of neurotrauma consortium (CENC) multi-centre study

ABSTRACT Objectives: Determine if mild traumatic brain injury (mTBI) history is associated with balance disturbances. Setting: Chronic Effects of Neurotrauma Consortium (CENC) centres. Participants: The CENC multi-centre study enrols post-9/11 era Service Members and Veterans with combat exposure. This sample (n = 322) consisted of enrolees completing initial evaluation by September 2016 at the three sites conducting computerized dynamic post-urography (CDP) testing. Design: Observational study with cross-sectional analyses using structural equation modelling. Main Measures: Comprehensive structured interviews were used to diagnose all lifetime mild traumatic brain injuries (mTBIs). The outcome, Sensory Organization Test (SOT), was measured on CDP dual-plate force platform. Other studied variables were measured by structured interviews, record review and questionnaires. Results: The overall positive/negative mTBI classification did not have a significant effect on the composite equilibrium score. However, the repetitive mTBI classification showed lower scores for participants with ≥ 3 mTBI versus 1–2 lifetime mTBIs. For repetitive mTBI, pain interference acted as a mediator for the indirect effect, and a direct effect was evident on some sensory condition equilibrium scores. Conclusion: These findings show that repeated mTBI, partially mediated by pain, may lead to later balance disturbances among military combatants. Further study of CDP outcomes within this accruing cohort is warranted.

Poster 465: Predicting Long-Term Global Outcome after Traumatic Brain Injury (TBI): Development of a Practical Prognostic Tool using the TBI Model Systems National Database

Main Outcome Measures: Muscle tone (AS) in upper and lower extremities, Functional Independence Measure (FIM), pain, and safety were assessed after 6 months of treatment. Results: Mean (SD) AS in the affected lower limbs decreased by 0.99 (0.75) in the ITB group compared to 0.43 (0.72) in the CMM patients (P<.05). Decrease of AS in upper extremities was 0.66 (0.59) versus 0.17 (0.70) in ITB and CMM groups, respectively (P<.05). FIM improved in the ITB group by 2.68 (10.31) compared to a worsening in CMM arm -2.58 (11.00) (P1⁄4.054). In addition, ITB patients reported reduction in actual, least and worst pain. Difference in the change from baseline to month 6 between ITB and CMM was statistically significant in least and actual pain (P<.05). Seven serious adverse drug reactions (SADR, constipation, fecal impaction, epilepsy, peripheral edema, hypotension, 2 urinary retention) and 4 serious device reactions (device dislocation, infection, catheter occlusion, intracranial hypotension) were observed in the implanted patients (24% and 16% of patients, respectively) versus 1 SADR (epilepsy) in the CMM group (3%). All serious events related to the device or drug were treated and resolved. Conclusions: This is the first RCT clinical evidence showing superior efficacy of ITB therapy compared to conventional oral medication in decreasing post-stroke spasticity. Level of Evidence: Level I