Brian D. Greenwald

A Randomized Controlled Trial of Sertraline for the Treatment of Depression in Persons With Traumatic Brain Injury

OBJECTIVEnTo examine the efficacy of sertraline in the treatment of depression after traumatic brain injury (TBI).nnnDESIGNnDouble-blind, randomized controlled trial.nnnSETTINGnResearch center at a major urban medical center.nnnPARTICIPANTSnSubjects were a referred and volunteer sample of 52 participants with TBI, a diagnosis of major depression disorder (MDD), and a score on the Hamilton Rating Scale for Depression (HAM-D) of 18 or greater. The majority of the sample was male (58%), had less than 14 years of education (73%), had incomes below

Longitudinal outcome of patients with disordered consciousness in the NIDRR TBI model systems programs

20,000 (82%), and were from minority backgrounds (75%). Approximately one third of the sample had mild brain injuries, and two thirds had moderate to severe brain injuries. The mean age was 47+/-11, and the mean time since injury was 17+/-14 years. One participant withdrew from the study because of side effects.nnnINTERVENTIONnDaily oral sertraline in doses starting at 25mg and increasing to therapeutic levels (up to 200mg) or placebo for 10 weeks.nnnMAIN OUTCOME MEASURESnThe HAM-D, the Beck Anxiety Inventory, and the Life-3 quality of life (QOL).nnnRESULTSnNo statistically significant differences were found at baseline between drug and placebo groups on baseline measures of depression (24.8+/-7.3 vs 27.7+/-7.0), anxiety (16.4+/-12.3 vs 24.0+/-14.9), or QOL (2.96+/-1.0 vs 2.9+/-0.9). The income level of those receiving placebo was significantly lower than those participants receiving medication. Analyses of covariance revealed significant changes from preintervention to posttreatment for all 3 outcome measures (P<.001) but no group effects. Random-effects modeling did not find any significant difference in patterns of scores of the outcome measures between the placebo and medication groups.nnnCONCLUSIONSnBoth groups showed improvements in mood, anxiety, and QOL, with 59% of the experimental group and 32% of the placebo group responding to the treatment, defined as a reduction of a persons HAM-D score by 50%.

Opioids for Managing Patients with Chronic Pain: Community Pharmacists’ Perspectives and Concerns

Few studies address the course of recovery from prolonged disorders of consciousness (DOC) after severe traumatic brain injury (TBI). This study examined acute and long-term outcomes of persons with DOC admitted to acute inpatient rehabilitation within the National Institute on Disability and Rehabilitation Research (NIDRR) TBI Model Systems Programs (TBIMS). Of 9028 persons enrolled from 1988 to 2009, 396 from 20 centers met study criteria. Participants were primarily male (73%), Caucasian (67%), injured in motor vehicle collision (66%), with a median age of 28, and emergency department Glasgow Coma Scale (GCS) score of 3. Participant status was evaluated at acute rehabilitation admission and discharge and at 1, 2, and 5 years post-injury. During inpatient rehabilitation, 268 of 396 (68%) regained consciousness and 91 (23%) emerged from post-traumatic amnesia (PTA). Participants demonstrated significant improvements on GCS (z=16.135, p≤0.001) and Functional Independence Measure (FIM) (z=15.584, p≤0.001) from rehabilitation admission (median GCS=9; FIM=18) to discharge (median GCS=14; FIM=43). Of 337 with at least one follow-up visit, 28 (8%) had died by 2.1 years (mean) after discharge. Among survivors, 66 (21%) improved to become capable of living without in-house supervision, and 63 demonstrated employment potential using the Disability Rating Scale (DRS). Participants with follow-up data at 1, 2, and 5 years post-injury (n=108) demonstrated significant improvement across all follow-up evaluations on the FIM Cognitive and Supervision Rating Scale (p<0.01). Significant improvements were observed on the DRS and FIM Motor at 1 and 2 years post-injury (p<0.01). Persons with DOC at the time of admission to inpatient rehabilitation showed functional improvement throughout early recovery and in years post-injury.

Functional Outcomes in Traumatic Disorders of Consciousness: 5-Year Outcomes From the National Institute on Disability and Rehabilitation Research Traumatic Brain Injury Model Systems

Previous studies of pharmacists have suggested poor availability of opioids and apprehension about dispensing these drugs. This pilot study surveyed 52 randomly selected New Jersey community pharmacists (response rate = 69%). Reluctance to stock opioids was attributed to concerns about robbery by 14% and to concerns about federal or state investigation by 17%. No correlation was found between respondents who had a high degree of concern about robbery and those who had incurred previous robbery. Of the 20% of respondents who had incurred a prior federal or state investigation, none expressed more than minimal concern about opioid regulatory issues. Pharmacist confidence in the acceptability of opioids for chronic pain was 75% for malignant pain in patients with no history of opioid abuse and declined to 3% for nonmalignant pain in patients with a history of opioid abuse.

Visual impairments in the first year after traumatic brain injury

OBJECTIVEnTo characterize the 5-year outcomes of patients with traumatic brain injury (TBI) not following commands when admitted to acute inpatient rehabilitation.nnnDESIGNnSecondary analysis of prospectively collected data from the National Institute on Disability and Rehabilitation Research-funded Traumatic Brain Injury Model Systems (TBIMS).nnnSETTINGnInpatient rehabilitation hospitals participating in the TBIMS program.nnnPARTICIPANTSnPatients (N=108) with TBI not following commands at admission to acute inpatient rehabilitation were divided into 2 groups (early recovery: followed commands before discharge [n=72]; late recovery: did not follow commands before discharge [n=36]).nnnINTERVENTIONSnNot applicable.nnnMAIN OUTCOME MEASURESnFIM items.nnnRESULTSnFor the early recovery group, depending on the FIM item, 8% to 21% of patients were functioning independently at discharge, increasing to 56% to 85% by 5 years postinjury. The proportion functioning independently increased from discharge to 1 year, 1 to 2 years, and 2 to 5 years. In the late recovery group, depending on the FIM item, 19% to 36% of patients were functioning independently by 5 years postinjury. The proportion of independent patients increased significantly from discharge to 1 year and from 1 to 2 years, but not from 2 to 5 years.nnnCONCLUSIONSnSubstantial proportions of patients admitted to acute inpatient rehabilitation before following commands recover independent functioning over as long as 5 years, particularly if they begin to follow commands before hospital discharge.

The Impact of Traumatic Brain Injury on Pituitary Function

Background: This article reviews literature regarding individuals with traumatic brain injury who have vision related impairments up to one year, post-injury. Such impairments may impact rehabilitation of activities of daily living and mobility since vision is integral in much of what one does on a daily basis. Methods: Search of Medline, Ovid, and PubMed was performed using terms including: traumatic brain injury, visual deficits after brain injury, vision and traumatic brain injury, and ADLs after brain injury. Results: Eighteen studies were analyzed and reviewed. A range of visual and visual-motor impairments are seen across the severity of traumatic brain injury. Visual impairment negatively impacts independence in mobility and activities of daily living. Common sensorimotor visual symptoms reported by those with traumatic brain injury include blurred vision, reading problems, double vision or eyestrain, dizziness or disequilibrium in visually-crowded environments, visual field defects, light sensitivity, and color blindness. Conclusions: This review should alert the reader to common visual complaints and defects seen after traumatic brain injury. It is important to screen persons who have suffered traumatic brain injury for sensorimotor vision deficits early on in recovery so that these issues may be addressed and recovery of function and independence in the community are not delayed.

Do Rehospitalization Rates Differ Among Injury Severity Levels in the NIDRR Traumatic Brain Injury Model Systems Program

It is paramount that clinicians who care for patients with traumatic brain injury (TBI) at any point in time, including neurosurgeons, rehabilitation physicians, internists, neurologists, and endocrinologists, are aware of the prevalence of posttraumatic hypopituitarism and its impacts on acute and long-term recovery. This article reviews the natural history, pathophysiology, and presenting features of hypopituitarism occurring after TBI. Proposed methodologies for screening, diagnosis, and initiation of treatment are discussed, as well as the effect of hormone replacement therapy on clinical outcomes.

Examining lactate in severe TBI using proton magnetic resonance spectroscopy

OBJECTIVEnTo compare the rate and nature of rehospitalization in a cohort of patients enrolled in the National Institute on Disability and Rehabilitation Research Traumatic Brain Injury Model Systems (TBIMS) who have disorders of consciousness (DOC) at the time of rehabilitation admission with those in persons with moderate or severe traumatic brain injury (TBI) but without DOC at rehabilitation admission.nnnDESIGNnProspective observational study.nnnSETTINGnInpatient rehabilitation within TBIMS with annual follow-up.nnnPARTICIPANTSnOf 9028 persons enrolled from 1988 to 2009 (N=9028), 366 from 20 centers met criteria for DOC at rehabilitation admission and follow-up data, and another 5132 individuals met criteria for moderate (n=769) or severe TBI (n=4363).nnnINTERVENTIONSnNot applicable.nnnMAIN OUTCOME MEASURESnParticipants and/or their family members completed follow-up data collection including questions about frequency and nature of rehospitalizations at 1 year postinjury. For the subset of participants with DOC, additional follow-up was conducted at 2 and 5 years postinjury.nnnRESULTSnThe DOC group demonstrated an overall 2-fold increase in rehospitalization in the first year postinjury relative to those with moderate or severe TBI without DOC. Persons with DOC at rehabilitation admission have a higher rate of rehospitalization across several categories than persons with moderate or severe TBI.nnnCONCLUSIONSnAlthough the specific details of rehospitalization are unknown, greater injury severity resulting in DOC status on rehabilitation admission has long-term implications. Data highlight the need for a longitudinal approach to patient management.

Posttraumatic Headache in the Rehabilitation Patient

Primary objective: Clinical management of acute traumatic brain injury (TBI) has emphasized identification of secondary mechanisms of pathophysiology. An important objective in this study is to use proton magnetic resonance spectroscopy (pMRS) to examine early metabolic disturbance due to TBI. Research design: The current design is a case study with repeated measures. Method and procedure: Proton magnetic resonance imaging was used to examine neurometabolism in this case of very severe brain trauma at 9 and 23 days post-injury. MRI was performed on a clinical 1.5 Tesla scanner. Main outcomes and results: These data also reveal that pMRS methods can detect lactate elevations in an adult surviving severe head trauma and are sensitive to changes in basic neurometabolism during the first month of recovery. Conclusions: The current case study demonstrates the sensitivity of pMRS in detecting metabolic alterations during the acute recovery period. The case study reveals that lactate elevations may be apparent for weeks after severe neurotrauma. Further work in this area should endeavour to determine the ideal time periods for pMRS examination in severe TBI as well as the ideal locations of data acquisition (e.g. adjacent or distal to lesion sites).

Poster 93 Systemic Hypersensitivity Reaction to Oral Phenytoin: A Case Report

Posttraumatic headaches are a common and disabling problem across the spectrum of severity after traumatic brain injury. Posttraumatic headaches can exacerbate other common disorders seen after TBI including insomnia, affective disorders, behavioral disorders, and cognitive impairments. Posttraumatic headaches therefore have a significant direct and indirect effect on social and vocational functioning. Evaluation needs to start with a broad differential diagnosis. This chapter reviews the common sources and characteristics of posttraumatic headaches. Potential sources of head pain that should be considered in the patient presenting with posttraumatic headaches include intracranial, cranial, and cervical structures. A careful history and physical can narrow the diagnoses. Musculoskeletal and neuropathic sources of posttraumatic headaches are reviewed.