Jason N. Doctor

Virtual reality as an adjunctive pain control during burn wound care in adolescent patients

Abstract For daily burn wound care procedures, opioid analgesics alone are often inadequate. Since most burn patients experience severe to excruciating pain during wound care, analgesics that can be used in addition to opioids are needed. This case report provides the first evidence that entering an immersive virtual environment can serve as a powerful adjunctive, nonpharmacologic analgesic. Two patients received virtual reality (VR) to distract them from high levels of pain during wound care. The first was a 16‐year‐old male with a deep flash burn on his right leg requiring surgery and staple placement. On two occasions, the patient spent some of his wound care in VR, and some playing a video game. On a 100 mm scale, he provided sensory and affective pain ratings, anxiety and subjective estimates of time spent thinking about his pain during the procedure. For the first session of wound care, these scores decreased 80 mm, 80 mm, 58 mm, and 93 mm, respectively, during VR treatment compared with the video game control condition. For the second session involving staple removal, scores also decreased. The second patient was a 17‐year‐old male with 33.5% total body surface area deep flash burns on his face, neck, back, arms, hands and legs. He had difficulty tolerating wound care pain with traditional opioids alone and showed dramatic drops in pain ratings during VR compared to the video game (e.g. a 47 mm drop in pain intensity during wound care). We contend that VR is a uniquely attention‐capturing medium capable of maximizing the amount of attention drawn away from the ‘real world’, allowing patients to tolerate painful procedures. These preliminary results suggest that immersive VR merits more attention as a potentially viable form of treatment for acute pain.

Do medicare patients with disabilities receive preventive services? A population-based study

OBJECTIVEnTo compare health maintenance procedure rates of Medicare patients with different levels of disability.nnnSTUDY DESIGNnObservational study analyzing data from the 1995 Medicare Current Beneficiary Survey (MCBS, n = 15,590). Self-reported Pap smears, mammograms, and influenza and pneumococcal vaccinations were compared between groups with different levels of health-related difficulties in six activities of daily living (ADL).nnnRESULTSnCompared to those without disabilities, the most severely disabled women (limitations in 5 or 6 ADL) reported fewer Pap smears (age < or =70, 23% vs 41%, p < .001) and mammograms (age > or = 50, 13% vs 44%, p < .001). In a controlled analysis, individuals with this high level of disability were 57% (95% confidence interval [CI], 33% to 72%) and 56% (95% CI, 43% to 76%) less likely to report receiving Pap smears and mammograms, respectively, compared with able-bodied women, regardless of their age, whether they were in an HMO, or whether they lived in a long-term care facility. Functional limitations were not a deterrent to receiving vaccinations. In general, patients in HMOs reported more procedures than those in fee-for-service, while those in long-term care facilities reported fewer procedures than those living in the community.nnnCONCLUSIONSnDisability among Medicare patients is a significant, independent risk factor for not receiving mammograms and Pap smears. Efforts should be made to identify the most severely disabled because they are at particular risk.

Functional status examination: a new instrument for assessing outcome in traumatic brain injury

The Functional Status Examination (FSE) is a new measure designed to evaluate change in activities of everyday life as a function of an event or illness, including traumatic brain injury. The measure covers physical, social, and psychological domains. The FSE is based on a structured interview and includes levels of functioning that accommodate the full spectrum of possible outcomes, from death through recovery to preinjury functioning. Based on 133 prospectively studied patients with moderate to severe traumatic brain injury, the FSE has favorable psychometric properties including good test-retest reliability (r = 0.80) and close correspondence of assessments provided by the patient and their significant other (SO; r = 0.80). The FSE correlated significantly with each of three severity indices with closest relationships occurring between the FSE assessed by the SO and posttraumatic amnesia (r = 0.76). The FSE assessed by the SO was significantly (p < 0.05) more closely related to each severity index than the Glasgow Outcome Scale (GOS) or Sickness Impact Profile and, for two of the three indices, than the SF-36. All measures showed significant change from 1 to 6 months after injury with the FSE showing the largest effect sizes. The FSE is significantly related to important constructs such as family burden, SO depression, and sacrifices the family makes, as well as overall indices of recovery and satisfaction with level of functioning. The latter relationships are significantly stronger than for the GOS. The FSE has demonstrated good reliability, validity, and sensitivity, and appears to be a promising instrument for monitoring recovery and assessing functional status in clinical trials.

Workers' risk of unemployment after traumatic brain injury: A normed comparison

We examined, among those persons working preinjury, the risk of unemployment 1 year after traumatic brain injury (TBI) relative to expected risk of unemployment for the sample under a validated risk-adjusted econometric model of employment in the U.S. population. Results indicate that 42% of TBI cases were unemployed versus 9% expected, relative risk (RR) = 4.5, 95% confidence interval (CI) (4.12, 4.95). The relative risk for unemployment was higher among males, those with higher education, persons with more severe injuries, and more impaired early neuropsychological or functional status. Difference in unemployment rates gave similar results for gender, severity of injury, and early neuropsychological and functional status. However, for education, the excess was smaller among those more highly educated, but the unemployment rate in the more highly educated in the general population was sufficiently small to yield a larger relative risk. In conclusion, after accounting for underlying risk of unemployment in the general population, unemployment is substantially higher after TBI for people who were employed when they were injured. The differential employment status varies depending on demographics, severity of brain injury, early functional outcome, and neurobehavioral indicators. For characteristics such as education, associated with rates of unemployment in the general population, different methods used to compare the rates may yield different results.

Stability of employment after traumatic brain injury

Although substantial information exists about factors related to who returns to work and time taken to return to work after traumatic brain injury (TBI), less is known about the stability of the work experience after the injury. One hundred sixty-five workers with complicated mild to severe traumatic brain injury were followed for 3 to 5 years postinjury. Work stability definitions included amount of time worked (amount of time worked divided by time observed postinjury) and maintenance of uninterrupted employment once a person returned to work. Amount of time worked was significantly and systematically related to brain injury severity, neuropsychological functioning at l-month postinjury, and preinjury characteristics such as prior work stability and earnings. However, once persons returned to work, the ability to maintain uninterrupted employment was largely related to premorbid characteristics such as being older, higher income before the injury, or a preinjury job with benefits. It was also related to higher neuropsychological functioning at 1-month postinjury (reflecting the combined effects of premorbid functioning and traumatic brain injury severity), but not related to neurologic indices of severity.

Application of influence diagrams to prostate intensity-modulated radiation therapy plan selection

The purpose is to incorporate clinically relevant factors such as patient-specific and dosimetric information as well as data from clinical trials in the decision-making process for the selection of prostate intensity-modulated radiation therapy (IMRT) plans. The approach is to incorporate the decision theoretic concept of an influence diagram into the solution of the multiobjective optimization inverse planning problem. A set of candidate IMRT plans was obtained by varying the importance factors for the planning target volume (PTV) and the organ-at-risk (OAR) in combination with simulated annealing to explore a large part of the solution space. The Pareto set for the PTV and OAR was analysed to demonstrate how the selection of the weighting factors influenced which part of the solution space was explored. An influence diagram based on a Bayesian network with 18 nodes was designed to model the decision process for plan selection. The model possessed nodes for clinical laboratory results, tumour grading, staging information, patient-specific information, dosimetric information, complications and survival statistics from clinical studies. A utility node was utilized for the decision-making process. The influence diagram successfully ranked the plans based on the available information. Sensitivity analyses were used to judge the reasonableness of the diagram and the results. In conclusion, influence diagrams lend themselves well to modelling the decision processes for IMRT plan selection. They provide an excellent means to incorporate the probabilistic nature of data and beliefs into one model. They also provide a means for introducing evidence-based medicine, in the form of results of clinical trials, into the decision-making process.

Stress ulcer prophylaxis in mechanically ventilated patients : integrating evidence and judgment using a decision analysis

ObjectiveStress ulcer prophylaxis with axa0histamine-2 receptor antagonist can reduce the risk of gastrointestinal bleeding in mechanically ventilated patients but may also increase the risk of ventilator-associated pneumonia. We sought to clarify the tradeoffs involved in selecting axa0prophylactic strategy.DesignDecision analysis.Patients and participantsAxa0decision tree was constructed for axa0hypothetical cohort of patients receiving mechanical ventilation for an expected duration of longer than 48u202fh, using probabilities estimated from the published literature.InterventionsPatients in the model could receive either prophylaxis with axa0histamine-2 receptor antagonist or no prophylaxis. Sensitivity analyses were preformed varying the estimated probabilities over their plausible ranges.Measurements and resultsBoth strategies were associated with approximately the same baseline expected mortality (16.6% for histamine-2 receptor antagonists and 16.9% for no prophylaxis, risk difference 0.3%). Varying the estimated probabilities resulted in only small changes in both the expected mortality and the absolute risk reduction associated with the preferred treatment. At the extremes of assumptions the absolute mortality reduction ranged from 0.1% to 3.3%.ConclusionsNo single strategy of stress ulcer prophylaxis is preferred when mortality is used as the outcome. In the absence of axa0clinical trial demonstrating survival benefit the individual clinicians assumptions regarding the effect of prophylaxis on gastrointestinal bleeding and pneumonia and the attributable mortality of pneumonia vs. gastrointestinal bleeding will have axa0significant effect on the decision.

Potential Impact of the New Medicare Prospective Payment System on Reimbursement for Traumatic Brain Injury Inpatient Rehabilitation

OBJECTIVEnTo evaluate the potential impact of the new Medicare prospective payment system (PPS) on traumatic brain injury (TBI) rehabilitation.nnnDESIGNnRetrospective cohort study of patients with TBI. Patients were assigned to their appropriate case-mix group (CMG) based on Medicare criteria.nnnSETTINGnFourteen urban rehabilitation facilities throughout the United States.nnnPARTICIPANTSnPatients with TBI admitted to inpatient rehabilitation and enrolled in the Traumatic Brain Injury Model Systems from 1998 to 2001 (N=1807).nnnINTERVENTIONSnNot applicable.nnnMAIN OUTCOME MEASURESnCost of inpatient rehabilitation admission, length of stay (LOS), and functional outcomes.nnnRESULTSnThe median cost of inpatient rehabilitation for patients with TBI exceeded median PPS payments for all TBI CMGs by 16%. Only 3 of the 14 hospitals received reimbursement under PPS that exceeded costs for their TBI patients.nnnCONCLUSIONSnCompared with current costs, the new Medicare payment system may reimburse facilities significantly less than their costs for the treatment of TBI. To maintain their current financial status, facilities may have to reduce LOS and/or reduce resource use. With a decreased LOS, inpatient rehabilitation services will have to improve FIM efficiency or discharge patients with lower discharge FIM scores.

Development of a telephone follow-up program for individuals following traumatic brain injury

ObjectiveTo describe the development of a telephone follow-up program that addresses the needs of survivors of traumatic brain injury (TBI) and their families in the year following injury. The process of developing the program is reviewed from the initial steps of identifying needs through final implementation of the program. ParticipantsEighty-four TBI survivors with moderate to severe injuries and their families. ResultsDescriptive statistics are presented including number of contacts, areas of concern for participants, and the types of interventions conducted. Case examples are provided to illustrate the impact of the telephone follow-up program. ConclusionThis project demonstrated the feasibility of using the telephone as a means of providing information and support during the first year after moderate to severe traumatic brain injury. Telephone follow-up may enhance service provision for persons with TBI, especially those with a lack of transportation or geographic isolation.

The Use of a World Wide Web-Based Consultation Site to Provide Support to Telephone Staff in a Traumatic Brain Injury Demonstration Project

Objectives:Distance from expertise in traumatic brain injury (TBI) is often an impediment to appropriate TBI care from local health care providers, especially in rural areas. To overcome this barrier to care and to support a randomized, controlled trial of telephone follow-up after discharge from acute rehabilitation, we demonstrated the use of a confidential consultation Web site to provide expert recommendations and advice to front-line telephone staff at a different site. Conclusions:This use of Internet communication proved convenient to all users, improved client confidence, and served as an excellent training tool to less experienced staff. In addition, use of a Web-based consultation method provided for archiving of all discussions for later review.