Lonnie A. Nelson

Traumatic Brain Injury, Posttraumatic Stress Disorder, and Postconcussive Symptom Reporting Among Troops Returning From Iraq

Objectives:Analyze the contribution of mild traumatic brain injury (mTBI) and/or posttraumatic stress disorder (PTSD) to the endorsement of postconcussive (PC) symptoms during Post Deployment Health Assessment. Determine whether a combination of mTBI and PTSD was more strongly associated with symptoms than either condition alone. Methods:Cross-sectional study design where both the exposure, mTBI and/or PTSD, and the outcomes of interest, PC symptoms, were ascertained after return from deployment. Subjects were injured soldiers (n = 1247) from one Fort Carson Brigade Combat Team (n = 3973). Main Outcome Measures:Positive history of PC symptoms. Results:PTSD and mTBI together were more strongly associated with having PC symptoms (adjusted prevalence ratio 6.27; 95% CI: 4.13–9.43) than either mTBI alone (adjusted prevalence ratio = 4.03; 95% CI: 2.67–6.07) or PTSD alone (adjusted prevalence ratio = 2.74; 95% CI: 1.58–4.74) after adjusting for age, gender, education, rank, and Military Occupational Specialty. Conclusions:In soldiers with histories of physical injury, mTBI and PTSD were independently associated with PC symptom reporting. Those with both conditions were at greater risk for PC symptoms than those with either PTSD, mTBI, or neither. Findings support the importance of continued screening for both conditions with the aim of early identification and intervention.

Relationship between processing speed and executive functioning performance among OEF/OIF veterans: implications for postdeployment rehabilitation

BackgroundComorbid mild traumatic brain injury (mTBI) with posttraumatic stress disorder (PTSD) is a common clinical presentation among troops returning from Operation Enduring Freedom and Operation Iraqi Freedom (OEF/OIF). This study examined processing speed and executive functioning in a sample of OEF/OIF veterans who had sustained mTBI, a subset of whom also had comorbid PTSD. MethodsFifty-three OEF/OIF veterans with a history of mTBI completed Wechsler Adult Intelligence Scale-III Symbol Search and Digit Symbol—Coding subscales, Stroop Word, color and color-word trials, and Trail Making Test, Parts A and B as part of a comprehensive neuropsychological test battery. ResultsExcluding from analysis those who scored poorly on effort testing, multiple regression showed that measures of processing speed accounted for 43% of the variance in performance on the Trail Making Test, Part B and 50% of the variance in performance on the Stroop task. Significant differences in processing speed and executive functioning were found on the basis of presence of comorbid PTSD. Stroop Color (F = 9.27, df = 52, P < .004) and Stroop Color Word (F = 7.19, df = 52, P < .01) scores differed significantly between the groups. Those having comorbid PTSD (+TBI/+PTSD) scored significantly poorer than the mTBI-only group (+TBI/−PTSD). Implications for treatment of the comorbid conditions are discussed.

Continuous and routine EEG in intensive care Utilization and outcomes, United States 2005–2009

Objectives: To evaluate the effect of intensive care unit continuous EEG (cEEG) monitoring on inpatient mortality, hospital charges, and length of stay. Methods: A retrospective cross-sectional study was conducted using the Nationwide Inpatient Sample, a dataset representing 20% of inpatient discharges in nonfederal US hospitals. Adult discharge records reporting mechanical ventilation and EEG (routine EEG or cEEG) were included. cEEG was compared with routine EEG alone in association with the primary outcome of in-hospital mortality and secondary outcomes of total hospital charges and length of stay. Demographics, hospital characteristics, and medical comorbidity were used for multivariate adjustments of the primary and secondary outcomes. Results: A total of 40,945 patient discharges in the weighted sample met inclusion criteria, of which 5,949 had reported cEEG. Mechanically ventilated patients receiving cEEG were younger than routine EEG patients (56 vs 61 years; p < 0.001). There was no difference in the 2 groups in income or medical comorbidities. cEEG was significantly associated with lower in-hospital mortality in both univariate (odds ratio = 0.54, 95% confidence interval 0.45–0.64; p < 0.001) and multivariate (odds ratio = 0.63, 95% confidence interval 0.51–0.76; p < 0.001) analyses. There was no significant difference in costs or length of stay for patients who received cEEG relative to those receiving only routine EEG. Sensitivity analysis showed that adjusting for diagnosis-related groups (DRGs) for any neurologic diagnoses, DRGs for neurologic procedures, and specific DRGs for epilepsy/convulsions did not substantially alter the association of cEEG with reduced inpatient mortality. Conclusions: cEEG is favorably associated with inpatient survival in mechanically ventilated patients, without adding significant charges to the hospital stay.

Utility of the Mild Brain Injury Atypical Symptoms Scale as a Screening Measure for Symptom Over-Reporting in Operation Enduring Freedom/Operation Iraqi Freedom Service Members with Post-Concussive Complaints

Evaluation of post-deployment conditions such as post-concussive syndrome (PCS) and posttraumatic stress disorder (PTSD) frequently relies upon brief, self-report checklists which are face valid and highly susceptible to potential symptom validity issues such as symptom exaggeration. We investigated the psychometric prope1rties of a 5-item measure of symptom exaggeration (mild brain injury atypical symptoms [mBIAS] scale) embedded in commonly used PCS and PTSD screening instruments in a sample of 403 patients seen in a brain injury clinic at a large military medical center. Exploratory factor analysis, examining measures of posttraumatic stress, post-concussive symptoms, and symptom over-reporting revealed a 6-factor model with the mBIAS scale items representing a unique factor. Analysis of psychometric properties demonstrated that a score of 8 on the mBIAS was optimal for the detection of symptom over-reporting (sensitivity = 0.94, specificity = 0.92) and appears to be the most favorable cut score for interpretive use. The findings provide a strong initial support for the use of the mBIAS in post-deployment populations.

Postdeployment traumatic brain injury screening questions: Sensitivity, specificity, and predictive values in returning soldiers

OBJECTIVE To evaluate the sensitivity, specificity, and predictive values of Post-Deployment Health Assessment traumatic brain injury (TBI) screening questions employed by the Department of Defense (DOD). PARTICIPANTS Complete data was obtained from 3,072 soldiers upon return from a 15-month deployment to Iraq. METHOD Comparisons were made between responses to the DOD four-item screener and a brief structured clinical interview for likely deployment-related TBI history. The interview process was facilitated using responses to the Warrior Administered Retrospective Casualty Assessment Tool (WARCAT). RESULTS The sensitivity and specificity of the DOD screening tool (positive response to all four items) in comparison to the clinician-confirmed diagnosis was 60% and 96%, respectively. The sensitivity increased to 80%, with a slight decrease in specificity to 93%, for positive TBI screening when affirmative responses to questions 1 and 2 only were included. CONCLUSIONS Affirmative responses to questions 1 and 2 of the DOD TBI screening tool demonstrated higher sensitivity for clinician-diagnosed deployment-related TBI. These two items perform better than positive responses to all four questions; the criteria presently being used for documentation and referral of a deployment-related TBI. These findings support further exploration of TBI screening and assessment procedures.

Stroke in American Indians and Alaska Natives: A Systematic Review

We conducted a systematic review of published studies on stroke epidemiology in American Indians and Alaska Natives (AI/ANs). We used MeSH terms and strict inclusion criteria to search PubMed, identifying a relevant sample of 57 refereed publications. We report a consensus view in which prevalent stroke is more common, and estimates of cerebrovascular risk factors are higher, among AI/ANs than among other US populations. Like other minority groups, AI/ANs suffer stroke at younger ages than do non-Hispanic Whites. However, data on AI/AN stroke mortality are significantly compromised by racial misclassification and nonrepresentative sampling. Studies correcting for these problems have found that stroke mortality rates among AI/ANs are among the highest of all US racial and ethnic groups. As with Black and non-Hispanic White stroke mortality, AI/AN stroke mortality varies by geographic region, with the highest rates in Alaska and the Northwest and the lowest in the Southwest. Our results underscore the need for a concerted national effort to collect accurate cross-sectional and longitudinal data on stroke in AI/ANs.

Effects of interactive metronome therapy on cognitive functioning after blast-related brain injury: a randomized controlled pilot trial.

OBJECTIVE We report preliminary findings on the efficacy of interactive metronome (IM) therapy for the remediation of cognitive difficulties in soldiers with persisting cognitive complaints following blast-related mild-to-moderate traumatic brain injury (TBI). METHOD Forty-six of a planned sample of 50 active duty soldiers with persistent cognitive complaints following a documented history of blast-related TBI of mild-to-moderate severity were randomly assigned to receive either standard rehabilitation care (SRC) or SRC plus a 15-session standardized course of IM therapy. Primary outcome measures were Repeatable Battery for the Assessment of Neuropsychological Status (RBANS) Index Scores. Secondary outcome measures included selected subtests from the Delis-Kaplan Executive Functioning System (Trail Making Test and Color-Word Interference) and the Wechsler Adult Intelligence Scale-Fourth Edition (Symbol Search, Digit-Symbol Coding, Digit Span, and Letter-Number Sequencing) as well as the Integrated Visual and Auditory Continuous Performance Test. RESULTS Significant group differences (SRC vs. IM) were observed for RBANS Attention (p = .044), Immediate Memory (p = .019), and Delayed Memory (p = .031) indices in unadjusted analyses, with the IM group showing significantly greater improvement at Time 2 than the SRC group, with effect sizes in the medium-to-large range in the adjusted analyses for each outcome (Cohens d = 0.511, 0.768, and 0.527, respectively). Though not all were statistically significant, effects in 21 of 26 cognitive outcome measures were consistently in favor of the IM treatment group (binomial probability = .00098). CONCLUSION The addition of IM therapy to SRC appears to have a positive effect on neuropsychological outcomes for soldiers who have sustained mild-to-moderate TBI and have persistent cognitive complaints after the period for expected recovery has passed.

The feasibility of hypnotic analgesia in ameliorating pain and anxiety among adults undergoing needle electromyography.

Slack D, Nelson L, Patterson D, Burns S, Hakimi K, Robinson L: The feasibility of hypnotic analgesia in ameliorating pain and anxiety among adults undergoing needle electromyography. Am J Phys Med Rehabil 2009;88:21–29. Objective:Our hypothesis was that hypnotic analgesia reduces pain and anxiety during electromyography (EMG). Design:We performed a prospective randomized, controlled clinical trial at outpatient electrodiagnostic clinics in teaching hospitals. Just before EMG, 26 subjects were randomized to one of three 20-min audio programs: education about EMG (EDU) (n = 8); hypnotic induction without analgesic suggestion (n = 10); or hypnotic induction with analgesic suggestion (n = 8). The blinded electromyographer provided a posthypnotic suggestion at the start of EMG. After EMG, subjects rated worst and average pain and anxiety using visual analog scales. Results:Mean values for the EDU, hypnotic induction without analgesic suggestion, and hypnotic induction with analgesic suggestion groups were not significantly different (mean ± SD): worst pain 67 ± 25, 42 ± 18, and 49 ± 30; average pain 35 ± 26, 27 ± 14, and 25 ± 22; and anxiety 44 ± 41, 42 ± 23, and 22 ± 24. When hypnosis groups were merged (n = 18) and compared with the EDU condition (n = 8), average and worst pain and anxiety were less for the hypnosis group than EDU, but this was statistically significant only for worst pain (hypnosis, 46 ± 24 vs. EDU, 67 ± 35; P = 0.049) with a 31% average reduction. Conclusions:A short hypnotic induction seems to reduce worst pain during electromyography.

Psychological trauma symptoms and Type 2 diabetes prevalence, glucose control, and treatment modality among American Indians in the Strong Heart Family Study☆☆☆★

AIMS The aims of this paper are to examine the relationship between psychological trauma symptoms and Type 2 diabetes prevalence, glucose control, and treatment modality among 3776 American Indians in Phase V of the Strong Heart Family Study. METHODS This cross-sectional analysis measured psychological trauma symptoms using the National Anxiety Disorder Screening Day instrument, diabetes by American Diabetes Association criteria, and treatment modality by four categories: no medication, oral medication only, insulin only, or both oral medication and insulin. We used binary logistic regression to evaluate the association between psychological trauma symptoms and diabetes prevalence. We used ordinary least squares regression to evaluate the association between psychological trauma symptoms and glucose control. We used binary logistic regression to model the association of psychological trauma symptoms with treatment modality. RESULTS Neither diabetes prevalence (22%-31%; p=0.19) nor control (8.0-8.6; p=0.25) varied significantly by psychological trauma symptoms categories. However, diabetes treatment modality was associated with psychological trauma symptoms categories, as people with greater burden used either no medication, or both oral and insulin medications (odds ratio=3.1, p<0.001). CONCLUSIONS The positive relationship between treatment modality and psychological trauma symptoms suggests future research investigate patient and provider treatment decision making.

Traumatic brain injury and mental health among two American Indian populations.

ObjectivesDescribes prevalence of traumatic brain injury (TBI) and associated neuropsychiatric problems among two American Indian (AI) communities. DesignAnalysis of cross-sectional epidemiological data. SettingA Southwest (SW) and 2 Northern Plains (NP) AI reservations. ParticipantsAI tribal members (N = 2687; 394 with history of TBI and 2293 noninjured comparisons) aged 15 to 54. Outcome measuresMood or anxiety disorders present more than 1 year after injury. ResultsPrevalences were high (>20% in males; >10% in females) in these populations. Associations between TBI and disorders meeting Diagnostic and Statistical Manual of Mental Disorder, Fourth Edition criteria were strong in the SW community (adjusted odds ratio [OR] = 2.4; 95% confidence interval [CI] = 1.5–3.8), less so in the NP community (adjusted OR = 1.4; 95% CI = 0.9–2.2). ConclusionsTBI is prevalent among AIs and is associated with increased OR of neuropsychiatric difficulties. This association may vary between tribes, though no interaction effect was found. AIs with TBI may require more thorough psychiatric screening to promote healthier outcomes.