Lori Keyser-Marcus

Acute predictors of successful return to work 1 year after traumatic brain injury: a multicenter analysis.

OBJECTIVE To investigate the influence of acute injury characteristics on subsequent return to work in traumatic brain injury (TBI) patients. DESIGN Descriptive statistics were performed in a comparative study of 49 TBI patients who were competitively employed at 1-year follow-up and 83 unemployed patients. Independent t tests were then performed to examine the differences between the two groups on specific measures including the Disability Rating Scale (DRS), Functional Assessment Measure (FIM), Rancho Los Amigos Scale (RLAS), Glasgow Coma Scale (GCS), Neurobehavioral Rating Scale (NRS), and neuropsychological test results. SETTING Four medical centers in the federally sponsored Traumatic Brain Injury Model Systems Project that provide emergency medical services, intensive and acute medical care, inpatient rehabilitation, and a spectrum of community rehabilitation services. PARTICIPANTS Patients were selected from a national database of 245 rehabilitation inpatients admitted to acute care within 8 hours of TBI and seen at 1-year follow-up. MAIN OUTCOME MEASURE Return to work at 1-year follow-up. RESULTS Persons employed at 1-year follow-up obtained significantly better scores on specific acute measures of physical functioning (Admission FIM, Admission DRS, Discharge DRS), cognitive functioning (Logical Memory Delay), behavioral functioning (Admission RLAS, Discharge RLAS, NRS Excitement factor), and injury severity (Admission GCS, Highest GCS, Length of Coma, Length of PTA) than their unemployed counterparts. CONCLUSIONS Persons obtaining better scores on certain acute measures (e.g., Admission GCS) are more likely to return to the workforce. Future research should focus on developing a standardized tool to assess a patients ability to return to work, as well as an operational definition for successful employment.

Functional outcome after brain tumor and acute stroke: A comparative analysis

OBJECTIVE To compare the functional outcome, length of stay, and discharge disposition of patients with brain tumors and those with acute stroke. DESIGN Case-controlled, retrospective study at a tertiary care medical center inpatient rehabilitation unit. SUBJECTS Sixty-three brain tumor patients matched with 63 acute stroke patients according to age, sex, and location of lesion. MAIN OUTCOME MEASURES The functional independence measure (FIM) was measured on admission and discharge. The FIM change and FIM efficiency were also calculated. The FIM was analyzed in three subsets: activities of daily living (ADL), mobility (MOB), and cognition (COG). Discharge disposition and rehabilitation length of stay were compared. RESULTS Demographic variables of race, marital status, and payer source were comparable for the two groups. No significant difference was found between the brain tumor and stroke populations with respect to total admission FIM, total discharge FIM, change in total FIM, or FIM efficiency. The admission MOB-FIM was found to be higher in the brain tumor group (13.6 vs 11.1, p = .04), whereas the stroke group had a greater change in ADL-FIM score (10.8 vs 8.3, p = .03). The two groups had similar rates of discharge to community at greater than 85%. The tumor group had a significantly shorter rehabilitation length of stay than the stroke group (25 vs 34 days, p < .01). CONCLUSION Brain tumor patients can achieve comparable functional outcome and rates of discharge to community and have a shorter rehabilitation length of stay than stroke patients.

Functional outcomes in patients with brain tumor after inpatient rehabilitation: comparison with traumatic brain injury.

OBJECTIVE To compare the functional outcome, length of stay, and discharge disposition of individuals with brain tumor versus those with acute traumatic brain injury. DESIGN In this study, 78 brain tumor patients were one-to-one matched by location of lesion and age with 78 acute traumatic brain injury patients. Outcome was measured by using the Functional Independence Measure (FIM 228) on admission and discharge. The FIM change and FIM efficiency were also calculated. FIM data were analyzed in three subsets, i.e., activities of daily living, mobility, and cognition. Discharge disposition and rehabilitation length of stay were also compared. RESULTS Demographic variables of race, marital status, and payer source were comparable for the two groups. No significant difference was found between the brain tumor and the traumatic brain injury populations with respect to total admission FIM, total discharge FIM, and FIM efficiency. The brain injury population had a significantly greater change in FIM. The tumor group had a significantly shorter rehabilitation length of stay and a greater discharge to community rate. CONCLUSIONS Thus, individuals with brain tumor can achieve comparable functional outcome and have a shorter rehabilitation length of stay and greater discharge to community rate than individuals with brain injury.

Impact of clinically significant heterotopic ossification on functional outcome after traumatic brain injury.

OBJECTIVE To assess heterotopic ossifications (HO) impact on functional outcome after TBI. DESIGN Retrospective with matched control group, single center. SETTING TBI Model System of Care at the Medical College of Virginia of Virginia Commonwealth University, Richmond, VA. PARTICIPANTS Twenty-six patients with TBI and triple-phase bone scan confirmed HO were matched with 26 patients without clinical evidence of HO. MAIN OUTCOME MEASURES Acute and rehabilitation lengths of stay (LOS), Admission and Discharge Functional Independence Measure (FIM) scores, FIM change, FIM efficiency (FIM gains per week), and discharge disposition. RESULTS The two groups had similar acute care LOS. Patients with HO had significantly longer inpatient rehabilitation LOS and significantly lower FIM mobility and activities of daily living subscale scores on admission and discharge. FIM efficiency was significantly lower for the group with HO. Significantly fewer patients with HO were able to be discharged to home. CONCLUSIONS HO is associated with a poorer functional outcome; however, it is not clear whether HO causes the decreased function or whether it may serve more generally as an indicator of those patients who will not progress as far or as rapidly during inpatient rehabilitation.

Development and Outcomes of a Text Messaging Tobacco Cessation Intervention With Urban Adolescents

BACKGROUND This paper describes the development of an urban adolescent text messaging tobacco cessation intervention and preliminary findings from a randomized, controlled trial. The authors successfully adapted a face-to-face intervention into a personalized, automated, and interactive 5-day texting protocol. METHODS Respondent-driven sampling was used beginning at a community substance abuse facility. Seventy-two tobacco-dependent adolescents were randomized into an automated computer texting program that delivered either the experimental condition of 30 motivational interviewing- and social network counseling-based personalized messages or the attention control condition consisting of a texting program covering general (non-smoking-related) health habits. All teens were provided smartphones for the study and were assessed at baseline and at 1, 3, and 6 months post intervention. Analyses examined condition×time interactions. RESULTS At 6 months, the experimental condition decreased the number of cigarettes smoked in the past 30 days, increased intentions not to smoke in the future, and increased peer social support compared with controls. Effect sizes were moderate to large. CONCLUSIONS These findings are unique, as they target urban adolescents with a mobile health format and add to the growing literature on the efficacy of text-delivered interventions.

Enhancing the Schooling of Students with Traumatic Brain Injury.

matic brain injury (TBI): • More than 1 million U.S. children are identified each year with TBI. • TBI is the most common cause of death and disability of children in the United States. • Between 9% and 38% of students with TBI are referred to special education. Many teachers, in both general and special education, may discover that one or more of their students has suffered from brain injury (see box, “What Does the Literature Say?”). This article explores how to identify these students, where the best placements might be, and what teaching strategies are effective. For example, one of the important considerations is how soon a child or youngster with TBI should return to school.

Lessons Learned from a Randomized Trial of Fixed and Escalating Contingency Management Schedules in Opioid-Dependent Pregnant Women

Background: Contingency management (CM) has shown promise for treating substance use disorders in pregnant women. Methods: A randomized clinical trial compared the relative efficacy of three conditions on the measures of opioid and cocaine abstinence and days retained in treatment. A total of 133 pregnant patients attending treatment for substance use disorders were randomized either to an escalating reinforcement condition, a fixed reinforcement condition, or an attendance control condition. Conditions were compared on drug abstinence rates and days retained in treatment. Results: As expected, the pooled escalating + fixed conditions received a greater total amount of voucher money than the control condition mean [M = 392.40 (SE = 40.47) vs. 219.74 (SE = 39.78)], respectively; p < .001. However, the escalating and fixed conditions did not differ on the outcome variables of drug abstinence and treatment retention. Conclusions: The CM conditions examined in the current study did not emerge as superior to the control condition. The lack of significant differences among study conditions may be attributed, in part, to study sample size. Additionally, methodological issues related to the CM intervention may also have compromised outcomes, including delay in reinforcement following the target behavior and limited contact with the reinforcer. Scientific Significance: This study highlights the importance of key CM implementation features, including immediate reinforcement, and adequate access to the reinforcer. It may also be that the reset feature for missing samples in CM interventions is an essential contingency for promoting behavior change. Trial registration: ClinicalTrials.gov identifier: NCT00497068.

Prevalence of mental health conditions after military blast exposure, their co-occurrence, and their relation to mild traumatic brain injury.

Abstract Primary objectives: To measure common psychiatric conditions after military deployment with blast exposure and test relationships to post-concussion syndrome (PCS) symptoms and mild traumatic brain injury (mTBI) history. Research design: Cross-sectional. Methods and procedures: Service members or Veterans (n = 107) within 2 years of blast exposure underwent structured interviews for mTBI, post-traumatic stress disorder (PTSD) and multiple mood and anxiety diagnoses. Main outcomes and results: MTBI history and active PTSD were both common, additionally 61% had at least one post-deployment mood or anxiety disorder episode. Psychiatric diagnoses had a high degree of comorbidity. Most dramatically, depression was 43-times (95% CI = 11–165) more likely if an individual had PTSD. PCS symptoms were greater in those with post-deployment PTSD or mood diagnosis. However, neither mTBI nor blast exposure history had an effect on the odds of having PTSD, mood or anxiety condition. Conclusions: These findings support that psychiatric conditions beyond PTSD are common after military combat deployment with blast exposure. They also highlight the non-specificity of post-concussion type symptoms. While some researchers have implicated mTBI history as a contributor to post-deployment mental health conditions, no clear association was found. This may partly be due to the more rigorous method of retrospective mTBI diagnosis determination.

Perceived Mental Health Treatment Need and Substance Use Correlates Among Young Adults

OBJECTIVES The relationship between perceived need for mental health treatment, reasons for not receiving care, substance use, and race and gender among young adults was examined to identify barriers to mental health care. METHODS Data from the 2010 National Survey on Drug Use and Health for 14,718 adults ages 18 to 23 were used. Logistic regression analysis compared substance use among young adults with perceived mental health treatment need grouped by race and gender. RESULTS A total of 7.6% of young adults wanted mental health treatment but did not receive care. Persons with perceived treatment need were more likely than recipients of treatment to smoke cigarettes, use marijuana, meet criteria for marijuana abuse or dependence, and engage in binge drinking, after analyses controlled for income and health insurance. White males with perceived need were 3.2 times more likely to smoke and to meet criteria for marijuana abuse or dependence and were 2.6 times more likely to engage in binge drinking. Hispanic males were 2.9 times more likely to smoke and meet criteria for marijuana abuse or dependence. White females were 1.7 times more likely than other subgroups to perceive need for mental health care. CONCLUSIONS Young adults with perceived mental health treatment need are at high risk of substance abuse and dependence. Results support targeting knowledge and attitudes surrounding mental health services by race-ethnicity and gender to improve willingness to receive care.

Functional outcome of individuals with traumatic brain injury and lower extremity deep venous thrombosis.

OBJECTIVE To determine the impact of acute lower extremity (LE) deep venous thrombosis (DVT) on functional outcome after traumatic brain injury (TBI). SETTING Tertiary university medical center rehabilitation unit. SUBJECTS Ninety-two TBI rehabilitation patients (46 patients with DVT and 46 patients without DVT). Forty-six TBI patients with a diagnosis of LE DVT were 1:1 matched with non-DVT TBI patients. Matching criteria included: primary diagnosis of TBI, admission Functional Independence Measure (FIM), Glasgow Coma Scale (GCS), and age. OUTCOME MEASURES FIM (admission, discharge, change, and efficiency), FIM subscores (activities of daily living [ADL], mobility, cognition), length of stay ([LOS] acute and rehabilitation), and discharge living disposition. DESIGN Cohort study utilizing prospectively collected data. DVT diagnoses were made upon rehabilitation admission using color flow duplex Doppler ultrasonography. Descriptive statistics were run on demographic variables. Analyses of variance (ANOVAs) were performed on the sample with regard to outcome measures, including FIM scores, FIM subscores, and LOS (acute and rehabilitation). RESULTS No significant between-group differences were found concerning LOS, rehabilitation costs, FIM total, or FIM subgroup scores. Chi-squared analyses revealed significant differences between groups with regard to discharge living disposition (chi(2) = 4.7, P <.03). CONCLUSION Lower extremity DVT does not appear to interfere with functional outcome after TBI. The data suggest that this patient population is appropriate for admission or continued participation in acute inpatient rehabilitation, despite the presence of LE DVT.