Associations of Nightmares and Sleep Disturbance With Neurobehavioral Symptoms Postconcussion.

OBJECTIVE: This study investigates the association of nightmares beyond general sleep disturbance on neurobehavioral symptoms in adults with mild traumatic brain injury (mTBI). DESIGN: Secondary analysis of a concussion cohort study. PARTICIPANTS: One hundred and eleven adults older than 20 years with mTBI were recruited from a specialized concussion treatment center. MAIN MEASURES: Behavioral Assessment Screening Tool, Pittsburgh Sleep Quality Index, and self-report of nightmare frequency in the past 2 weeks. RESULTS: Among adults with mTBI, nightmares accounted for the greatest amount of variability in negative affect (ß = .362, P < .001), anxiety (ß = .332, P < .001), and impulsivity (ß = .270, P < .001) after adjusting for age and sex. Overall sleep disturbance had the strongest association with depression (ß = .493, P < .001), fatigue (ß = .449, P < .001), self-reported executive dysfunction (ß = .376, P < .001), and overall burden from concussive symptoms (ß = .477, P < .001). CONCLUSIONS: Nightmares and sleep disturbance are differentially associated with variance in neurobehavioral symptoms. Nightmares were independently associated with neurobehavioral symptoms representing an excess of normal functioning (eg, anxiety, impulsivity), while general sleep disturbance was associated with neurobehavioral symptoms representing functioning below normal levels (eg, depression, fatigue, self-reported executive dysfunction). Clinical and research implications are discussed.

Neurobehavioral Symptom Profiles for the Behavioral Assessment Screening Tool in Chronic Traumatic Brain Injury.

OBJECTIVE: To identify neurobehavioral symptom profiles among persons with chronic traumatic brain injury (TBI) using the Behavioral Assessment Screening Tool (BAST) and to consider participant characteristics that differ between profile groups. SETTING: Community. PARTICIPANTS: Participants (n = 615) were English-speaking adults (≥18) and had a self-reported history of at least one TBI of any severity. DESIGN: Secondary analysis of cross-sectional data. MAIN MEASURES: The BAST measures neurobehavioral symptoms in the domains of Negative Affect, Fatigue, Executive Dysfunction, Impulsivity, and Substance Misuse. RESULTS: Using latent profile analysis (LPA), we identified 3 different neurobehavioral profiles. Overall symptom frequency and differences in the pattern of symptom frequency across domains differentiated the profile groups. Average domain scores differed significantly across the profiles (P < .001) for all domains except Fatigue (P = .076). Those in profile 3 (High-Risk group) reported the most frequent symptoms across all domains (similar Negative Affect frequency as profile 1). Substance Misuse was especially high in this group. Compared to profile 2 (High Negative Affect group), participants in profile 1 (Moderate-Risk group) endorsed significantly more frequent (and more variable) symptoms across all BAST domains, particularly Impulsivity and Substance Misuse. Participants in profile 2 endorsed the least frequent symptoms across all domains. Demographic comparison showed that groups differed based on gender, age, and injury severity (mild vs moderate-severe), with profile 3 composed of the most men and the most persons in early adulthood, and profile 2 composed of the most women and those with mild TBI. CONCLUSIONS: We differentiated 3 neurobehavioral symptom profiles among persons with chronic TBI and determined differences in sociodemographic factors between the groups. Future research should focus on validating these profiles in another sample of individuals with chronic TBI. Characterizing persons according to multidimensional symptom profiles could allow for more tailored approaches to predict and prevent long-term negative outcomes.

Emotional, Behavioral, and Cognitive Symptom Associations With Community Participation in Chronic Traumatic Brain Injury.

OBJECTIVES: To determine the association between self-reported emotional and cognitive symptoms and participation outcomes in chronic traumatic brain injury (TBI) and to explore the relative contribution of self-reported versus performance-based cognition to participation outcomes. SETTING: Community. PARTICIPANTS: Community-dwelling adults ( n = 135) with a lifetime history of mild to severe TBI. DESIGN: Secondary analysis of a cross-sectional study on neurobehavioral symptoms in chronic TBI. MAIN MEASURES: Behavioral Assessment Screening Tool (BAST) (Negative Affect, Fatigue, Executive Dysfunction, Impulsivity, Substance Abuse subscales) measured self-reported neurobehavioral symptoms; Participation Assessment with Recombined Tools (Productivity, Social Relations, and Out and About) measured self-reported participation outcomes; and Brief Test of Adult Cognition by Telephone (BTACT) measured performance-based cognition (Episodic Memory and Executive Function summary scores) in a subsample ( n = 40). RESULTS: The BAST Executive Dysfunction was significantly associated with less frequent participation and had the strongest effect on participation in all participation domains. No other BAST subscales were associated with participation, after adjusting for all subscale scores and age, with the exception of BAST Impulsivity, which was associated with more frequent Social Relationships. Exploratory analysis in the sample including the BTACT revealed that, after accounting for subjective Executive Dysfunction using the BAST, performance-based Executive Function was associated with Productivity and Working Memory was associated with Social Relations, but neither was associated with being Out and About; the BAST Executive Dysfunction remained significant in all models even after including BTACT scores. CONCLUSIONS: Self-reported Executive Dysfunction contributed to participation outcomes after mild to severe TBI in community-dwelling adults, whereas self-reported emotional and fatigue symptoms did not. Performance-based cognition measures may capture different variability in participation after injury.

Heart rate variability (HRV) after traumatic brain injury (TBI): a scoping review.

BACKGROUND: Heart rate variability (HRV), defined as the variability between successive heart beats, is a noninvasive measure of autonomic nervous system (ANS) function, which may be altered following traumatic brain injury (TBI). This scoping review summarizes the existing literature regarding changes in HRV after TBI as well as the association between measures of HRV and outcomes following TBI. METHODS: A literature search for articles assessing 'heart rate variability' and 'brain injury' or 'concussion' was completed. Articles were included if HRV was measured in human subjects with TBI or concussion. Review articles, protocol papers, and studies including non-traumatic injuries were excluded. RESULTS: Sixty-three articles were included in this review. Varied methods were used to measure HRV in the different studies. Forty articles included information about differences in HRV measures after TBI and/or longitudinal changes after TBI. Fifteen studies assessed HRV and symptoms following TBI, and 15 studies assessed HRV and either functional or cognitive outcomes after TBI. CONCLUSIONS: HRV has been studied in the context of mortality, clinical symptoms, and medical, functional, or cognitive outcomes following TBI. Methods used to measure HRV have varied amongst the different studies, which may impact findings, standardized protocols are needed for future research.

The Behavioral Assessment Screening Tool for Mobile Health (BASTmHealth): Development and Compliance in 2 Weeks of Daily Reporting in Chronic Traumatic Brain Injury.

OBJECTIVES: To develop and evaluate the feasibility of a short form of the Behavioral Assessment Screening Tool (BASTmHealth) for high frequency in situ self-reported assessment of neurobehavioral symptoms using mobile health technology for community-dwelling adults with traumatic brain injury (TBI). DESIGN: Prospective, repeated-measures study of mHealth assessment of self-reported neurobehavioral symptoms in adults with and without a lifetime history of TBI over a 2-week period. SETTING: Community. PARTICIPANTS: Community-dwelling adults with (n=52) and without (n=12) a lifetime TBI history consented to the study (N=64). INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: BASTmHealth subscales (2-items each): negative affect, fatigue, executive function, substance abuse, impulsivity; feasibility measured via compliance (assessments assigned/assessments completed) and participant-reported usability. RESULTS: We developed the 10-item BASTmHealth as a screener for high frequency in situ self-reported assessment of neurobehavioral symptoms leveraging mHealth. Compliance for 2 weeks of BASTmHealth supports its feasibility. Fifty-six of 64 participants (87.5%) who completed baseline assessments completed the 2 weeks of daily assessments; all 8 participants who did not complete ecological momentary assessment had a history of TBI. Overall compliance was 81.4% (496 completed of 609 assigned assessments) among all 52 participants with TBI and 96.7% (494 completed of 511 assigned assessments) among the 44 who completed any daily measures, compared with 91.8% (135 completed of 147 assigned assessments) among those with no TBI history. Participants thought the daily surveys were easy to understand and complete and the number of prompts were reasonable. CONCLUSIONS: Conducting daily high-frequency in situ self-reported assessment of neurobehavioral symptoms using the BASTmHealth is feasible among individuals with and without a lifetime history of TBI. Developing and evaluating self-reported assessments for community-based assessment is a critical step toward expanding remote clinical monitoring systems to improve post-TBI outcomes.

Predictors of High School and College Graduation After Sustaining a Moderate-to-Severe Traumatic Brain Injury.

OBJECTIVE: To identify early predictors of US high school and college graduation after moderate-to-severe traumatic brain injury (TBI). SETTING: Inpatient rehabilitation and community. PARTICIPANTS: TBI Model Systems participants, aged 16 to 24 years, enrolled as high school or college students at time of injury. DESIGN: Prospective cohort study. MAIN MEASURES: Successful graduation was defined as having a diploma (high school) or an associate/bachelor's degree (college) at 1-, 2-, or 5-year follow-up. Predictors were sex, race/ethnicity, urbanicity, preinjury substance abuse, primary rehabilitation payer, and functional independence at inpatient rehabilitation discharge. METHOD: We descriptively characterized differences between those who did and did not graduate high school and college within the first 5 years postinjury and identified early predictors of successful high school and college graduation using 2 binomial logistic regressions. RESULTS: Of those with known graduation status, 81.2% of high school and 41.8% of college students successfully graduated. Graduates in both groups were more often White than Black and had more functional independence at discharge. Among high school students, preinjury substance abuse was also a risk factor for not graduating, as was identifying as Hispanic or "other" race. CONCLUSIONS: Sociodemographic factors and disability influence graduation outcomes, requiring structural, institutional, and personal interventions for success.

Bullying among children with heart conditions, National Survey of Children's Health, 2018-2020.

Children with chronic illnesses report being bullied by peers, yet little is known about bullying among children with heart conditions. Using 2018-2020 National Survey of Children's Health data, the prevalence and frequency of being bullied in the past year (never; annually or monthly; weekly or daily) were compared between children aged 6-17 years with and without heart conditions. Among children with heart conditions, associations between demographic and health characteristics and being bullied, and prevalence of diagnosed anxiety or depression by bullying status were examined. Differences were assessed with chi-square tests and multivariable logistic regression using predicted marginals to produce adjusted prevalence ratios and 95% confidence intervals. Weights yielded national estimates. Of 69,428 children, 2.2% had heart conditions. Children with heart conditions, compared to those without, were more likely to be bullied (56.3% and 43.3% respectively; adjusted prevalence ratio [95% confidence interval] = 1.3 [1.2, 1.4]) and bullied more frequently (weekly or daily = 11.2% and 5.3%; p < 0.001). Among children with heart conditions, characteristics associated with greater odds of weekly or daily bullying included ages 9-11 years compared to 15-17 years (3.4 [2.0, 5.7]), other genetic or inherited condition (1.7 [1.0, 3.0]), ever overweight (1.7 [1.0, 2.8]), and a functional limitation (4.8 [2.7, 8.5]). Children with heart conditions who were bullied, compared to never, more commonly had anxiety (40.1%, 25.9%, and 12.8%, respectively) and depression (18.0%, 9.3%, and 4.7%; p < 0.01 for both). Findings highlight the social and psychological needs of children with heart conditions.

Neurobehavioral Symptoms and Heart Rate Variability: Feasibility of Remote Collection Using Mobile Health Technology.

OBJECTIVES: To determine the covariance of heart rate variability (HRV) and self-reported neurobehavioral symptoms after traumatic brain injury (TBI) collected using mobile health (mHealth) technology. SETTING: Community. PARTICIPANTS: Adults with lifetime history of TBI (n = 52) and adults with no history of brain injury (n = 12). DESIGN: Two-week prospective ecological momentary assessment study. MAIN MEASURES: Behavioral Assessment Screening Tool (BASTmHealth) subscales (Negative Affect, Fatigue, Executive Dysfunction, Substance Abuse, and Impulsivity) measured frequency of neurobehavioral symptoms via a RedCap link sent by text message. Resting HRV (root mean square of successive R-R interval differences) was measured for 5 minutes every morning upon waking using a commercially available heart rate monitor (Polar H10, paired with Elite HRV app). RESULTS: Data for n = 48 (n = 38 with TBI; n = 10 without TBI) participants were included in covariance analyses, with average cross-correlation coefficients (0-day lag) varying greatly across participants. We found that the presence and direction of the relationship between HRV and neurobehavioral symptoms varied from person to person. Cross-correlation coefficients r ≤ -0.30, observed in 27.1% to 29.2% of participants for Negative Affect, Executive Dysfunction, and Fatigue, 22.9% of participants for Impulsivity, and only 10.4% of participants for Substance Abuse, supported our hypothesis that lower HRV would covary with more frequent symptoms. However, we also found 2.0% to 20.8% of participants had positive cross-correlations (r ≥ 0.30) across all subscales, indicating that higher HRV may sometimes correlate with more neurobehavioral symptoms, and 54.2% to 87.5% had no significant cross-correlations. CONCLUSIONS: It is generally feasible for community-dwelling adults with and without TBI to use a commercially available wearable device to capture daily HRV measures and to complete a short, electronic self-reported neurobehavioral symptom measure for a 2-week period. The covariance of HRV and neurobehavioral symptoms over time suggests that HRV could be used as a relevant physiological biomarker of neurobehavioral symptoms, though how it would be interpreted and used in practice would vary on a person-by-person and symptom domain basis and requires further study.

Using participatory culture-specific consultation to support the mental health needs of summer camp staff.

Nearly 30% of all U.S. youth attend summer camp each year, making it one of the broadest reaching out-of-school-time interventions in the country. Camp provides a space for seasonal employees, who are often emerging adults, to explore work values and identity, engage in mentoring and support opportunities, and stay connected to a community larger than themselves. However, research on camp experiences also suggests camp settings and expectations around emotional and physical care can cause counselors to experience burnout, compassion fatigue, and reduced job satisfaction. Using participatory culture-specific consultation, the current study addressed a gap in the literature about systemic interventions to manage camp counselor mental health by designing, implementing, and evaluating a mental health consultation model at one of the largest YMCA summer camps in the country. Results suggest the intervention effectively addressed certain administrator and staff needs; results also suggest the model could be refined to more effectively respond to the particular contextual challenges of summer camps. Implications and recommendations for other summer camps are discussed.

Promoting Equity, Diversity and Social Justice Through Faculty-Led Transformative Projects.

We present a transformative professional development project with a focus on equity, diversity and social justice (EDSJ) to raise cultural awareness among faculty, increase agency, and promote positive change through transformative projects. Twenty-three faculty members from nine different colleges located at a Research I university were provided with critical cultural awareness workshops and then supported to develop transformative projects related to EDSJ. Based on focus group interviews and pre-post surveys, we identified four themes and five categories: two outcome-related (Building Community and Transformative Actions) and two operational themes (Barriers and Facilitators). We conclude that faculty-centered and transformative professional development projects could significantly benefit all those interested in establishing a culturally inclusive, positive and responsive climate. Our study also contributes to the emerging research on scholar activism and provides a practical model for implementation.

Factor analysis of the adolescent version of the behavioural assessment screening tool (BAST-A) in adolescents with concussion.

Objective: Develop and validate the Behavioral Assessment Screening Tool for Adolescents with brain injury.Setting: Concussion clinicsParticipants: Adolescents with mild traumatic brain injury 3 months after initial concussion clinic visit (n = 138).Design: Assessment development and validation (cross-sectional cohort) studyMain Measures: Behavioral Assessment Screening Tool - AdolescentResults: Expert panel members added or modified items specific to adolescents to the original Behavioral Assessment Screening Tool for adults. The Content Validity Index was 97.2%. Exploratory factor analysis of the Behavioral Assessment Screening Tool - Adolescent reduced the initial 70 items to 46 primary items with a 3-factor solution: Negative Affect & Fatigue, Executive & Social Function, and Risk Behaviors. Internal consistency reliabilities ranged from good to excellent for all factors (Cronbach's α =.80-.95). We retained four secondary maladaptive coping items (from an initial six), though these require further modification and testing (Cronbach's α =.67).Conclusion: The Behavioral Assessment Screening Tool for Adolescents, a measure of neurobehavioral symptoms after mild traumatic brain injury in adolescents, has a multidimensional factor structure with evidence of good internal consistency reliabilities. Future work will further evaluate its convergent and discriminant validity and employ item response theory analyses for validation in a new sample of adolescents with concussion.

Convergent, discriminant, and known groups validity of the Behavioral Assessment Screening Tool (BAST) in chronic traumatic brain injury.

The Behavioral Assessment Screening Tool (BAST) measures self-reported neurobehavioral symptoms commonly experienced by adults with traumatic brain injury (TBI). To assess the convergent, discriminant, and known-groups validity of the BAST among community-dwelling adults with chronic traumatic brain injury (TBI), we conducted correlation analyses and tests of group differences with previously validated symptom measures in two samples (n = 111, n = 134). Measures used for comparison were: Patient Health Questionnaire (depression), Generalized Anxiety Disorder-7 (anxiety), Positive and Negative Affect Schedule, Frontal Systems Behavior Scale (Executive Dysfunction, Apathy, Disinhibition), Modified Fatigue Impact Scale, PROMIS Fatigue, Aggression Questionnaire (anger, hostility, physical and verbal aggression), and Alcohol Use Disorders Test (alcohol misuse). BAST subscales had stronger correlations with measures of similar (|r|=.602-.828, p < .001) and related (|r|>.30, p < .001) constructs and weaker correlations (|r|<.300) with measures of dissimilar/unrelated constructs, supporting hypotheses of convergent and discriminant validity, respectively. Statistically significant group differences (p's < .001) in BAST subscales were found, with large effect sizes (Cohen's d = 1.2-1.9), for known-groups with moderate-severe depression, moderate-severe anxiety, clinically significant fatigue, problematic disinhibited and frontal-executive behaviors, and alcohol use. Conclusions: Results support the convergent and discriminant validity of the BAST subscales. The BAST was specifically developed as a self-reported measure for remote symptom reporting, supporting its incorporation into mobile health platforms to improve chronic symptom monitoring in community-dwelling adults with TBI. With further validation research, the BAST could be used for early identification of persons with TBI who could benefit from intervention.

Characterization of telerehabilitation visits and patient satisfaction in outpatient physical medicine and rehabilitation clinics from March 2020 to November 2021.

OBJECTIVE: To explore the usability of and satisfaction with telerehabilitation services provided to rehabilitation patients with various diagnoses at two large urban medical facilities during the Covid-19 pandemic. DESIGN: This was a usability study and all patients that received telerehabilitation services from March 2020 to November 2021 were included. Of the 4,070 surveys sent via mail or email links to RedCap, 405 were completed (10% Response Rate). Participants completed demographic surveys, surveys on the telerehabilitation visit characteristics, telerehabilitation usability, and overall satisfaction with the visit. RESULTS: Patients were mostly women (64.4%), White, non-hispanic (74.3%) and English speaking (99%). Most patients were seen via telerehabilitation due to Covid-19 restrictions (37.1%). Patients were generally satisfied with their telerehabilitation visit (3.64 out of 4). Additionally, patients generally found telerehab to be useful (6.4 out of 7), easy to use (6.3 out of 7), effective (6.2 out of 7), satisfactory (6.3 out of 7) and comparable to in-person visits (6.5 out of 7). CONCLUSION: Patients generally reported feeling satisfied and comfortable with telerehabilitation visits, and felt they were comparable to in-person visits. Future research should examine the impact of socioeconomic factors on telerehabilitation use, with a focus on education level and non-English speakers.

Impact of elexacaftor/tezacaftor/ivacaftor on bacterial cultures from people with cystic fibrosis.

BACKGROUND: Cystic fibrosis transmembrane conductance regulator (CFTR) modulators have shown beneficial effects on both forced expiratory volume in 1 s (FEV1 ) and frequency of pulmonary exacerbations in people with cystic fibrosis (CF). These positive outcomes may be related to changes in bacterial colonization within the lungs. Elexacaftor/tezacaftor/ivacaftor (ELX/TEZ/IVA) is the first triple therapy CFTR modulator approved for use in people with CF 6 years and older. This study aimed to determine the impact of ELX/TEZ/IVA on the isolation of Pseudomonas aeruginosa (Pa), methicillin-resistant and methicillin-susceptible Staphylococcus aureus (MRSA and MSSA, respectively) in respiratory cultures. METHODS: A retrospective chart review of the electronic medical record at the University of Iowa was completed for individuals 12 years and older taking ELX/TEZ/IVA for at least 12 months. The primary outcome was determined by assessing bacterial cultures pre- and postinitiation of ELX/TEZ/IVA. Baseline demographic and clinical characteristics were summarized using mean and standard deviation for continuous outcomes and count and percentage for categorical outcomes. Culture positivity for Pa, MSSA, and MRSA was compared among enrolled subjects between pre- and posttriple combination therapy periods using an exact McNemar's test. RESULTS: One hundred and twenty-four subjects prescribed ELX/TEZ/IVA for at least 12 months met the requirements for inclusion within our analysis. Culture positivity for Pa, MSSA, and MRSA was approximately 54%, 33%, and 31%, respectively, for the pre-ELX/TEZ/IVA period. Prevalence decreased to approximately 30%, 32%, and 24% (-24.2% [p < 0.0001], -0.7% [p = 1.00], and -6.5% [p = 0.0963], respectively) post-ELX/TEZ/IVA. The source of bacterial culture was predominantly sputum (70.2%) in the pre-ELX/TEZ/IVA group, whereas a throat source (66.1%) was more common post-ELX/TEZ/IVA. CONCLUSIONS: ELX/TEZ/IVA treatment has an appreciable impact on the detection of common bacterial pathogens in CF respiratory cultures. While previous studies have found a similar effect with single and double CFTR modulator therapies, this is the first single-center study to show the impact of triple therapy, ELX/TEZ/IVA, on bacterial isolation from airway secretions.

Hyperbaric Oxygen Therapy versus placebo for post-concussion syndrome (HOT-POCS): A randomized, double-blinded controlled pilot study.

Post-Concussion Syndrome (PCS) refers to the persistence of physical, cognitive, and emotional symptoms following mild traumatic brain injury (mTBI)/concussion, occurring in roughly 15-30% of individuals. Hyperbaric oxygen therapy (HBOT) has been suggested as a potential treatment for PCS; however, the evidence to date is mixed due to inconsistencies in the treatment protocol and focus on veterans with combat-related injuries, which may not be generalizable to the general population. The goal of Hyperbaric Oxygen Therapy for Post-Concussion Syndrome (HOT-POCS) is to assess the efficacy and safety of HBOT for the treatment of PCS in the civilian population. This randomized, controlled pilot study will be using a standardized HBOT protocol (20 sessions of 100% O2 at 2.0 atm absolute [ATA]) compared with a true placebo gas system that mimics the oxygen composition at room air (20 sessions of 10.5% O2 and 89.5% nitrogen at 2.0 ATA) in a cohort of 100 adults with persistent post-concussive symptoms 3-12 months following injury. Change in symptoms on the Rivermead Post-concussion Questionnaire (RPQ) will be the primary outcome of interest. Secondary outcomes include the rate of adverse events, change in the quality of life, and change in cognitive function. Exploratory outcome measures will include changes in physical function and changes in cerebral brain perfusion and oxygen metabolism on MRI brain imaging. Overall, the HOT-POCS study will compare the efficacy of a standardized HBOT treatment protocol against a true placebo gas for the treatment of PCS within 12 months after injury.

Multisite randomized feasibility study of Problem-Solving Training for care partners of adults with traumatic brain injury during inpatient rehabilitation.

BACKGROUND: Problem-Solving Training (PST) during inpatient rehabilitation could provide care partners the skills needed to manage their life roles after discharge. OBJECTIVE: Determine the feasibility of PST+ Education versus Education for care partners of adults with traumatic brain injury (TBI) during inpatient rehabilitation. METHODS: We conducted a multisite randomized feasibility trial across three sites. We present recruitment rates, reasons for refusal to participate, and reasons for non-completion of interventions. We measured client satisfaction, participant engagement, and fidelity for both interventions. We compared change in depressive symptoms and caregiver burden between PST and Education groups. RESULTS: Though the interventions were generally feasible, recruitment and retention rates were lower than anticipated largely due to the COVID-19 pandemic. Participants who completed >3 sessions were less likely to be employed full-time and more often spouses and co-residing. Length of inpatient rehabilitation stay was correlated with number of sessions completed. We observed potential benefits of PST over Education, specifically for reducing depression symptoms and caregiver burden. CONCLUSION: High satisfaction, engagement, and fidelity, overall recruitment and retention, and positive change in outcomes suggest that PST is generally feasible and beneficial for care partners of persons with TBI. Adaptations, such as developing a 3-session version of PST, could improve feasibility.

Branching out: Feasibility of examining the effects of greenspace on mental health after traumatic brain injury.

Aim: This pilot study's aim was to determine the feasibility of examining the effects of an environmental variable (i.e., tree canopy coverage) on mental health after sustaining a brain injury. Methods: A secondary data analysis was conducted leveraging existing information on mental health after moderate to severe traumatic brain injury (TBI) from the TBI Model System. Mental health was measured using PHQ-9 (depression) and GAD-7 (anxiety) scores. The data were compared with data on tree canopy coverage in the state of Texas that was obtained from the Multi-Resolution Land Characteristics (MRLC) Consortium using GIS analysis. Tree canopy coverage as an indicator of neighborhood socioeconomic status was also examined using the Neighborhood SES Index. Results: Tree canopy coverage had weak and non-significant correlations with anxiety and depression scores, as well as neighborhood socioeconomic status. Data analysis was limited by small sample size. However, there is a higher percentage (18.8%) of participants who reported moderate to severe depression symptoms in areas with less than 30% tree canopy coverage, compared with 6.6% of participants who endorsed moderate to severe depression symptoms and live in areas with more than 30% tree canopy coverage (there was no difference in anxiety scores). Conclusion: Our work confirms the feasibility of measuring the effects of tree canopy coverage on mental health after brain injury and warrants further investigation into examining tree canopy coverage and depression after TBI. Future work will include nationwide analyses to potentially detect significant relationships, as well as examine differences in geographic location.

Impact of elexacaftor/tezacaftor/ivacaftor on vitamin D absorption in cystic fibrosis patients.

BACKGROUND: Cystic fibrosis (CF) is a multisystem disorder that results in the buildup of mucus in various organs. Ninety percent of CF patients are classified as pancreatic insufficient, leading to malabsorption of nutrients and fat-soluble vitamins without the assistance of exogenous pancreatic enzymes. This study was designed to determine if serum 25-hydroxyvitamin D concentrations were impacted by initiation of elexacaftor/tezacaftor/ivacaftor (ELX/TEZ/IVA). METHODS: Serum 25-hydroxyvitamin D concentrations were measured before and 1 year post-ELX/TEZ/IVA initiation. A Wilcoxon signed-rank test was used to compare values. RESULTS: Seventy-six patients were included in the final analysis. The average age of our population was 25.8 years (SD = 13.2 years) with a majority being male, homozygous F508del, pancreatic insufficient, and not modulator-naive. The median increase of serum vitamin D concentration after initiating ELX/TEZ/IVA was 5 ng/ml (interquartile range = -4, 13; p = .0035). CONCLUSIONS: We suggest that ELX/TEZ/IVA may improve fat-soluble vitamin absorption, specifically serum 25-hydroxyvitamin D. These results may lead to adjustments in vitamin supplementation in patients receiving cystic fibrosis transmembrane conductance regulator modulator therapy.

Caregiver Characteristics of Adults with Acute Traumatic Brain Injury in the United States and Latin America.

Objectives: To compare characteristics of caregivers of adults with acute traumatic brain injury (TBI) in the U.S. and Latin America (Mexico and Colombia). Design: Secondary data analysis of two cohorts. Cohort 1: English-speaking caregivers of adults with TBI in the U.S. (n = 80). Cohort 2: Spanish-speaking caregivers of adults with TBI in Mexico or Colombia (n = 109). Results: Similarities between the U.S. and Latin American caregiver groups, respectively, were: predominantly women (81.3%, 81.7%, respectively); spouses/domestic partners (45%, 31.2%); and motor vehicle accident (41.5%, 48.6%) followed by fall etiologies (40%, 21.1%). Differences between U.S. and Latin American caregivers were: age (49.5 years, 41.5 years, p < 0.001); employment status ((Χ52 = 59.63, p < 0.001), full-time employment (63.7%, 25.7%), homemaker (2.5%, 31.2%), and retired (17.5%, 1.8%)); violence-related etiology (2.5%, 15.6%); and severity of depressive symptoms (M = 7.9, SD = 5.8; M = 5.8, SD = 5.7; p = 0.014). Conclusions: TBI caregivers in the U.S. were older and employed full-time or retired more often than those in Latin America. Violence-related etiology was nearly five times more common in Latin America, raising concerns for potential implications of post-traumatic stress and family adjustment after injury. Although both groups likely could use mental health support, this was particularly true of the U.S. cohort, maybe due to differential demographics, mechanisms of injury, or family and community support.

Rasch analysis of the Behavioral Assessment Screening Tool (BAST) in chronic traumatic brain injury.

The Behavioral Assessment Screening Tool (BAST) measures neurobehavioral symptoms in adults with traumatic brain injury (TBI). Exploratory Factor Analyses established five subscales: Negative Affect, Fatigue, Executive Function, Impulsivity, and Substance Abuse. In the current study, we assessed all the subscales except Substance Abuse using Rasch analysis following the Rasch Reporting Guidelines in Rehabilitation Research (RULER) framework. RULER identifies unidimensionality and fit statistics, item hierarchies, targeting, and symptom severity strata as areas of interest for Rasch analysis. The BAST displayed good unidimensionality with only one item from the Impulsivity scale exhibiting potential item misfit (MnSQ 1.40). However, removing this item resulted in a lower average domain measure (1.42 to -1.49) and higher standard error (0.34 to 0.43) so the item was retained. Items for each of the four subscales also ranged in difficulty (i.e. endorsement of symptom frequency) with more severe symptoms being endorsed in the Fatigue subscale and more mild symptoms being endorsed in the Impulsivity subscale. Though Negative Affect and Executive Function displayed appropriate targeting, the Fatigue and Impulsivity Subscales had larger average domain values (1.35 and -1.42) meaning that more items may need to be added to these subscales to capture differences across a wider range of symptom severity. The BAST displayed excellent reliability via item and person separation indices and distinct strata for each of the four subscales. Future work should use Rasch analysis in a larger, more representative sample, include more items for the Fatigue and Impulsivity subscale, and include the Substance Abuse subscale.